surge capacity for terrorist bombings: challenges and proposed
TRANSCRIPT
CS123209
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Challenges and Proposed Solutions
US DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention NationalCenterforInjuryPreventionandControl
DivisionofInjuryResponse
AtlantaGeorgia April2007
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings is a publication of the National Center for Injury Prevention and Control Centers for Disease Control and Prevention
Centers for Disease Control and Prevention Julie Louise Gerberding MD MPH
Director
Coordinating Center for Environmental Health and Injury Prevention Henry Falk MD MPH
Director
National Center for Injury Prevention and Control Ileana Arias PhD
Director
Division of Injury Response Richard C Hunt MD FACEP
Director
Authors
Scott M Sasser Richard C Hunt Bob Bailey Jon Krohmer Steve Cantrill Kevin Gerold Mark Johnson Arthur Kellermann Patricia Lenaghan James Morris Brent Myers Richard Orr Thomas Peters Paul Schmidt on behalf of the Surge Capacity Expert Panel
Suggested Citation National Center for Injury Prevention and Control In a Momentrsquos Notice Surge Capacity for Terrorist Bombings Atlanta (GA) Centers for Disease Control and Prevention 2007
Contents
Executive Summary1
Background3
Surge Capacity Challenges7
System-wideChallenges7
Discipline-specificChallenges10
Surge Capacity Solutions 19
AddressingSystem-wideChallenges19
AddressingDiscipline-specificChallenges21
Conclusion 47
Acknowledgements 47
References 50
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings i
Executive Summary Explosivedevicesandhigh-velocityfirearmsaretheterroristsrsquoweaponsofchoiceThe devastationwroughtintwoEuropeancapitalsMadridandLondondemonstratethe impactthatcanbeachievedbydetonatingexplosivesamongdenselypackedciviliansIn aninstantanexplosioncanwreakhavocmdashproducingnumerouscasualtieswithcomplex technicallychallenginginjuriesnotcommonlyseenafternaturaldisasterssuchasfloods tornadoesorhurricanesBecausemanypatientsself-evacuateafteraterroristattack andprehospitalcaremaybedifficulttocoordinatehospitalsnearthescenecanexpect toreceivealargeinfluxmdashorsurgemdashofvictimsafteraterroriststrikeThisrapidsurgeof victimstypicallyoccurswithinminutesexemplifiedbytheMadridbombingswherethe closesthospitalreceived272patientsin25hoursSuchasurgediffersdramaticallyfrom thegradualinfluxofpatientsafteranoutbreakofinfectiousdiseaseoranenvironmental emergencysuchasaheatwavewhichcanlastseveraldaystoweeksafterwardsInaddition injuriestoworkersinvolvedinrecoveryprocedurescanleadtoasecondarywaveinsurge ThekeyquestionisthisCanhospitalsmeetthechallenge
Healthcareandpublichealthspecialistsanticipateprofoundproblemsinadequatelycaring fortheresultingsurgeofvictimsOurcurrenthealthcaresystemespeciallytheemergency caresystemisalreadyseverelystrainedbyitsroutinevolumeofdailycare
Furtherthehealthcaresystememergencydepartmentsandintensivecareunits(ICUs) ofacutecarehospitalsarechronicallyovercrowdedandresource-constrainedWithout immediatefederalassistancemanyifnotmostcommunitieswouldhavedifficulty caringforasurgeofvictimsbecauseeachhospitalandemergencymedicalservicediffers dramaticallyincapacitytrainingandlevelofcoordinationIndeedaterroristbombingin theUnitedStateswouldbealdquopredictablesurpriserdquo
ToaddressthechallengesposedbysuchaneventCDCrsquosNationalCenterforInjury PreventionandControl(CDCrsquosInjuryCenter)convenedanexpertpanelinOctober 2005andJanuary2006Thepanelincludedexpertsintheareasofemergencymedical servicesemergencymedicinetraumasurgeryburnsurgerypediatricsotolaryngology intensivecaremedicinehospitalmedicineradiologypharmacologynursinghospital administrationlaboratorymedicine(bloodbank)andpublichealthThepanelwas chargedwithidentifyingcreativestrategiesthatcouldbeadoptedinatimelymannerto addresssurgeissuesfromterrorismThepanelfocusedonrecommendingstrategiesfor rapidmanagementoflargenumbersofbombingcasualtiesTheyexaminedtherelated challengesthatwouldconfrontnotonlythegeneralemergencymedicalresponseand healthcaresystembutwouldalsoaffectselectmedicaldisciplinesThoughdeveloped inthecontextofasurgeofinjuriesfromaterroristbombingtherecommendationsin thisreportmayimprovetheresponsetoandmanagementofasurgeofpatientsfromany causeincludingbiologicalchemicalornuclear Thisdocumentwhichistheresultoftheexpertpanelmeetingsreflectstheopinionsand recommendationsoftheexpertsItincludesadescriptionofsystem-wideanddiscipline-
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Challenges and Proposed Solutions
US DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention NationalCenterforInjuryPreventionandControl
DivisionofInjuryResponse
AtlantaGeorgia April2007
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings is a publication of the National Center for Injury Prevention and Control Centers for Disease Control and Prevention
Centers for Disease Control and Prevention Julie Louise Gerberding MD MPH
Director
Coordinating Center for Environmental Health and Injury Prevention Henry Falk MD MPH
Director
National Center for Injury Prevention and Control Ileana Arias PhD
Director
Division of Injury Response Richard C Hunt MD FACEP
Director
Authors
Scott M Sasser Richard C Hunt Bob Bailey Jon Krohmer Steve Cantrill Kevin Gerold Mark Johnson Arthur Kellermann Patricia Lenaghan James Morris Brent Myers Richard Orr Thomas Peters Paul Schmidt on behalf of the Surge Capacity Expert Panel
Suggested Citation National Center for Injury Prevention and Control In a Momentrsquos Notice Surge Capacity for Terrorist Bombings Atlanta (GA) Centers for Disease Control and Prevention 2007
Contents
Executive Summary1
Background3
Surge Capacity Challenges7
System-wideChallenges7
Discipline-specificChallenges10
Surge Capacity Solutions 19
AddressingSystem-wideChallenges19
AddressingDiscipline-specificChallenges21
Conclusion 47
Acknowledgements 47
References 50
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings i
Executive Summary Explosivedevicesandhigh-velocityfirearmsaretheterroristsrsquoweaponsofchoiceThe devastationwroughtintwoEuropeancapitalsMadridandLondondemonstratethe impactthatcanbeachievedbydetonatingexplosivesamongdenselypackedciviliansIn aninstantanexplosioncanwreakhavocmdashproducingnumerouscasualtieswithcomplex technicallychallenginginjuriesnotcommonlyseenafternaturaldisasterssuchasfloods tornadoesorhurricanesBecausemanypatientsself-evacuateafteraterroristattack andprehospitalcaremaybedifficulttocoordinatehospitalsnearthescenecanexpect toreceivealargeinfluxmdashorsurgemdashofvictimsafteraterroriststrikeThisrapidsurgeof victimstypicallyoccurswithinminutesexemplifiedbytheMadridbombingswherethe closesthospitalreceived272patientsin25hoursSuchasurgediffersdramaticallyfrom thegradualinfluxofpatientsafteranoutbreakofinfectiousdiseaseoranenvironmental emergencysuchasaheatwavewhichcanlastseveraldaystoweeksafterwardsInaddition injuriestoworkersinvolvedinrecoveryprocedurescanleadtoasecondarywaveinsurge ThekeyquestionisthisCanhospitalsmeetthechallenge
Healthcareandpublichealthspecialistsanticipateprofoundproblemsinadequatelycaring fortheresultingsurgeofvictimsOurcurrenthealthcaresystemespeciallytheemergency caresystemisalreadyseverelystrainedbyitsroutinevolumeofdailycare
Furtherthehealthcaresystememergencydepartmentsandintensivecareunits(ICUs) ofacutecarehospitalsarechronicallyovercrowdedandresource-constrainedWithout immediatefederalassistancemanyifnotmostcommunitieswouldhavedifficulty caringforasurgeofvictimsbecauseeachhospitalandemergencymedicalservicediffers dramaticallyincapacitytrainingandlevelofcoordinationIndeedaterroristbombingin theUnitedStateswouldbealdquopredictablesurpriserdquo
ToaddressthechallengesposedbysuchaneventCDCrsquosNationalCenterforInjury PreventionandControl(CDCrsquosInjuryCenter)convenedanexpertpanelinOctober 2005andJanuary2006Thepanelincludedexpertsintheareasofemergencymedical servicesemergencymedicinetraumasurgeryburnsurgerypediatricsotolaryngology intensivecaremedicinehospitalmedicineradiologypharmacologynursinghospital administrationlaboratorymedicine(bloodbank)andpublichealthThepanelwas chargedwithidentifyingcreativestrategiesthatcouldbeadoptedinatimelymannerto addresssurgeissuesfromterrorismThepanelfocusedonrecommendingstrategiesfor rapidmanagementoflargenumbersofbombingcasualtiesTheyexaminedtherelated challengesthatwouldconfrontnotonlythegeneralemergencymedicalresponseand healthcaresystembutwouldalsoaffectselectmedicaldisciplinesThoughdeveloped inthecontextofasurgeofinjuriesfromaterroristbombingtherecommendationsin thisreportmayimprovetheresponsetoandmanagementofasurgeofpatientsfromany causeincludingbiologicalchemicalornuclear Thisdocumentwhichistheresultoftheexpertpanelmeetingsreflectstheopinionsand recommendationsoftheexpertsItincludesadescriptionofsystem-wideanddiscipline-
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings is a publication of the National Center for Injury Prevention and Control Centers for Disease Control and Prevention
Centers for Disease Control and Prevention Julie Louise Gerberding MD MPH
Director
Coordinating Center for Environmental Health and Injury Prevention Henry Falk MD MPH
Director
National Center for Injury Prevention and Control Ileana Arias PhD
Director
Division of Injury Response Richard C Hunt MD FACEP
Director
Authors
Scott M Sasser Richard C Hunt Bob Bailey Jon Krohmer Steve Cantrill Kevin Gerold Mark Johnson Arthur Kellermann Patricia Lenaghan James Morris Brent Myers Richard Orr Thomas Peters Paul Schmidt on behalf of the Surge Capacity Expert Panel
Suggested Citation National Center for Injury Prevention and Control In a Momentrsquos Notice Surge Capacity for Terrorist Bombings Atlanta (GA) Centers for Disease Control and Prevention 2007
Contents
Executive Summary1
Background3
Surge Capacity Challenges7
System-wideChallenges7
Discipline-specificChallenges10
Surge Capacity Solutions 19
AddressingSystem-wideChallenges19
AddressingDiscipline-specificChallenges21
Conclusion 47
Acknowledgements 47
References 50
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings i
Executive Summary Explosivedevicesandhigh-velocityfirearmsaretheterroristsrsquoweaponsofchoiceThe devastationwroughtintwoEuropeancapitalsMadridandLondondemonstratethe impactthatcanbeachievedbydetonatingexplosivesamongdenselypackedciviliansIn aninstantanexplosioncanwreakhavocmdashproducingnumerouscasualtieswithcomplex technicallychallenginginjuriesnotcommonlyseenafternaturaldisasterssuchasfloods tornadoesorhurricanesBecausemanypatientsself-evacuateafteraterroristattack andprehospitalcaremaybedifficulttocoordinatehospitalsnearthescenecanexpect toreceivealargeinfluxmdashorsurgemdashofvictimsafteraterroriststrikeThisrapidsurgeof victimstypicallyoccurswithinminutesexemplifiedbytheMadridbombingswherethe closesthospitalreceived272patientsin25hoursSuchasurgediffersdramaticallyfrom thegradualinfluxofpatientsafteranoutbreakofinfectiousdiseaseoranenvironmental emergencysuchasaheatwavewhichcanlastseveraldaystoweeksafterwardsInaddition injuriestoworkersinvolvedinrecoveryprocedurescanleadtoasecondarywaveinsurge ThekeyquestionisthisCanhospitalsmeetthechallenge
Healthcareandpublichealthspecialistsanticipateprofoundproblemsinadequatelycaring fortheresultingsurgeofvictimsOurcurrenthealthcaresystemespeciallytheemergency caresystemisalreadyseverelystrainedbyitsroutinevolumeofdailycare
Furtherthehealthcaresystememergencydepartmentsandintensivecareunits(ICUs) ofacutecarehospitalsarechronicallyovercrowdedandresource-constrainedWithout immediatefederalassistancemanyifnotmostcommunitieswouldhavedifficulty caringforasurgeofvictimsbecauseeachhospitalandemergencymedicalservicediffers dramaticallyincapacitytrainingandlevelofcoordinationIndeedaterroristbombingin theUnitedStateswouldbealdquopredictablesurpriserdquo
ToaddressthechallengesposedbysuchaneventCDCrsquosNationalCenterforInjury PreventionandControl(CDCrsquosInjuryCenter)convenedanexpertpanelinOctober 2005andJanuary2006Thepanelincludedexpertsintheareasofemergencymedical servicesemergencymedicinetraumasurgeryburnsurgerypediatricsotolaryngology intensivecaremedicinehospitalmedicineradiologypharmacologynursinghospital administrationlaboratorymedicine(bloodbank)andpublichealthThepanelwas chargedwithidentifyingcreativestrategiesthatcouldbeadoptedinatimelymannerto addresssurgeissuesfromterrorismThepanelfocusedonrecommendingstrategiesfor rapidmanagementoflargenumbersofbombingcasualtiesTheyexaminedtherelated challengesthatwouldconfrontnotonlythegeneralemergencymedicalresponseand healthcaresystembutwouldalsoaffectselectmedicaldisciplinesThoughdeveloped inthecontextofasurgeofinjuriesfromaterroristbombingtherecommendationsin thisreportmayimprovetheresponsetoandmanagementofasurgeofpatientsfromany causeincludingbiologicalchemicalornuclear Thisdocumentwhichistheresultoftheexpertpanelmeetingsreflectstheopinionsand recommendationsoftheexpertsItincludesadescriptionofsystem-wideanddiscipline-
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Contents
Executive Summary1
Background3
Surge Capacity Challenges7
System-wideChallenges7
Discipline-specificChallenges10
Surge Capacity Solutions 19
AddressingSystem-wideChallenges19
AddressingDiscipline-specificChallenges21
Conclusion 47
Acknowledgements 47
References 50
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings i
Executive Summary Explosivedevicesandhigh-velocityfirearmsaretheterroristsrsquoweaponsofchoiceThe devastationwroughtintwoEuropeancapitalsMadridandLondondemonstratethe impactthatcanbeachievedbydetonatingexplosivesamongdenselypackedciviliansIn aninstantanexplosioncanwreakhavocmdashproducingnumerouscasualtieswithcomplex technicallychallenginginjuriesnotcommonlyseenafternaturaldisasterssuchasfloods tornadoesorhurricanesBecausemanypatientsself-evacuateafteraterroristattack andprehospitalcaremaybedifficulttocoordinatehospitalsnearthescenecanexpect toreceivealargeinfluxmdashorsurgemdashofvictimsafteraterroriststrikeThisrapidsurgeof victimstypicallyoccurswithinminutesexemplifiedbytheMadridbombingswherethe closesthospitalreceived272patientsin25hoursSuchasurgediffersdramaticallyfrom thegradualinfluxofpatientsafteranoutbreakofinfectiousdiseaseoranenvironmental emergencysuchasaheatwavewhichcanlastseveraldaystoweeksafterwardsInaddition injuriestoworkersinvolvedinrecoveryprocedurescanleadtoasecondarywaveinsurge ThekeyquestionisthisCanhospitalsmeetthechallenge
Healthcareandpublichealthspecialistsanticipateprofoundproblemsinadequatelycaring fortheresultingsurgeofvictimsOurcurrenthealthcaresystemespeciallytheemergency caresystemisalreadyseverelystrainedbyitsroutinevolumeofdailycare
Furtherthehealthcaresystememergencydepartmentsandintensivecareunits(ICUs) ofacutecarehospitalsarechronicallyovercrowdedandresource-constrainedWithout immediatefederalassistancemanyifnotmostcommunitieswouldhavedifficulty caringforasurgeofvictimsbecauseeachhospitalandemergencymedicalservicediffers dramaticallyincapacitytrainingandlevelofcoordinationIndeedaterroristbombingin theUnitedStateswouldbealdquopredictablesurpriserdquo
ToaddressthechallengesposedbysuchaneventCDCrsquosNationalCenterforInjury PreventionandControl(CDCrsquosInjuryCenter)convenedanexpertpanelinOctober 2005andJanuary2006Thepanelincludedexpertsintheareasofemergencymedical servicesemergencymedicinetraumasurgeryburnsurgerypediatricsotolaryngology intensivecaremedicinehospitalmedicineradiologypharmacologynursinghospital administrationlaboratorymedicine(bloodbank)andpublichealthThepanelwas chargedwithidentifyingcreativestrategiesthatcouldbeadoptedinatimelymannerto addresssurgeissuesfromterrorismThepanelfocusedonrecommendingstrategiesfor rapidmanagementoflargenumbersofbombingcasualtiesTheyexaminedtherelated challengesthatwouldconfrontnotonlythegeneralemergencymedicalresponseand healthcaresystembutwouldalsoaffectselectmedicaldisciplinesThoughdeveloped inthecontextofasurgeofinjuriesfromaterroristbombingtherecommendationsin thisreportmayimprovetheresponsetoandmanagementofasurgeofpatientsfromany causeincludingbiologicalchemicalornuclear Thisdocumentwhichistheresultoftheexpertpanelmeetingsreflectstheopinionsand recommendationsoftheexpertsItincludesadescriptionofsystem-wideanddiscipline-
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Executive Summary Explosivedevicesandhigh-velocityfirearmsaretheterroristsrsquoweaponsofchoiceThe devastationwroughtintwoEuropeancapitalsMadridandLondondemonstratethe impactthatcanbeachievedbydetonatingexplosivesamongdenselypackedciviliansIn aninstantanexplosioncanwreakhavocmdashproducingnumerouscasualtieswithcomplex technicallychallenginginjuriesnotcommonlyseenafternaturaldisasterssuchasfloods tornadoesorhurricanesBecausemanypatientsself-evacuateafteraterroristattack andprehospitalcaremaybedifficulttocoordinatehospitalsnearthescenecanexpect toreceivealargeinfluxmdashorsurgemdashofvictimsafteraterroriststrikeThisrapidsurgeof victimstypicallyoccurswithinminutesexemplifiedbytheMadridbombingswherethe closesthospitalreceived272patientsin25hoursSuchasurgediffersdramaticallyfrom thegradualinfluxofpatientsafteranoutbreakofinfectiousdiseaseoranenvironmental emergencysuchasaheatwavewhichcanlastseveraldaystoweeksafterwardsInaddition injuriestoworkersinvolvedinrecoveryprocedurescanleadtoasecondarywaveinsurge ThekeyquestionisthisCanhospitalsmeetthechallenge
Healthcareandpublichealthspecialistsanticipateprofoundproblemsinadequatelycaring fortheresultingsurgeofvictimsOurcurrenthealthcaresystemespeciallytheemergency caresystemisalreadyseverelystrainedbyitsroutinevolumeofdailycare
Furtherthehealthcaresystememergencydepartmentsandintensivecareunits(ICUs) ofacutecarehospitalsarechronicallyovercrowdedandresource-constrainedWithout immediatefederalassistancemanyifnotmostcommunitieswouldhavedifficulty caringforasurgeofvictimsbecauseeachhospitalandemergencymedicalservicediffers dramaticallyincapacitytrainingandlevelofcoordinationIndeedaterroristbombingin theUnitedStateswouldbealdquopredictablesurpriserdquo
ToaddressthechallengesposedbysuchaneventCDCrsquosNationalCenterforInjury PreventionandControl(CDCrsquosInjuryCenter)convenedanexpertpanelinOctober 2005andJanuary2006Thepanelincludedexpertsintheareasofemergencymedical servicesemergencymedicinetraumasurgeryburnsurgerypediatricsotolaryngology intensivecaremedicinehospitalmedicineradiologypharmacologynursinghospital administrationlaboratorymedicine(bloodbank)andpublichealthThepanelwas chargedwithidentifyingcreativestrategiesthatcouldbeadoptedinatimelymannerto addresssurgeissuesfromterrorismThepanelfocusedonrecommendingstrategiesfor rapidmanagementoflargenumbersofbombingcasualtiesTheyexaminedtherelated challengesthatwouldconfrontnotonlythegeneralemergencymedicalresponseand healthcaresystembutwouldalsoaffectselectmedicaldisciplinesThoughdeveloped inthecontextofasurgeofinjuriesfromaterroristbombingtherecommendationsin thisreportmayimprovetheresponsetoandmanagementofasurgeofpatientsfromany causeincludingbiologicalchemicalornuclear Thisdocumentwhichistheresultoftheexpertpanelmeetingsreflectstheopinionsand recommendationsoftheexpertsItincludesadescriptionofsystem-wideanddiscipline-
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
specificchallengesaswellasrecommendedsolutionstoaddressthesechallengesThe proposedsolutionsforthediscipline-specificchallengeshavebeenincorporatedintoeasy tousetemplatesthatcanassistvariousdisciplinesinmanagingsurgeneedsforinjuries Theneedsandresourcesofeachcommunitymustbeconsideredtoeffectivelyplanfora surgeofpatientsintoanalreadyoverburdenedhealthcaresystemAdmittedlycommunity resourcesarenotspecifictohandlingcasualtiesofexplosivesbutthelikelihoodofthis threatandthesuddendemanditwouldplaceonthehealthcaresystemmakeitimperative tomanagedeficienciesinsurgecapacitynowmdashnotwhencrisisstrikesmdashandtodosoinan aggressivebutthoughtfulmanner
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Background Currentpatternsinterroristactivityincreasethepotentialforciviliancasualtiesfrom explosionsRecenteventsinEgyptIndiaIraqIsraelSpainandtheUnitedKingdom clearlyindicatethatbombingstargetingcivilianpopulationsareanever-presentdanger worldwideTheUSDepartmentofStatereported7000terroristbombingsworldwide between1968and19991From2001through200morethan500internationalterrorist bombingscausedmorethan4600deaths1-excludingtheattacksofSeptember112001 whichessentiallyusedplanesasflyingbombs
TheUSFederalBureauofInvestigationconfirmed24incidentsofterroristbombingsin theUnitedStatesbetween1980and20014Morethan21000bombingincidents(actual accidentalattempted)occurredintheUSbetween1988and19985
In2005aloneaccordingtoreportscompiledfromtheTerroristAttackArchivesTerrorism ResearchCenter758terroristeventswerestagedin45countriesandmorethanhalf(N=99) werebombingsTheseeventsresultedin8019injuredpersonsand049deaths6
Despitejustifiableconcernsaboutthedangersofchemicalbiologicornuclearattacks bombingswithconventionalexplosivesremaintheterroristsrsquomethodofchoice Explosionsparticularlyinconfinedspacescaninflictmulti-systeminjuriesonnumerous patientsandproduceuniquemanagementchallengestohealthprovidersUnlikethe gradualinfluxofpatientsaftereventssuchasinfectiousdiseasesthesurgeofpatients afteranexplosiontypicallyoccurswithinminutesoftheeventandoverwhelmsnearby hospitalresources78Thepotentialforlargenumbersofcasualtiesandanimmediatesurge ofpatientsmaystressandlimittheabilityofemergencymedicalservices(EMS)systems hospitalsandotherhealthcarefacilitiestocarefortheonslaughtofcriticallyinjured victims9-11
Theongoingandincreasingthreatofterroristactivitiescombinedwithdocumented evidenceofdecreasingemergencycarecapacityrequirespreemptiveactionHealthcare andpublichealthsystemsindividualhospitalsandhealthcarepersonnelmustcollaborate toensurethatstrategiesareinplacetoeffectivelyreceiveevaluateandtreatlarge numbersofinjuredpatientstorapidlyidentifyandstabilizethemostcriticallyinjuredto evaluatetheseeffortsandtostrategicallyplanforfutureincidents
TheRoleoftheNationalCenterforInjuryPreventionandControl(CDCrsquos InjuryCenter)CentersforDiseaseControlandPrevention(CDC)
ThemissionofCDCrsquosInjuryCenteristopreventprematuredeathanddisabilityandto reducethehumansufferingandmedicalcostcausedbyinjuriesThismissionsupports CDCrsquosstrategicgoaltoprotectpeopleinallcommunitiesfromterroristthreatsAsameans topreventinjuriesandminimizetheconsequencesofinjurytheInjuryCenterusesthe publichealthapproachmdashasystematicprocesstodefinetheinjuryproblemidentifyrisk andprotectivefactorsdevelopandtestpreventioninterventionsandstrategiesandensure widespreadadoptionofeffectiveinterventionsandstrategies
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Manyagencieshaveaddressedissuesofsurgecapacityforeventssuchasbiological attacksmdashmostnotablyCDCrsquospublichealthandlaboratorysurgeprogramsandtheHealth ResourcesandServicesAdministrationrsquos(HRSA)hospitalpreparednessprogramTodate littleefforthasbeendirectedtowardincreasingsurgecapacityinresponsetoterrorist bombingsAfterin-depthdiscussionswithHRSAtheDepartmentofHomelandSecurity theFederalEmergencyManagementAgency(FEMA)theNationalHighwayTrafficSafety Administration(NHTSA)andCDCrsquosCoordinatingOfficeforTerrorismPreparednessand EmergencyResponsetheInjuryCenterlearnedthatCDCcouldplayauniquerolein identifyingsurgecapacityissuesrelatedtoterroristbombingsandproposingsolutions Furthermoreanysolutionstoenhancesurgecapacityinpreparationforterroristbombings directlyapplytosurgeissuesforothermanmadeornaturaldisasters
TothisendCDCrsquosInjuryCenterconvenedanexpertpanelinOctober2005andJanuary 2006Theexpertpanelwaschargedwithidentifyingcreativestrategiesthatcouldbe adoptedinatimelymannertoaddresssurgeissuesfromterrorisminessenceidentifying bothsystem-wideanddiscipline-specificconcernsandrecommendingfeasibleandaffordable strategiesforrapidlymanaginglargenumbersofbombingcasualtiesThisdocumentisthe resultofthosemeetingsreflectstheopinionsandrecommendationsofthisexpertpanel andincludesitsrecommendationsTheserecommendationsweredesignedforemergency medicalhealthcareandpublichealthsystemswiththecaveatthatimmediatestepsbetaken toensureaneffectiveresponseTokickofftheprocesstheexpertpanelsetobjectives
bull IncreasecollaborationbetweenCDCandfederalagenciesexternalpartnersand otherexpertsonissuesofsurgecapacityforinjuriesfromconventionalweapons
bull Identifyfactorsthatlimitrapidassessmentandtreatmentofinjuredpatientsin thefieldandathospitals(includingtriageavailabilityofradiologyandaccessto operatingtheatres)anddevelopmechanismstoaddressthesefactorsand
bull Developastrategyandidentifymechanismstowidelydisseminateandimplement findingsfromtheexpertpanel(egWebprintpublicationsandtrainingcurricula)
Thepanelrepresentedabroadspectrumofmedicalcareandadministrativedisciplines requiredtocareforvictimsofabombingPanelmembersincludedpersonnelfromemergency medicalservicesphysiciansspecializinginemergencymedicinetraumasurgeryburnsurgery pediatricsotolaryngologyintensivecaremedicinehospitalmedicineandradiologyexperts inpharmacologynursinghospitaladministrationandbloodbankingandexpertsinpublic healthExpertpanelmembersarelistedintheacknowledgementssectionofthisreport
TheEvolutionofTerrorism
Attheheartofandasanimpetusforthismeetingisthefactthatterroristattacksremain anever-presentthreatTerroristeventscontinuetooccurgloballyandonanalarming scaleBombingsmdashtheperpetratorsrsquomethodofchoicemdashremainarealandconstantthreat averagingtwoterroristattacksperdayworldwidein20056Inthepastthirtyyears terrorismhasevolvedfrommostlysecularnationalistmovementstodiversemultinational globalorganizations12Theseorganizationshavedifferentmotivationsandtacticsand theirbombingsareincreasinglylethal1aswitnessedinMadrid(March2004)London
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
(July2005)andMumbai(July2006)terroristeffortsrevealanever-increasingdegreeof sophisticationcoordinationandcapacityforharm
LessonsLearnedinMadrid
Inanefforttoprovideaframeworktothemeetingsandsubsequentdiscussionsthepanel waspresentedwiththeexampleoftheMarch2004Madridbombingsatthebeginning ofthefirstmeetingTheMadridexperienceprovidesareal-lifescenarioofwhatUS healthcareprovidersandsystemsmustbepreparedtoconfrontacomplexcoordinated attackwiththousandsinjuredandarapidsurgeofpatientsintosurroundinghospitalsOn March112004between079and0742hourstenterroristbombsdetonatedonfour crowdedcommutertrainskilling177peopleinstantlyandinjuringmorethan2000Three hundredandtwelvepatientswereevaluatedandtreatedatGregarioMaranonUniversity GeneralHospital(GMUGH)272ofthemarrivingbetween0759and100hoursThe Madridresponseentailedmultiplelogisticalandoperationalchallengesincludingfield triageandtransportationofinjuredpersonsinpatientdischargeevacuationofemergency departments(EDs)andintensivecareunits(ICUs)andmultiplesurgicalproceduresand tests(hundredsofradiographscomputerizedtomography(CT)scansandultrasounds)By 2100hoursthatsameday140casualtieshadbeentreatedatmultiplehospitalsofthese 966hadbeentransportedto15publiccommunityhospitals14Panelmemberswereasked todescribehowtheirdisciplinewouldrespondtotheMadridexample
TerroristBombingsintheUnitedStatesAldquoPredictableSurpriserdquo
TherealityofpersistentcomplexglobalterroristbombingssuchasMadridmake terroristbombingsintheUSaldquopredictablesurpriserdquoTheexpertpanelreviewedthe characteristicsofldquopredictablesurprisesrdquolistedbelowearlyinthecourseofthemeetingprocess toprovidebackgroundoncommonproblemsthatcouldhindereffectivesurgeresponse andinanefforttoidentifyconcernsandissuesthatneededtobeaddressedwithintheir recommendations
ThefollowingcharacteristicsofldquopredictablesurprisesrdquooutlinedbyBazermanand Watkins15applytoterroristbombingsandtheUS
1Asharedtraitofpredictablesurprisesisthatleadersknewaproblem existedandthattheproblemwouldnotsolveitself
ReportsofbombingsoccuralmostdailyWhenmdashnotifmdashterrorismreturnstothe USourEMSandhospitalsystemswillbeill-equippedtomanagethe consequences
2Predictablesurprisescanbeexpectedwhenorganizationalmembers recognizethataproblemisgettingworseovertime
TerroristeventsshownosignsofabatingBetween2001and200morethan500 internationalterroristbombingsresultedinmorethan4600deathsasreported bytheUSDepartmentofState1-In2005alone758worldwideterroristevents occurredofwhich99werebombingsTheseeventsoccurredin45countriesand resultedin8019personsinjuredand049deaths6
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
3Fixingtheproblemwouldincursignificantcostsinthepresentwhilethe benefitsofactionwouldbedelayedandambiguous
AcentralissueinpreparingforterroristbombingsintheUSistoproactively educatehealthcareprovidersintheclinicalmanagementofbombinginjuries EducationisexpensiveEvenifhealthcareprovidersareinitiallytrainedtocare forbombing-relatedinjuriesunlesstheseterroristeventsbecomeamorefrequent andunfortunaterealityeducationmustberepeatedregularlytoassurecurrency ofknowledgeandclinicalcompetencyAnotherissueconcernstherapidpushof clinicalinformationimmediatelyafteraneventThemechanismsandcapabilityto dothisneedtobedevelopedandmaybecostlyFinallymanyEMSsystemsand hospitalsdonothavecapacitytocareforpatientsbeyondtheirusualvolumeand somedonothavecapacitytocareforthevolumetheynowhaveasevidenced byfrequentambulancediversionsandlengthydelaysforambulancestooff-loadpatientsathospitalEDsThecostofincreasingfacilitycapacityintheEMS andhospitalsystemsmaybesubstantialAlthoughincreasingcapacitywillhave immediateimpactondailyoperationsinEMSandhospitalsthebenefitsofeducation andbettersystemsfordisseminatinginformationwillnotbefullyrecognizeduntil usedinresponsetoaterroristattackorotherdisaster
4Decisionmakersoftenfailtoprepareforpredictablesurprisesbecause thenaturalhumantendencyistomaintainthestatusquo
Outsidethemilitaryourcountryrsquoshealthcareprovidershavelittleexperience withterroristbombingsmdashparticularlythosecapableofproducingmanypotentially survivableinjuriesInjuryistheleadingcauseofdeathintheUnitedStatesfor personsbetweentheagesof1and4416thusmanycivilianhealthcareproviders especiallythoseintraumasystemshavevastexperienceininjurycareincluding incidentswithmultiplecasualtiesHoweverwehavelearnedfromtheexperiences ofourmilitaryandinternationalcolleaguesthatclinicalmanagementofcasualties fromterroristbombingsdiffersconsiderablyfromthatseendailyintraumacenters (egbluntandpenetratingtrauma)Toassumewecanprovidethesamelevelof careforlargenumbersofvictimsfromterroristbombingsaswedoforvictimsofa buscrashisself-deceivingmdashanaturalreactionistomaintainthestatusquoRelying ontraditionaldisastermanagementandtraumalifesupporttrainingisfareasierand lessexpensivethanlearningandpracticingnewskills
5Asmallvocalminoritybenefitsfrominactionandismotivatedtosubvert theactionsofleadersfortheirpersonalbenefit
Nomatterwhatthemotivationsomepeoplebenefitfrominaction
6Leaderscanexpectlittlecreditforthepreventionofpredictablesurprises
Advocatingforandacquiringresourcesforterroristbombingpreparednessand responseischallengingmdashespeciallywhensomanycompetingpreparednessand responseneedsmustalsobemetWithlimitedresourcesandtheneedfornear-term resultsleaderswhoprepareforeventsthatmaynotoccurcanexpectlittlecredit forbeingproactive
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Surge Capacity Challenges System-wideChallenges
ThethreatofterrorismexistsatatimewhenourhospitalsandEDsarestrugglingtocare forthepatientswhopresentduringroutineoperationseachdayHospitalsandemergency healthcaresystemsarestressedandfaceenormouschallengesAmbulancesareroutinely divertedfromonefacilitytoanotherAccordingtoa200reportfromtheNationalCenter forHealthStatistics4ofUSEDsdivertedambulancesfromprimarydestinations diversionsoccurredmorefrequentlyinmetropolitanareas(50ofmetrohospitals)16 EmergencydepartmentsroutinelyoperateabovecapacitySometimesparamedicsare forcedtowaitforextendedperiodsbeforetheirpatientscanbetransferredtohospital staffPatientsareevaluatedandtreatedinEDhallwaysandheldforhoursorevendays awaitingplacementinaninpatientbedashospitalsstrugglewithhighoccupancyIn 200therewere119millionvisitstoEDsintheUSrepresentinga26increasefrom 199rsquos90millionvisitsDuringthissameperiodthenumberofUSEDsdecreased 1417Theproblembecameworseinthe1990swhenournationlost10000staffed inpatientmedicalsurgicalbedsand7800ICUbeds18ReductionsinhospitalswithEDs regionalizationofsurgicalcareincreasesinnon-emergencypatientvisitstoEDsdiversion ofEMSandpersonnelshortageshaveledtounprecedentedcrowdinginEDs19-2The InstituteofMedicinerecentlyreleasedathree-partreporthighlightingthechallengesfacing ournationrsquosemergencycaresystem24-26
Thisisthecontextinwhichweconfrontthegrowingthreatofinternationalterrorism Hospitalsarewhollyunequippedtohandleasuddensurgeofhighlycomplexinjuries
Ifalarge-scaleevent(manmadeornatural)occurshealthcaresystemsandhospitals mustbeabletotreatanimmediateandpotentiallylargeinfluxofpatientsArecent CDCpublicationdeterminedthataboutthreefourthsofhospitalshaddisasterplansthat addressedexplosivesbutfew(onefifth)hadactuallyconductedadrillinvolvingimagined useofexplosives27
Issuesaffectthespectrumofinjurycarefromprehospitalthroughrehabilitationandalso affectpersonnelfromfirechiefstraumasurgeonsandnursingsupervisorstoemergency medicaltechniciansManyproblematicareasstandbetweenthecurrentrealityof emergencycareintheUnitedStatesandtheeffectivemanagementofaMadrid-likeevent
1OrganizationandLeadership
Effectivepreparednessandresponsedemandanestablishedfunctionalleadership structurewithclearorganizationalresponsibilitiesInmanyinstancesparticularly atalocaloperationallevelsuchpreparationhasnotoccurredConsequently confusionoverwhohasresponsibilityforspecificactionswilloccurincreasingthe potentialforredundanteffortsorgapsindecision-making
2AlterationsinStandardsofCare
Alteringthestandardsofmedicalcareprovidedinordertodothegreatestgoodfor thecommunityisaconceptandpracticethatisfraughtwithethicalsocietaland legalissuesmakingitdifficulttosurmount
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
3Education
Disasterpreparednessandresponseeducationisnotincludedinmostmedical ornursingschoolcurriculaandwiththeexceptionofemergencymedicine preparednessandresponseisnotarequirementinresidencytrainingprograms Thusmosthealthcareprovidersarenotpreparedtohandleclinicalcareduringa disasterAsstandardcurriculumemergencymedicaltechnician(EMT)paramedics arerequiredtocompleteamoduleonldquomedicalincidentcommandrdquoYetEMTshyIntermediatesandEMT-BasicsdonotalwaysreceivethisessentialtrainingAwellshylinkededucationalprocessforthoseinvolvedinmasscasualtydisasterpreparation andresponseisnotyetavailable
4Communications
Effectiveandtimelycommunicationsareessentialtofunctionalcommandand controladmittedlycommunicationfailure(prehospitalhospitalandpublic)isa recurrentthemeduringandimmediatelyafteradisaster
5Transportation
Coordinatedtransportationserviceisvitalandoftentimelyandeffectiveuse ofmutualaidtransportunitstotransportortransferpatientstotertiarycareis challengingAdditionallythereiscurrentlynocomprehensiveplanfordisaster responsewhicheffectivelyintegratescivilianwithmilitarymedicaltransport resources
6InfrastructureandCapacity
Communitiesdifferintheircapabilitiesandinfrastructuretohandledisastersinthe prehospitalandhospitalarenasRegardlessofacommunityrsquoscapabilitiesandthelevel ofcoordinationbetweenresourcesthoseinjuredfromanexplosionwillrapidlyseek carefromorwillbetransportedtothenearesthospital28andmaynotseekcareatthe facilitiesdesignatedbyexistingresponseplansThusallcommunitiesneedplansthat havebeensuccessfullyandrepeatedlydrilledAdditionallyfacilitiesvaryincapabilities andstaffingAnyfacilitywhetheritofferstertiary(iespecialty)careorcommunity ruraloralternatecarewillundoubtedlyfaceproblemsinseveralareas
bull Personnel
Shortagesofqualifiedpersonnelincludingnursesandspecializedtechnicians existthroughoutourhealthcaresystemDuringamasscasualtyeventthese shortagescouldmanifesttocatastrophiclevelsSomestaffmaynotrespond duringabombingorotherdisastereventforvariousreasonsincludingfear forpersonalsafetyfamilyissuesorinjuryEstimatingavailablestaffmaybe difficultbecausemanyworkatmultiplefacilitiesConverselythescreening managingandcredentialingofwell-intentionedvolunteersduringadisaster canbechallengingifnotimpossible
bull Equipment and supplies
Shortagesofessentialequipmentandsuppliesoftenoccurintheaftermathof alarge-scaleterroristbombingornaturaldisasterMoreovermostfacilitiesin agivenregionusethesamesuppliersforback-upstockandequipment(eg pharmaceuticalsgeneralmedicalsuppliesventilators)
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Information technology (data managementdata systems)
OftentimessoftwaresystemsinvolvingEMSserviceshospitalsandhealth departmentsareincompatibleTomaximizepatientoutcomesandallow familymemberstoquicklylocatelovedonesadatamanagementsystemmust havetheabilitytotrackpatientsfromthescenetothehospitaltrackpatients throughoutthefacilityandtracktransferstootherfacilities
bull Cost
Preparationandincidentmitigationrequiresacommitmentofresources Trainingprehospitalprovidersstockpilingkeyequipmentsuchasstretchers andreservingcapacityinthebloodsupplywillbeexpensive
bull Interoperability
Aneffectivemedicalresponsetoaterroristbombingdemandsthatthe responsesystemcomponents(personnelorganizationsandcommand structures)areinteroperableYetservicesagenciesandsystemsare notintegratedformaximumefficiency(ieequipmentpreparation communicationsandincidentcommandbothprehospitalandhospital)
7PotentialBottlenecks
Despitetheimpactoftheseeventsonmultipleareasofclinicalcaretherearesome areaswhoseresponseandcapabilitymayimpactpatientsacrossthespectrumofcare
bull Radiology
Giventhenatureofinjuriesrelatedtoterroristbombingsthemostvictims willundergomultipleradiologystudiesInMadrid50radiologystudies andinterventionswereperformedthedayofthebombing14Thenumbers ofpatientsrequiringstudiesmayleadtoabottleneckandhinderthe institutionrsquosabilitytostreamlinecareHowevertodateprofessional radiologysocietieshavenotfocusedonsurgecapacityforbombingvictims andthepotentialforradiologytobecomeabottleneckInsteadtheyhave focusedexclusivelyondetectionandtreatmentofradiationemergenciesand disasters
bull Critical Care
IfaterroristbombingincreasesthedemandforcriticalcareICUservices whichinturnexceedsreserveICUcapacityhospitalswouldhavelimited abilitytodivertortransferpatientstootherhospitalsandwillneedaplanin placetoprovideemergencymasscriticalcare
bull Pharmacy
Ensuringanadequatesupplyofrequiredpharmaceuticalsthroughoutthe institutionandcommunityisessentialandmayprovechallengingThismay becomplicatedbythefactasnotedabovethatmanyfacilitiesinagiven regionusethesamesuppliersforback-upstockandsupply
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
8Triage
Ourcurrentplanningandpreparednessactivitiesassumethatprehospitalproviders willbedispatchedincoordinatedfashionwillarriveonthescenetotriagepatients andwilltransportthemtotheappropriatefacilitiestherebypreventingany componentofthesystemfrombeingoverwhelmedInmanydisastershowever mostvictimsself-transportoraretransportedbyotherlaypersonsVictimsdonot waitforanorganizedfieldtriagesystemtocomeintoeffectconsequentlythe systemorfacilitiesareoverwhelmed28
9LegalIssues
Multiplelegalissuesimpacttheresponsetoaterroristbombingorothermajor disasterandmayimpacteffectivecoordinatedmedicalcarethatoptimallyutilizes allofacommunityrsquosresourcesExamplesincludecredentialingofprovidersaltered standardsofcarestandardsforclinicaldocumentationtheEmergencyMedical TreatmentandActiveLaborAct(EMTALA)theHealthInsurancePortabilityand AccountabilityAct(HIPAA)orClinicalLaboratoryImprovementAmendments(CLIA)
Discipline-specificChallenges
Eachoftheaforementionedproblemshasanimpactonthespectrumofcarehowever uniqueexamplesexistformanydisciplinesTheexpertpanelalsoidentifiedthefollowing discipline-specificchallengesandprovidedfeasibleandaffordablestrategiesforeffectively addressingsurgecapacity(Theproposedsolutionsareprovidedinatemplateformatat theendofthisdocument)
1EmergencyMedicalServiceResponse
AsinitialrespondersEMSprovidersandpersonnelmustconfrontseveralissues including
bull Personal protection
Currentlythereisnounifiedapproachtoprotectrescuersorstagea responseWhendoappropriateconcernsforscenesafetyandthepotential forsecondaryexplosivedeviceshindertheinitialresponse
bull Decontamination
Thoughtreatmentwillbedelayeddecontaminationmaybeimperative Uniformpoliciesandprotocolsfordecontaminationofpersonnelandpatients needtobeestablishedforallscenarios(egweatherbombing)
bull Incident command
Interoperabilitybetweenprehospitalandhospitalcommandstructuresisa challengeThischallengemanifestsnotonlyinthetechnicalaspectsofradio interoperabilitybutalsointheinterdisciplinaryaspectsofcommunications plansAunifiedincidentcommandstructuremustbeincorporatedintohealth careandEMSpracticefurtherEMSmustbedesignatedaspartofthefield responsecommandstructure
10 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Field triage
Althoughmultipletriagesystemsareusedacrossthecountrythereisno agreed-uponmethodologyforfieldtriageduringadisaster
bull Destination decisions
Determiningtheappropriatedestinationintheaftermathofaneventmaybe difficultespeciallyiftheinitialsceneldquosize-uprdquohasnotbeenperformed
bull Hospital evacuations
WheneverEMStransferspatientsfromhospitalstofreeupacutecarebeds normalhospitalfunctionsareadverselyaffected
bull Sustainability of operations
Providingpersonnelwithneededsupport(egphysicalemotional)and maintainingfacilitiesequipmentandsuppliesintheaftermathofaneventis anongoingchallenge
2EmergencyDepartmentResponse
Theemergencydepartment(ED)isacentralportaltoanyhospitalassuchthe EDiswhereinitialinformationaboutadisasteriscommunicatedThechallengeis todeterminethemagnitudeoftheeventandinitiatetheappropriateinstitutional responseThisresponsemustbeinconcertwiththeassessedmagnitudeincluding decisionstodeclareaninstitutionaldisastertodeclareaninstitutionallock-down andtodetermineifrecipientvictimdecontaminationisneededTodetermine theextentoftheresponsethequalityandquantityofinformationfromthefield andbetweentheregionalemergencyoperationscenterandhospitaliscritical Frequentlyinformationchallengesandcommunicationsareasourceoffailure
Inalarge-scaleeventeachhospitalmusthavethecapabilitytoincreasestaffing rapidlyassessitsavailablebedstatusandmakeoccupiedbedsavailablemdashespecially intheEDoperatingtheatresandcriticalcareunitsTofreeupbedshospitals shouldcancelelectivesurgeriesandadmissionsopentraditionallynon-patient hospitalareasforpatientcare(egclassroomsofficesetc)andbeginearly dischargeforinpatientsasappropriate
Duringamasscasualtyeventtransferofpatientstoanalternativecaresitemaybe delayedduetothetimepersonnelandequipmentneededtosetupthatsiteHowever developmentofanalternativesitewillovertimefreeupnon-criticalcarebeds
Keyissuesfollow
bull Ascertaining the validity and scope of the eventNotificationisessentialto activateandimplementanappropriateresponseinformationupdatesmust beconsistentandfrequent
bull Incident commandAHospitalIncidentCommandSystem(HICS)mustbe implementedwithintheEDhospitalandcommunityHICSisawidelyused emergencymanagementsystemknownforprovidingachainofcommand thatcanmobilizeatamomentsnoticeprovideaccountabilityofposition functionsallowflexibleresponsestoemergenciesimprovedocumentation
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 11
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
offacilityactionsprovideacommonlanguagetofacilitateoutsideassistance anddevelopprioritizedresponsechecklistsforseniorleadershipEach hospitalshouldbepartofaregionalunifiedcommandstructure
bull Discharging patients from the EDTofreeupresourcespatientsshouldbe dischargedortransferredtootherareasforcare
3SurgicalandIntensiveCareUnitResponse
Multiplefactorsaffecttraumasurgeryanditspreparednessandresponsetoa bombingeventornaturaldisaster
bull Changes in surgical practice
Therecentincreasedinterestindisasterresponsecapabilitiesisincontrastto thegeneralsurgerycommunityrsquosdecreasedinterestinmanagingemergency surgeryThustheknowledgebaseandskillsettomanageaMadrid-type scenarioisbeingconcentratedatfewerhospitalsManyhospitalswiththe capacitytohandlesurgeasitrelatestobedsandstaffinghavelittletechnical capabilitytomanageasurgeofpatientsfromabombing
bull Time of day
AsintheMadridbombingsthetimeoftheeventiscriticalfortraumacenters andcommunityhospitalsHoweverdisasterplanningoftendoesnotconsider timeofdayAt0200hoursforexampleacommunityhospitalmaynothave operatingtheatrecapability
bull Limited ICU beds
Overcrowdingmayrequiredecisionstodelaysurgeriesidentifybedsinother areasofthehospitalandortransferpatientstoanotherfacility
bull Loss of excess capacityCapacity on a given day
TheUShealthcaresystemhassystematicallyanddeliberatelyeliminated capacitybecauseunusedcapacityisanadditionalexpense
bull Education
Moresurgeonsespeciallythoseintraumacentersneedfurthereducationon theplanningandresponseprocessTheUSmilitaryinIraqhassuccessfully demonstratedconceptsinsurgicalsurgecapacitymanagementthatshould betranslatedimmediatelytocivilianmedicineFurtherIraqrsquosexperience withdamage-control(emergency)surgeryhasshownthatmorepatientsrsquolives canbesavedthroughtemporizingdamage-controlsurgerythanifpatients receivedtime-consumingdefinitivesurgery
AdditionallyafteraterroristattackcriticalcareandICUserviceswillbeneeded totreattheseriouslyillorinjuredcasualtiesTheemergencymasscriticalcare planshouldaddresshemodynamicresuscitationandsupportusingintravenous fluidsandvasopressorsadministrationofantibioticandotherdisease-specific countermeasuresprophylacticinterventionstoreduceadverseconsequencesof criticalillnessandbasicmodesofmechanicalventilationandshouldinclude
12 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
1 Interventionsthatimprovesurvivalwithoutwhichdeathislikely
2 Interventionsthatdonotrequireextraordinarilyexpensiveequipmentand
Interventionsthatdonotconsumeextensivestafforhospitalresources
Ifventilatorsareunavailabletotreatallpatientsinneedminimallyskilledindividuals coulduseanendotrachealtubetomanuallyventilatethepatientCriticalcareareas shouldbeequippedtomeasureataminimumoxygensaturationtemperature bloodpressureandurineoutputWhencriticalcareICUsarefullhospitalscan createadditionalcapacityinnon-ICUroomsconcentratedonspecificwardsor floorsPatientcareareasthatalreadycontainequipmentsimilartoICUrsquos(endoscopy andsurgicalsuites)aregoodalternativesbuttheseadhoccriticalcareareaswill increasecapacityonlyslightlyandrequirecessationofservicesnormallyprovided
Whenahospitalcannotmeetincreaseddemandforcriticalcareservicesusing itsexistingcriticalcarepractitionersatwo-tieredstaffingmodelcomprising noncriticalcarephysiciansandnursesmaybesubstitutedMembersoftheWorking GrouponEmergencyMassCriticalCare(CenterforBioterrorismattheUniversity ofPittsburgh)andtheSocietyofCriticalCareMedicineconcludedthatacritical carephysiciancansuperviseuptofournoncriticalcarephysicianswhocaneach manageuptosixcritically-illpatientsTheyalsoconcludedthatacriticalcarenurse couldsuperviseuptothreenoncriticalcarenurseswitheachcaringforuptotwo patientsInthismodelahospitalrsquoscriticalcarestaffismultipliedtowhereone criticalcarephysiciancouldoverseethecareofupto24critically-illpatientsand onecriticalcarenursecouldoverseethecareofuptosixcritically-illpatients29
AdditionallymanyofournationrsquosleadingchildrenrsquoshospitalswithlargePediatric IntensiveCareUnits(PICUs)operateatmaximumcapacityIfamasscasualty involvingchildrenandinfantsweretooccurthePICUsrsquoresponseandabilityto provideintensivecarewouldbeseverelyconstrained
Theemotionalissuessurroundingthecareforadyingordeadchildcompounds thisissueasparamedicsphysiciansandothersgenerallydonotwanttopronounce childrendeadatthesceneThustheywilltransportachildwhohasbeenpulseless andapneicforanhourandstillhopelesslyreceivingCPRtotheEDandultimately tothePICUwherethechildwillbedeclareddeceasedSuchconsiderationsaffect fieldtriageandcareinamasscasualtysituationFinallyPICUshaveachronic shortageoftrainedavailableandexperiencedstaff
4RadiologyResponse
Whereasinmanyareas(ICUbedsoperatingroomsventilatorsetc)theUnited Stateshasdiminishedcapacityithasinfactaslightsurplusofcapacityin radiologywhichwouldbebeneficialinmanagingmultiplebombingvictims
AdministratorshavelearnedthathospitalslosemoneywhenpatientswaitinanED orhospitalduetoinsufficientradiologycapacityForthisreasonhospitalshave investedinimagingtechnologiessuchascomputedtomography(CT)magnetic resonanceimaging(MRI)ultrasoundanddigitalimagingRadiologycapacityhas increasedandimprovedtechnologiesarenowwidelyusedStillrelativelyfew
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
UShospitalcentersandhealthcaresystemshaveenoughcapacityandabilityto maintainsufficientstaffinglevelstoeffectivelyusethisequipmentEachhospital differsinitscapabilitiesequipmentandpersonnel(techniciansandradiologists) Additionalproblemsmayincludepreservingradiologyforthemostappropriate criticalpatientsensuringimmediateaccesstobackupcomponentsofcritical equipmentandinteractingwithvendortechnicians
5BloodBankResponse
Inthelast0yearstheUnitedStateshasexperiencedonlyfivedisastersinwhich morethan100unitsofbloodwereusedIfalarge-scaleterroristbombingtook placelargeamountsofbloodwouldbeneededonlyifmanyvictimswereseriously injured
Thebloodbankingcommunityhasformedaninterorganizationaltaskforceto addressbloodneedsintheeventofadisasterTheAABB(formerlyknownasthe AmericanAssociationofBloodBanks)InterorganizationalTaskForceonDomestic DisastersandActsofTerrorism(AABBInterorganizationalTaskForce)unites nationalbloodorganizationsrepresentingvirtuallyallthenationrsquosbloodcenters (AABBAmericarsquosBloodCentersandAmericanRedCross)andhospitalandsupplier associationswithliaisonsfromtheDepartmentofHealthandHumanServicesFood andDrugAdministrationCDCandArmedServicesBloodProgramtocoordinate effortsinpreparationforandresponsetodisastersaffectingthebloodsupply Potentialissueswithournationrsquosbloodsupplyfollow
bull Disruption of the blood supply system
Lackofbloodwillprobablynotbeaproblembutdisruptionorinterference ofthebloodsupplysystemcouldwreakhavocDuringtimesofdisaster includingterroristattacksAmericanswillsearchforwaystohelpPotential donorswilldescendonhospitalsandbloodcentersandquicklyoverburden thesystemBloodcollectionprocessingandtestingarehighlyregulated proceduresinatechnicalsystemthatrequirestrainedstaffOnSeptember11 2001NewYorkandNewJerseyused224unitsofbloodwhileWashington andVirginiaused4mdashtotaling258unitsallofwhichwereontheshelfbefore thedisasteroccurred0Acrossthenationmorethanahalfmillionpotential donorrsquosvolunteeredblood
IntheeventofadisastertheAABBInterorganizationalTaskForcewillinform theAmericanpublicifblooddonationsareneededandtellthemhowandwhere todonateInmostinstancestheappropriatemessageisthatadditionalbloodis notneededimmediatelyafterthedisasterbutthatindividualsshouldcontact theirlocalbloodcenterstoscheduleadonationintheupcomingweeks
bull Transportation of blood
Evenwhenbloodproductsarenotshelvedatthesurgecapacitysitethe productscanbeavailableinhoursInfactbloodcanbetransportedtoa disasterlocationfasterthandonationscanbeprocessedTherearesome issueswithtransportingbloodforexampleauthorizationmayberequiredto transportbloodaroundthestateorcountryInadditionbloodcentersmay
14 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
havedifficultyobtainingdieselandunleadedfueltopowergeneratorsorto operatestaffvehiclesthattransportbloodFederalstateandlocalemergency preparednessofficesneedtomakebloodproductsapriorityforobtaining transportationandfuel
bull Local organization
Inadisasterbloodneedstobeplacedexactlywhereitisneededmdashatthe hospitalsservingthelargeinfluxofpatientsFewhospitalsregularlycollect bloodfewerstillarecapableofhandlinganinfluxofdonorswhilecaring fordisasterpatientsInsomemetropolitanareashospitalsmaybeserved almostentirelybyonebloodcenterinotherareashospitalsmightgetblood regularlyfromseveralsourcesPlannedandcoordinatedeffortsareneeded duringadisastertoknowwhichbloodcenterswillservicethehospitalsat surgecapacityWithinanhourofadisastertheAABBInterorganizational TaskForcewillconveneaconferencecallofnationalbloodorganizations HHSandlocalaffectedbloodcenterstodeterminelocalneedsforbloodand actionsnecessarytomeetthoseneedsTheTaskForcewillmeetagainhours ordayslatertocoordinatesubsequentblood-relatedefforts
bull Staff who can administer blood
Mosthospitalsaimforathree-daysupplyofbloodIfbloodisnotstoredat thehospitaltypicallythebloodcanbereadilyaccessedForahospitalto consumeathree-daybloodsupplyinthreehoursishighlyunlikelyInstead thehospitalmayhavetoofewtrainedstafftoadministerbloodSeveral documentsareavailabletoassistbloodcentershospitalbloodbanksand transfusionservicesprepareforandrespondtodisastersandactsofterrorism thatcouldaffectthebloodsupply1-
6HospitalistsrsquoReponse
Bytheendofthisdecadetherewillbemorehospitalists(physiciansorinternists caringforhospitalpatients)thanothermedicalsubspecialtiescurrentlyhalfthe hospitalswith200ormorebedsemployhospitalistsAlthoughtheymaynotbe directlyinvolvedinthecareofcasualtiesfromaterroristeventhospitalistswillbe vitalinrapidlydischarginginpatientsacceptingtransfersfromICUsandfreeingbed spaceforvictims
7AdministrationResponse
Whenaninstitutionisstressedclinicallyitwillalsobestressedadministratively Hospitalsfaceformidablechallengesinthepost-911eraShrinkingrevenuemargins putpressureonbudgetsandcomplicateinvestmentdecisionstopurchaseitemsfor contingencyoperationsUnlikenationswithpubliclyfundedhealthsystemsthe UShealthcareindustrymustsupportitscontingencyinvestmentneedsbypooling amixofprivatefundingwithlocalstateandfederalresourcesAsaresultevery hospitalhassomecapabilitybuttheclinicalandadministrativecapabilitiesofeach varywidely
TheUnitedStateshas4919communityhospitalsofwhich221aremajorteaching hospitalsThemajorteachinghospitalsarecomponentsofacademicmedical
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 15
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
centersoftenincludeaLevel1traumacenterandmaycoordinatelocalEMS transportThese221hospitalsarethefocalpointsofgraduatemedicaleducation technologyandtertiaryservicesShouldanincidentoccurthesehospitalswill beexpectedtoservethelocalcommunitythrougheitherdirectclinicalcareor systemcoordinationMaintainingthesehospitalsinthefaceoffallingrevenue marginsstrainstheabilityofanyorganizationtosupportinfrastructureforldquoresponse capabilityrdquo
TherestofthehospitalindustryissimilarlystressedTotalstaffedbedsintheUnited Stateshavedroppedtojustbelow956000Outsourcingoutpatientservicesand procedurestonon-hospitalsettingsfurtherreducesrevenueLessmoneymeansless opportunitytoinvestinhospitalinfrastructurewhichgraduallyerodessophisticated diagnosticservicesinhospitalsandcomplicatesournationrsquoshealthcareindustry fromrespondingintraditionalwaysletaloneunderextraordinarycircumstances
Withineachcommunityleadershipfromthehealthcareindustryisakeyelementin aneffectiveresponseHospitalexecutivesrecognizethatmajoreventswillactivate politicalandlawenforcementleadershipandthattheymustbeproactiveandform professionalandcollegialcontactswithcommunityleadersSimilarlyhospitalsmust belinkedtoprovidemutualaidandassistpatienttransfersBusinessesfunctionon increasinglynarrowinventorylevelsandhospitalsinthesamecommunityusually relyonthesamesuppliersInacrisissupplierswillresorttorationinginventory Regionalandmultistatemutualaidplansshouldbedevelopedbutincatastrophic eventshelpfromthoseoutsidetheaffectedzonemaytakedaystoarrive underscoringtheneedtoidentifyresourcestosupportthreedaysofoperations beforereorderingsupplies
HospitalresponsestomasscasualtyeventsareoftenchaoticInpartthisisdue tolackoftrainingandexperiencebutthedisorganizedresponseiscompounded bynothavinganappropriatecommandstructuresuchastheHICSUseofan appropriateincidentcommandsystemdoesnotguaranteeasuccessfulresponse butwithoutonefailureisalmostcertainHospitalpersonnelneedtounderstand theconceptofregionalunifiedcommandandbewillingtoparticipateappropriately duringadisaster
Whenasituationdemandsswiftactionhospitaladministratorshavetofocuson manyareassimultaneouslyUsingastep-by-stepapproachadministratorscan bringsomeordertochaosandinfactimproveresponsetimesandsavelives Administratorsshouldfocusonthecriticalareaslistedbelow
bull Control of the external environment
Theexternalenvironmentwillchangerapidlyduringalargeevent Maintainingcontrolofhospitalgrounds(egfacilitysecurityandtraffic)is essentialClearingbedstoaccommodateincomingcasualtiesredirecting nonemergencypatientstootherresourcesandmanagingoverallcomings andgoingsofstaffwillrequireeffectivecontroloftheexternalenvironment includingmediacontrol
16 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Implementation of Hospital Incident Command System
Inafast-paceddisasterliketheMadridbombingsitisofcrucialimportanceto haveidentifiedtheappropriatedecision-makersbeforehandfortheHICSIna crisisthereislittletimeformeetingsordiscussionabouttheappropriateuse ofsupportfunctionsandpersonnel
bull Personnel Issues
Thereshouldbeabalancebetweentheindividualneedsofstaffandthe organizationasawholetoassureadequatecoverageforshort-andlong-term medicalresponsesDecisionsmustbemadeearlyaboutwhenstaffcango hometocheckonfamilymembersorwhattodoifstaffersleaveinthemiddle oftheresponseAmethodtorequestadditionalstaffonshortnoticecoupled withdefininganindividualinstitutionrsquossurgecapacitycanassistinfinding therightmixofclinicalandnonclinicalsupporttohandletheincreased workload
bull Memorandums of Understanding or Agreement
Prescriptedagreementstosharesuppliespersonnelorequipmentshould bewrittenanddrilledtosupportlocalregionalandstatepartnersintimeof need
bull Logistics and supplies
Coordinationwithkeysuppliersandmaintenanceofinventoriesthroughout thehealthsystemwillmakerampingupthelevelofefforteasierDepending ontheeventsomeareas(ieobstetricsoutpatientsurgeryandvariousclinics) maynotbedirectlyaffectedandcouldprovidesuppliesEffectivelogistics managementwouldalsoincludepatienttransportationtoandfromappropriate caresettingsAlthoughthehousingofevacueesisamunicipalfunction knowingthelocationsofdesignatedRedCrosssheltersthroughoutthevicinity andtransportationresourcesforlow-acuitypatientsandtheirfamilymembers willhastendischargeplanningandimprovepatientflowintheED
bull Alternate care sites
Ahospitalismosteffectivewhenitcanmobilizequicklyandexpandcareto thecityrsquoswalkingwoundedTriagesystemsaretypicallyusedtoprioritize patientssothatlow-prioritypatientscanbedirectedfromthemainhospital thusallowingambulancesandhospitalstafftofocusonhigh-prioritypatients (ieburnsdehydrationmultipleinjuries)Alternatesitesmayallow largehealthsystemstofacilitatetriageanddirectpatientsandfamiliesto appropriatesourcesofcare
bull Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations (JCAHO)emergencycredentialingsystemdoesworkbutitmustbetested withinanorganizationbeforeitisneededStateEmergencySystemsfor AdvanceRegistrationofVolunteerHealthProfessionals(ESARndashVHP)reflect JCAHOrequirementsandprovideastandardizedsetofverifiedcredentialsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 17
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
volunteerswhomaybecalledtoassisthospitalsduringemergencysituations Manyaspectsofstaffcredentialingandprivilegingcanbestreamlinedbut theformalenrollmentcannotbecircumventedInmosthospitalsformal enrollmentprovidesaccesstoenteringordersprescribingmodalities writingprescriptionsorderinglaboratorytestsanddocumentingcareusing automatedsystemsNomatterwhethercredentialingishandledbyhuman resourcesoraprofessionalstaffingofficethedesignofthesystemshould supporttheuseofvolunteersinnonclinicalactivities
bull Patient tracking
Trackingpatientmovementisacriticalfunctionduringanymasscasualty situationSuccessfultrackingbeginsatthepointapatiententersthehealth caresystemWhenmoretimeisspentidentifyingandtrackingpatientsthe prospectofreimbursementforrelatedcostsisbetterTheabilitytotrack patientsidentifytheirsupplyconsumptionandmonitorbeduseenables seniormanagementtoproactivelymeettheneedsofhealthcareproviderson thefrontlineManypatienttrackingsystemsexistandifatallpossiblethe systemshouldallowautomatedtrackingforexercisesandrealdisasters
ThislistisnotallencompassingforeveryfacilityThestaffofanyhealthcare organizationshouldperiodicallyevaluateareaslikeplantmanagementsocialwork resourcessafetymaterialsmanagementbiomedicalequipmentandrepairservice procurementandpatientadmittancetohelppreparefortheunexpectedOften disasterpreparednessisfocusedsolelyonthetransferofcarebetweenproviderand patientandnotontheinfrastructuretosupporttheeffort
18 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Surge Capacity Solutions AddressingSystem-wideChallenges
HowdoweaddressacuteeventsthatstressouroverburdenedsystemApparentlywe mustprepareforthepredictablesurprisemdashabombingmdashwhichisthemostcommonform ofterroristattackTheUnitedStateshasabasicfunctionalcapabilitytorespondtothe surgeofpatientsfollowingaterroristeventsuchasabombinghoweverseveralcritical areasmustbeaddressedforeffectivesurgecapacitytooccurToaddressthesystemshyspecificchallengesrelatedtosurgecapacitythatarehighlightedabovetheexpertpanel outlinedthefollowingrecommendationsforeachchallenge
1OrganizationandLeadership
Leadershipisimportantforsuccessfulpreparednessandresponseatalllevelsmdashfield hospitalcitystateandfederalmdashanditismandatoryintheplanningandresponse phases
2AlterationsinStandardsofCare
CulturallytheUnitedStatesmayneedtoreviseitsstanceonhealthcareInsteadof doingthegreatestgoodfortheindividualwemayneedtodothegreatestgood forthecommunity(iesavethemostvictims)Thereishowevernouniversally acceptedmethodologyofdoingthisandtheprocessisfraughtwithethical societalmedicalandlegalissuesAprotocolisneededtodeterminewhenand howtodeviatefromthenormwithoutthecivilianhealthcareproviderorfacility experiencingrepercussionsAnalteredprotocolwouldimprovetheciviliansectorrsquos abilitytomanagepatientassessmenttreatmentflowandoutcomesforthegreatest numberofpatientsItisclearthatchangingstandardsofcarewillrequireeffortsto preservequalityofcareaformalprocessineachcommunitytodeterminewhen andhowtotransitionfromstandardoperatingprocedurestoanalteredstandardof careanddeterminingwhowillhavetheauthoritytoorderthetransitionInAugust 2004theAgencyforHealthcareResearchandQualityUSDepartmentofHealth andHumanServices(HHS)convenedapanelofexpertstoexaminethecomplex issuessurroundingalterationsinclinicalcareTheirfindingsarepublishedinthe monographAltered Standards of Care in Mass Casualty Events4
Therationaleforsuspendingstandardsofcareinanemergencyisthatmorepatients willsurviveaterroristattackifkeyinterventionsareprovidedtothegreatest numbersofcasualtieslikelytobenefitfromreceivingcareHospitalsandEMS systemsatsurgecapacitywillrequireautonomytosuspendregularstandardsofcare andshifttoemergencycriticalcarepractices
bull Althoughcarecanbealteredattheinstitutionallevelifallhospitalsaffected byacrisisswitchtoemergencycriticalcarepracticestandardsatthesame timemorepatientswillreceiveeffectivecare
bull Theethicalpoliticallegalregulatoryandlogisticalimplicationsof suspendingstandardsofcareandtriagingpatientstolimitedresourceswill requiretheparticipationofstateandfederalgovernmentLegislationwill berequiredtosuspendstandardsofmedicalpracticeduringanemergency withoutpractitionersandhospitalsincurringlegalliability
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 19
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Amechanismisneededtoaddressissuesassociatedwithchangefromroutine toaltered(emergency)standardsofcaresufficiencyofcare
bull Communityeducationbeforeduringandafteraneventisnecessaryfor acceptanceandunderstanding
3Education
Educationaleffortsmustincludeanall-hazardsapproachthataddressesthemost likelypredictableterroristeventabombingTheeducationgiventocareproviders shouldreflectthepotentialseverityoftheeventTrainingmustbestandardized acrossalllevelsofproviderssothatthereisconsistencyamongthedisciplines Trainingshouldaddressclinicalcareandsystemsissues
4Communications
Communicationplansshouldincludeinteroperableredundantregionalemergency communicationssystemsideallywithmulti-frequencybandsandtrunkedsystems withthecapabilitytopoolusergroups(forexampleamonghospitals)viatheincident commandstructureIfacatastrophicincidentresultsinmassivepowerfailure emergencybackupsystemssuchasmobilesatellitetelephoneswillbeneededalong withotherconventionalmethodsofcommunicationCommunicationplansalso shouldaddresscommandandcontrolstructuresanddisastercrisiscounseling
Informaticsanddatasystemslinkinformationforreal-timeimpact(iewhich hospitalshavebedswherepatientscanbedivertedhowtofindlovedonesand howtoaccesssurvivaldata)Withoutpatienttrackingandinformaticsnoonewill beabletoevaluatewhatworksandwhatdoesnotworkinagivensituation
5Transportation
Themilitaryisprobablytheonlygroupwiththecapabilitytotransportpatientson alargescalehowevernotonshortorderasitmaytakehourstoarrangeasingle transferRegionalstatewideandnationalplansandagreementsshouldaddress therolesofNationalGuardandactive-dutymilitarypersonnelforprovidinglargeshyscaleairmedicalresourcesonrelativelyshortnoticeTheremayalsobeaneedto integrateprivateandpublictransportationresourceswithmilitaryresources
6InfrastructureandCapacity
Giventhewidevariabilitythatexistsnationwidebasicstrategiesandsolutionsmust bedevelopedtoenableourhospitalandmedicalsysteminfrastructurestorespond moreeffectivelytomasscasualtyevents
StaffingissuesmustbeaddressedinadvancePlansshouldaddressmulti-facility credentialinginterstatelicensingagreementsandpotentialuseofvolunteersThe HealthResourcesandServicesAdministration(HRSA)isdevelopingguidelinesand standardstoverifythecredentialsofhealthcareprofessionalsWhencompleted theEmergencySystemforAdvanceRegistrationofVolunteerHealthProfessionals (ESAR-VHP)programwillhaveestablishedanetworkofstate-ownedandoperated systemscapableofregisteringandverifyingthecredentialsofhealthcarevolunteers beforeanemergencyThevalueofregistrieswasdemonstratedintheaftermathof HurricanesKatrinaandRitawhen21statessentmorethan800pre-credentialed (documented)volunteerhealthprofessionalstoaffectedareas
20 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
7PotentialBottlenecks
bull Radiology
Perhapsaminimalistapproachtousingradiologymakessensemdashidentifying andstandardizingabaselinethatcouldbeusedinmanyfacilitiesBy identifyingandaddressingcriticallifethreatsandmajorproblemsthrough ldquotieredrdquoreportsmdashinitialldquowetrdquointerpretationsthataremadeandleftwithon thepatientandactedonwhenresourcesbecomeavailableandfinalreports andinterpretationsarecompletedndashbothpatientflowandcaremaybegreatly improved
bull Critical Care
Plansmustbeinplacetoprovideforemergencymasscriticalcareincluding basicmodesofmechanicalventilationhemodynamicresuscitationand supportusingintravenousfluidsandvasopressorsadministrationof antibioticsandotherdisease-specificcountermeasuresandprophylactic interventionstoreduceadverseconsequencesofcriticalillnessIfanevent exceedsalocalityrsquoscriticalcareICUcapacityhospitalsmustbeableto activateemergencymasscriticalcarepracticessuspendingusualstandardsof careanddefiningpatientsandinterventionsofhighestpriority
bull Pharmacy
Pharmaciesmustbepreparedandtheroleofpharmaceuticalsystemsinthe overallresponsefallsintotwoareas
bull Selectionoftheproperpharmaceuticalsforstockpilingand
bull ProperstockpilingofldquoCHEMPACKSrdquo
8Triage
Preparednessandresponseplansmustrecognizedthattherearenoevidenceshybasedstandardsformasscasualtyeventsincludingthosethatresultfromterrorist bombingsandthatfieldtriageoftendoesnotoccurforthemajorityofinjured victimsResponseplansmustaccountfortheselfreferralofpatientstonearby hospitalsandtheimpactthisphenomenamayhaveonthecareofthecritically injured
9LegalIssues
IssuesrelatedtoEMTALAHIPAAandprovidercredentialingmustbeaddressedon bothanationalandlocalleveltoensurethattheemergencymedicalsystemand individualproviderscanrespondinatimelyandeffectivemanner
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 21
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
AddressingDiscipline-specificChallenges
Ournationrsquoshealthcaresystemhasachronicproblemwithmanagingsurgecapacity Providersandadministratorsstruggledailytoprovidethefullspectrumofinjurycarefor victimsoftraumaplacingourpreparednessforterrorisminaprecariousposition
Thissectioncontainsninetemplatesdevelopedbytheexpertpaneltohelpvarious disciplinesaddressissuesofsurgecapacityThoughdevelopedinthecontextofasurge ofinjuriesfromaterroristbombingtherecommendationsinthissectionmayimprove theresponsetoandmanagementofasurgeofpatientsfromanycauseincluding biologicalchemicalornuclearMostbutnotallofthesedisciplines(egldquoDrugsand PharmaceuticalSuppliesrdquoandldquoNursingCarerdquo)havebeendiscussedinthepreceding sectionsHowevertheseissuesrepresentasignificantconcernforsystemsplannersand thereforetheexpertpanelfelttheymustbeincludedinthesolutionssectionBecause manydisciplineswillbeaffectedsimultaneouslyitisdifficultifnotimpossibletoidentify alongitudinaltimelineForthisreasonthetemplatesarelistedinageneralorderofflow throughthesystem
1 EmergencyMedicalServiceResponse
2 EmergencyDepartmentResponse
SurgicalandIntensiveCareUnitResponse
4 RadiologyResponse
5 BloodBankResponse
6 HospitalistsrsquoResponse
7 AdministrationResponse
8 DrugsandPharmaceuticalSupplies
9 NursingCare
Alongwithprovidinggeneralinformation(iepurposebackgroundgoals)eachtemplate providesbasicandinmostcaseslow-coststrategiesthatcanbeimplementedrapidlyto avoidproblemsassociatedwithmanagingsurgecapacityThetemplatesemphasizethe importanceofpracticingandevaluatingplans
Thetemplatesareintendedasguidesonlyasneedspreferencesandcapabilitiesvary amongcommunitiesFurthermoretemplatesproposesolutionsthatassumecommunities arealreadyactivelyengagedindisasterplanningandpreparednessactivitiesthereforeitis expectedthatasignificantportionofthepersonnelandresourcecostswouldbeabsorbed bytheseongoingactivitiesExactcostsshouldbedeterminedbylocalcommunitiesand institutionstherein
22 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Emergency Medical Service Response
PURPOSE Toprovideguidanceforlocalemergencymedicalservice(EMS)responseandto operationalizeadditionalEMS-relatedresourcesneededinacommunitywithin fourhoursofanexplosionTheseresourcesareintendedtotreat00injured patientsforupto72hours
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL TomobilizetheappropriatenumberandtypeofEMSresourcestoadequately evaluateinjuriesinitiatetriagebegintransporting00injuredpatientsandto establishongoingEMSoperationsforupto72hours
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
REQUIREDRESOURCES 1 Personnelmustbe
bull Appropriatelyequippedandknowledgeableaboutchemicalbiological radiologicalnuclearandexplosives(CBRNE)detectionpersonal protectionanddecontamination
bull Educatedinthecareofblast-relatedinjuriesforadultandpediatricpatients
bull Preparedtoinstitutetriage
bull Preparedtoinstituteandparticipateinunifiedincidentcommand
2 Acommunicationssystemthatisinteroperablewithpublicsafetydisciplines (firelawenforcementEMSandemergencymanagement)andwithreceiving hospitalsandlocalpublichealthofficials
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 2
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Rapidaccesstosufficientambulanceresourcestotransportcriticallyinjuredpatients
4 Rapidaccesstosufficientalternativeresources(egbuses)totransportnoncritical injuredpersons
5 HavethenecessarymaterialandthecapabilitytodetectCBRNEagentstoassistwith decontaminationplans
6 Decontaminationequipmentforambulatoryandnon-ambulatorypatientsequipment shouldberapidlydeployabletotheexplosionsiteasecondarytreatmentsiteora hospital
7 Determineimplementsecondarytriageandtreatmentsiteswithinthecommunity
ASSUMPTIONS 1 EMSsystemsintheUnitedStatesarehighlyvariablewithawiderangeofavailable
resourcesexperienceandfinancing
2 AfunctionalEMSsystemisacriticalcomponentforplanningtheprehospital managementofinjuredbombingvictims
ACTIONSTEPS 1 Education
bull TrainrespondingEMSpersonnelabouthowtotreatprimarysecondarytertiaryand quaternaryblast-relatedinjuriesForguidancegotowwwbtcdcgovmasstrauma explosionsasp
bull TrainEMSpersonnelaboutNationalIncidentManagementSystem(NIMS) complianceIncidentCommandSystem(ICSHomelandSecurityPresidential Directive5)andtheimportanceofcommandstagingtriageandtreatinginitial casualties(regardlessofrankoftheprovider)shouldbeemphasized
bull TrainEMSpersonnelabouttheuseofpersonnelprotectiveequipment(PPE)andthe risksoftransportingpotentiallycontaminatedpatientsTherelativeimportanceof grossvstechnicaldecontaminationshouldbereviewed
bull TrainEMSofficialsinadvancedICS(ICS700orequivalent)
2 Localpolicyandplanning
FireEMSlawenforcementemergencymanagementhospitalsandpublichealth shouldcollaboratetodevelopandcompletewrittenplanswithinsixmonthsaslisted belowWithinoneyearotheragencieslistedintheseplans(includingmutualaid agenciesetc)mustbeincludedinongoingplanningandevaluation
bull Planformobilizing50ambulanceswithin10minutesaftertheblastAtleast75of theseresourcesshouldarriveatstagingareasinthefirsthourwithallarrivinginthe first90minutesThisshouldbeaccomplishedusing9-1-1EMSresourcesmutualaid agreementswithotherEMSprovidersormutualaidagreementswithnonemergency transportproviders
24 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull PlandescribingeachagencyrsquosroleinthecommandstructureThisshould includehowcriticalfunctionsofcommandstagingtriageandtreatmentwillbe accomplishedinthefirst10minutesofaresponsehowadditionalICSelements willbefilledoverthefirsthourandhowtheICSstructurewillbeformallyfilledby officialstrainedinadvancedICS(ICS-700orequivalent)bytheendofthefirsthour
bull Plandescribinghowalternativetransportfor200ambulatorypatientswillbe initiatedinthefirst10minutesafteranexplosion
bull Plandescribingthedetailsofinterdisciplinarycommunications(primaryand alternatives)RepresentativesfromfirepreventionEMSlawenforcement emergencymanagementhospitalsandpublichealthmustbeincludedinthisplan
bull Planfordecontaminatingandprotectingpersonnelthataddressesthefollowing
ndash Agencyresponsibleforsceneassessmentanddeterminingwhat(ifany) decontaminationmeasuresarerequired
ndash Realisticassessmentofthetimerequiredtodeploydecontaminationresourcesfor ambulatoryandnon-ambulatorypatients
ndash Deploymentofdecontaminationresourcestoeventsitesecondarytriagesitesor receivinghospitals
ndash Transportofpatientsaftergrossdecontamination(technicaldecontaminationof patientsbeforetransportappropriatepersonalprotectiveequipmentorPPEand appropriatelyequippeddestinationchoices)
bull Plantoestablishsecondarytriagepointsforambulatorypatients(ideallywithinthe firsthouraftertheexplosion)Thisshouldaddressthefollowing
ndash Howsitescanbeactivatedandstaffedwithatleastonetransportambulance sufficientlawenforcementpersonnelforsecurityandadequatesupportstaffto recordarrivals
ndash Howgrossandtechnicaldecontaminationcouldbeaccomplishedataffectedsite(s)
ndash Howmedicalcareatsecondarytriagesitescouldbeconvertedtotreatmentareas (egprovisionofmedicalsuppliesadditionalmedicalpersonnelandother logisticalconcerns)
bull Plantoestablishcriteriafordeterminationofdeathatthesceneparticularlyina masscasualtysituationandappropriatelymanagethedeceased
EVALUATION 1 Planandconductacommunity-widedrillAfterwardsevaluateitbyassessingoverall
operationsandEMSresourcessuchaspersonnelambulancesandPPEEvaluate compliancewithNIMS
2 Assessandrefineplan
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 25
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Emergency Department Response
PURPOSE Toactivateadditionalemergencydepartmentresourcesneededwithinfourhours ofanexplosionTheseresourcesshouldtreat00injuredpatientsforupto72 hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive Care Unit Response commuter trains in Madrid killing 177 people instantly and injuring more than
Radiology Response 2000 That day 966 patients were taken to 15 public community hospitals More
Blood Bank Response than 270 patients arrived at the closest facility between 0800 and 1030 hours
Hospitalistsrsquo Response
Administration Response Federal resources should not be expected to arrive sooner than 72 hours from the Drugs and Pharmaceutical time of the explosion Resources can be delayed by the time taken to deploy them Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresdidactictraininganddrillstoimprove institutionalpreparednessfortreating00injuredpatientsforupto72hours
RESOURCESREQUIRED Thereshouldbeadequatemedicalnursingandsupportstafftoprovideinitial triageandtoevaluateandstabilize00persons This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Developedpacketsforeachpatientcontainingdisasterbands(thosefrom
bloodbanksworkbest)manualchartingformsandmanuallabandradiology orderformsThesepacketsshouldbepreparedinadvanceandstoredintheED
2 Establishedproceduresforobtainingadditionalpersonnelequipmentsupplies andbedsestablishamechanismfornotifyingandactivatingbackuppersonnel
Establishedproceduresfortriagepatientemergencyidentificationofpatients anddischargeandquickdocumentation
4 Establishedtemporarydisasterlogtodocumentbasicinformation
26 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
ACTIONSTEPS 1 Implementanddrillahospitalemergencyincidentcommandsystem(suchasHospital
IncidentCommandSystemorldquoHICSrdquo)includeclinicalcareprovidersinthetraining anddrill
Ifhospitalpersonnel(egpractitionersadministratorsnurses)havenottrainedor drilledinahospitalincidentcommandsystemlearnedabouttheNationalIncident ManagementSystem(NIMS)ordonotunderstandthefunctionofaHospitalIncident CommandCenterthisinformationshouldbeincludedintrainingsessions
2 Instructclinicalstaffespeciallysurgeonsandemergencyphysiciansabouttheunique aspectsofblast-relatedinjuriesandcarefollowinganattackwitharadiationdispersal device(RDD)
Establishaninstitutionallockdownprocessanddrillonaregularbasisinclude radiationdetectionanddecontaminationofarrivingpatients
4 Updatetheinstitutionalcall-downlistandperformafunctionalcall-downexercise
5 Identifypotentialinstitutionalsurgestaffingfromemployeeswithclinicaltrainingbut notcurrentlytaskedwithclinicaljobs
6 IdentifypatientcaresuppliesforasurgesituationsuchasadditionalIVequipment bandagesdressingsgownsglovesmasksotheroperatingroomsuppliesetc
7 DeveloparegionalUnifiedCommandStructurethatincludeslocalemergency managementandareahospitalsThisshouldbeachievedundertheguidanceand leadershipofthelocalemergencymanagers
8 Identifynon-patientcareareasintheinstitutionthatcouldbeconvertedtopatientcare toexpandbedsurgecapacity
9 Establishanddrillaprocedureforearlypatientdischargetoincreasebedcapacity ThisprocedureshouldincludeevaluationofICUpatientsforpotentialmovementtoa non-ICUbedandevaluationofallpatientsforpotentialearlydischargeortransfertoan alternativecaresite(internalorexternaltotheinstitution)
EVALUATION WhenappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 27
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Surgical and Intensive Care Unit Response
PURPOSE Tomobilizeandassignoperatingroomsandrelatedassetsforlife-andlimb-saving surgicalcaretothemostcriticallyinjuredof00patientsfromexplosions(care extendstopatientsfromthecommunitywithacutesurgicalillnessforupto72 hoursafterabombing)
INJURY PREVENTION
Emergency Medical BACKGROUND Service Response TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor Emergency Department managingrapidsurgeproblemsduringamasscasualtyevent Response
Surgical and Intensive Care Unit Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Radiology Response commuter trains in Madrid killing 177 people instantly and injuring more than Blood Bank Response 2000 That day 966 patients were taken to 15 public community hospitals More Hospitalistsrsquo Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Administration Response
Drugs and Pharmaceutical Supplies Federal resources should not be expected to arrive sooner than 72 hours from the Nursing Care time of the explosion Resources can be delayed by the time taken to deploy them
and by responding to multiple communities
GOAL Withintwohoursofablasteventestablishincidentcommandfortheoperating roomsandsurgicalsupportareasforupto72hours
RESOURCESREQUIRED Resourcesneededforcommunicatingwithintheorganizationandwiththe community(egsatellitephonewalkie-talkie)
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Operatingroom(OR)assetsareacriticalcomponentofsurgecapacityafteran
explosionandmustbemobilizedquickly
2 TheORcapacityofanyinstitutionorcommunity(ienumberofoperating rooms)isfixedbecauseofstructuralrequirements
Oneormoresurgeonsanesthesiologistsandcriticalcarespecialistswillbein thehospitaloravailableimmediatelyafteranevent
28 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
4 Othersurgeonsanesthesiologistsandcriticalcarespecialistscanbeavailablewithin twohoursofaneventtoprovidedirectpatientcareintheORsandrelatedareas
5 TheORspost-anesthesiacareunits(PACU)andintensivecareunitswillalreadybeinuse
6 Casualtiesoftheblastandpatientsalreadyinthehospitalsystemorinothertreatmentcenters inthecommunitywilloccupyoneormoreofthesethreeareaswithinthenext72hours
7 Iftheseareasarenotmadeavailableinatimelymannerpatientswillsuffergreaterharm
8 Somepatientscouldbemovedtodifferentcaresites
9 Federalresourcescannotbeexpectedtoarrivesoonerthan72hoursfromthetimeof anexplosion
ACTIONSTEPS Thenear-term(sixmonths)solutionslistedbelowincludeestimatedhoursforeachtask
1 Identifymedicalleadershipwithinsurgeryandanesthesiologyfordisasterplanning
bull Leadershipshouldcollaborateinthedesignimplementationandrefinementof anincidentcommandsystemforanoperatingroomInitiallyleadershipinsurgery andanesthesiologyshouldmeetwithrepresentativesfromcriticalcareemergency medicineadministrationandothersinvolvedwiththeinstitutionrsquosdisasterplanning Thesediscussionswillbefacilitatedbyappointingahospitaldisastercommittee
2 Selectindividualsforincidentcommandroles
bull SpecifytheauthorityprocessesandresponsibilitiesoftheORincidentcommand andacallscheduleidentifyingindividualsavailabletofilltheirroles24hoursaday beginningwithintwohoursoftheeventandextendingfor72hours
bull Althoughindividualsfromseveraldisciplinesanddepartmentsintheoperatingroom andrelatedareasmayassisttheincidentcommandfinaldecision-makingauthority shouldrestwithonepersonmdashanldquoOperatingRoomCzarrdquoTheORCzarwouldhave authoritytocancelscheduledORcasesrearrangeORschedulesidentifypatients thatcouldbetransferredcallinanddeployORteamsandprioritizepatientsforbeds intheORPACUandICUsTheORCzarwouldreporttohospitalincidentcommand
bull Candidatesforthisroleshouldbeabletoassessthemedicalneedsofavarietyof patientsrequiringORservicesTheymustbephysiciansandwouldmostlikelybe surgeonsAnindividualservinginthisroleshouldnothaveprimarypatientcare responsibilityatthesametime(iebepartofasurgicalteam)
bull Communicationsystemslinkingsurgerynursinganesthesiologycriticalcare emergencydepartmentandhospitaladministrationshouldbespecified
bull TheORincidentcommandsystemmustaccountforpersonnelavailabilityat differenttimesofthedayandweekandprovidefortransferofincidentcommand responsibilityastheincidentevolvesover72hours
bull ThecircumstancesunderwhichtheORincidentcommandbeginsandendsshould bespecified
bull Methodsfordatacollectiontestingmonitoringandimprovingthesystemshouldbe specified
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 29
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Assurethatindividualswhomightassumeanincidentcommandroleareknowledgeable aboutincidentcommandoperationsofotherhospitalcomponentsandcommunity disasterresponse
ThisstepassuresthateligiblecandidatesforORincidentcommandreceiveappropriate trainingRequirementsandstandardsforsuchtrainingshouldbespecified
4 Identifylinesofcommunicationandinteractionswithothercomponentsofthe community-widedisasterplanandregionaltraumasystem
EVALUATION 1 Participateincommunity-widedrillsandevaluateperformanceofORincident
command
DeterminewhenindividualsshouldbepresentonsiteReviewtriagedecisionsquality quantityandappropriatenessofinformationobtainedfromandgiventoothers includinghospitalincidentcommandemergencymedicineandothercommunity assets
2 Refineandconductfurtherplanningbasedondrillexperience
0 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Radiology Response
PURPOSE Withinfourhoursofanexplosionoperationalizeradiologysupportfortheinitial treatmentof00injuredpatientsandforongoingcareupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toestablishpoliciesproceduresanddrillstoimproveradiologicalpreparedness fortreating00patientsinjuredfromanexplosionforupto72hours
RESOURCESREQUIRED Theremustbeenoughradiologypersonnel(radiologiststechniciansandsupport staff)equipmentandsuppliestocarefor00injuredpatients
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Radiologyserviceswillbeacriticalcomponentofthehospitalresponsetoa
bombing
2 Manypatientsoverarelativelyshorttimeperiodrequiringradiologymaylead toslow-downsandbottle-necks
ACTIONSTEPS Thenear-termsolutionslistedbelowincludeestimatednumberofhoursneeded toperformeachtask 1 Developamanagementplanandcalllistfortheradiologydepartmentto
useduringamasscasualtyeventDrilltheplaninvolvingradiologistsfor
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 1
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
immediate(ldquowetrdquo)readingsofplainfilmsandspecialstudiesThiswillassistinrapid evaluationandtreatmentofpatientsTheplanshouldalsooptimizeandstreamline radiologystudyprotocolsforuseduringamasscasualtyevent
Enhancedradiologypatientthroughputwillbeessentialintheinitialevaluationand treatmentofblast-injuriesEachradiologydepartmentmustdevelopaplantoensure rapidturnaroundofpatientstudiesandtheirresults
2 Whendisasterpatientsarrivearadiologyultrasoundtechnicianshouldbeavailablein theemergencydepartmenttosupporttheperformanceofanimmediateFAST(Focused AbdominalSonographyforTrauma)examIfthisisnotpossibletheemergency physiciansandtraumasurgeonsshouldbetrainedtoconductone
Conductanimagingequipmentsurveyevaluatethestatusoftheequipmentfor multipletraumasmakingsurethereareadequateamountsofportableequipment availableandupdateifneeded
Radiologyequipmentisexpensiveandusuallyrequiresplanninginadvancefor acquisitionandinstallationHoweverbyevaluatinghowavailableequipmentcouldbe puttomaximumuseduringamasscasualtyeventcanimprovepatientthroughput
4 Establishaprotocolforaugmentingpatientmovementandmonitoringintheradiology departmentAfterwardsreviewtheavailabilityofpatientmonitoringpersonneland equipmenttoenhancedepartmentalthroughputespeciallyforstudiessuchasCT scans
EVALUATION WhereappropriateevaluationdrillshavebeenincorporatedintotheldquoActionStepsrdquolisted aboveTheinstitutionaldisasterpreparednessplanshouldbeupdatedbasedoneachdrill experience
2 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
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1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
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15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
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19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
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26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Blood Bank Response
PURPOSE Withinfourhoursofaneventprovidebloodproductsforupto00injured patientsandsustainsupportforupto72hours
BACKGROUND TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
INJURY PREVENTION managingrapidsurgeproblemsduringamasscasualtyevent
Emergency Medical Service Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Emergency Department commuter trains in Madrid killing 177 people instantly and injuring more than Response
2000 That day 966 patients were taken to 15 public community hospitals More Surgical and Intensive Care Unit Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Radiology Response
Blood Bank Response Federal resources should not be expected to arrive sooner than 72 hours from the Hospitalistsrsquo Response time of the explosion Resources can be delayed by the time taken to deploy them Administration Response and by responding to multiple communities Drugs and Pharmaceutical Supplies
Nursing Care GOAL Duringthefirstfourhoursofadisasterensurethatthatappropriateblood productscanbelocatedprocessedandquicklyadministeredtoatleast00 patientsrequiringtransfusionsIdentifyadditionalneedssothatbloodproducts canbecollectedprocessedandadministeredforupto72hours
RESOURCESREQUIRED bull AABBdocuments
bull Disasterresponseplansforhospitalandbloodcollectioncenters
bull Laboratorypersonneltocollectprocessanddistributeproducts
bull Transportationresourcesdieselandunleadedfuelandstorageequipment (egdryice)
bull Transfusionsupplies
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS bull Themostdifficultproblemsinvolvedisruptionorinterferenceoftheblood
supplysystem
ndash Historicallybloodsupplyneedsduringdisasterresponsehavebeenmet withthequantityofbloodproductsavailableatthattime
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
ndash Facilitiescurrentlymaintainaboutathree-daysupplyofbloodproductsmdashwhichmay needtobeexpandedtoaseven-daysupply
ndash Typicallyfewercasualtiesrequirebloodproductsthanthetotalnumberofvictims
ndash Localcommunitieshavelimitedsourcesofbloodproducts
ndash Iffacedwithasurgeindemandbloodproductswilllikelybetransportedfrom bloodcentersoutsidethelocalarea
bull Afteradisasterthepublicusuallyrespondsbyvolunteeringtodonatelargerquantities ofbloodproductsthanareneeded
ndash Aninfluxofblooddonorscouldtaxcollectingandprocessingefforts
ndash Whenresources(personnelequipmentandsupplies)areunnecessarilyappliedto collectingandprocessingunneededproductstheseresourcescannotprocessand distributeavailableandurgentlyneededproductstothoseinurgentneed
bull Themediamustcontinuouslyprovidethecommunitywithreliableinformationabout theneedandsupplyofbloodproducts
bull Therearelimitedpersonnelwiththetrainingeducationandskillstoprocessand administerbloodproductswithintreatingfacilities
ndash Additionalqualifiedlaboratorypersonnelmaybeneededtoprocessrequestsfor bloodproducts
ndash Additionalnursingpersonnelmaybeneededtoadministerbloodproducts
bull Theremaybelimitedmethodsoftransportingortransferringbloodproductsfrom suppliertodestinationduringadisaster
ndash Commercialtransport(airandground)maybelimited
ndash Bloodneedsareconsideredbyfederalstateandlocalgovernmentstobeacritical elementofthepublichealthinfrastructureintimesofemergency
bull TheAABBInterorganizationalTaskForceonDomesticDisastersandActsofTerrorism formedinJanuary2002hasdevelopedaprocesstoeducatethecommunityabout donationsandhowtocollectprocessandmovebloodproductsatthetimeofa disaster
ndash Thismulti-organizationaltaskforceincludesfederalandnationalorganizations
ndash PublishedreferencesincludeaDisasterOperationsHandbookandahospital supplementthataddressestheseissuesTheyincludeaflowchartoutliningthe processforinvolvingtheAABBandappropriatenationalandfederalorganizations thatprovidebloodproductsduringadisaster
ACTIONSTEPS bull WorkwithAABBtodistributedocumentstohospitalsandbloodcollection
organizationsfacilities
bull Identifyresources(personnelequipmentsupplies)tomeetlocalneedsforcollection processingdistributionandtransfusionofbloodproductsThiseffortmustinclude localmediatoprovideconsistentmessagestothecommunityaboutbloodproducts supplyandneeds(NoteIndividualhospitalsandcollectionorganizationsincorporate theAABBprocessintotheirlocaldisasterresponseplans)
4 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Workwithotherorganizationsandgovernmentagencies(localregionalstatefederal) tomakesurebloodproductsareconsideredcriticalelementsofthepublichealth infrastructureintheeventofadisasteremergency
EVALUATION bull EnsurethatsurveyhospitalsandcollectionorganizationsincorporateAABBprocesses
intolocaldisasterresponseplansafter4to6months
bull Requestthathospitalsandcollectionorganizationsparticipateinalocalorregional exerciserequiringadministrationofbloodproductswithinfourhoursofaneventfor upto72hours
ndash IncludeactivationandresponseoftheAABBsystemandlocalregionalandstate resourcesintheexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 5
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Hospitalistsrsquo Response
PURPOSE Withinfourhoursleveragetheknowledgeandskillsofhospitaliststotreat00 patientsinjuredfromexplosionsandtosustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosiondeploystaffandfunctioningbedstotreatat least00injuredpatientswhorequireacuteinpatientandintensivecarefor72 hours
Theboldfacedtermshavethefollowingmeaning bull deployndashrepresentsthesumofthefollowing
n redefine(standardsofcare) n reallocate(on-sitestaff) n recruit(off-sitestaff)
bull functioning-representsthesumofthefollowing n supplied(itemsnecessaryforcareareavailable) n serviced(patientswithassignedcaregiversavailableclinicalsupport
servicessuchaslaboratoryradiologyandpharmacy) n stepped-down(patientscapableofbeingtransferredfromICUbutinneed
ofclosemonitoring)
RESOURCESREQUIRED 1 Thegeneralpublicrsquosandhealthcarecommunitiesrsquoeducationandacceptance
oftheconceptandneedforalteredstandardsofcareduringalarge-scale disasterresponse
6 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
2 Adequatestaffingtosupportresponseefforts(physiciansnursestechnicianssupport staffsuppliesandequipment)
MechanismtoimplementanalteredstandardofcareThisshouldincludeways torapidlyldquostepdownrdquosuitablepatients(egfromICUtofloorandfromfloorto elsewhere)
4 Mechanismwithinhospitalsthatplacehospitalistsintoldquoreal-timerdquorolesthatenable themtoallocateandrationresourcesandtoserveasadvisorstoandoutreacharmsof IncidentCommand
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Effectiveclinicalresponsetoasurgeofpatientsfromabombingeventwillrequire
coordinationandcooperationamongmultiplemedicalspecialties
2 Hospitalistswillbeanintegralcomponentinidentifyingavailablehospitalbeds dischargingpatientscaringforpatientsandprovidingadditionalsupportduringthe response
ACTIONSTEPS 1 Developanddisseminateanalternatestandard-of-carepolicyforuseduringadisaster
situationIncludein-hospitaltriageforalternatelevelsofcareearlytransfertolower levelsofcareandearlydischargeConsiderusingtheAgencyforHealthcareResearch andQualitydocumentasareference
2 ConveneethicspanelasnecessaryEnlistSocietyofHospitalMedicine(SHM)Ethics Committeeasneeded
Educateappropriatestaffaboutthealternatestandardofcarepolicy
4 Ensurethathospitalistsareincorporatedintothedisasterresponseofeachhospitalto addressissuesrelatedtoeffectivepreparednessandresponse
EVALUATION 1 Conductanexercisethatimplementsthealternatestandardofcarepolicyanduses
hospitalsasdesignatedinthedisasterplan
2 Critiquetheexerciseagainsttheresponseplanemphasizeissuesaboutalternate standardsofcareandperformanceofhospitalists
Revisethealternatestandardofcarepolicyanddisasterplanbasedontheoutcomeof theexercise
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 7
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Administration Response
PURPOSE Withinfourhoursoperationalizeadditionaladministrative-relatedresourcesto treat00patientsinjuredfromanexplosionandsustaincarefor72hours
BACKGROUND INJURY PREVENTION
TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
Emergency Medical developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Toorganizeandsupportresponsetoinfluxof00patientsinjuredfroman explosionfora72-hourperiod
RESOURCESREQUIRED Theworkloadassociatedwithanadministrativeresponsewillrequireaccessto multiplefacilitiestosupporttheneedsofpatientsstaffandthegeneralpublic Administratorswillmanagecommunicationsacquirepoliticalsupportwork withandrespondtomediahandlepublicinquiriesmanageinternalsystemsand departments
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary
ASSUMPTIONS bull Healthcaresystemsandhospitalsshouldfunctionasanintegratedsystemfor
thebestuseofresources
bull Amedicalresponsetoamasscasualtyeventmustbecomprehensive communitybasedandcoordinated
bull Legalandregulatoryissuesneedtobeincludedinthehospitalemergency preparednessplanEmergencyMedicalTreatmentandActiveLaborAct
8 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
(EMTALA)HealthInsurancePortabilityandAccountabilityAct(HIPAA)Federal VolunteerProtectionActGoodSamaritanLawslaborlawsOSHAandfacilitycodes
bull ActivatingthecommunityEmergencyOperationsCenter(EOC)andhospitalrsquos commandcenterarecriticaltosuccess
bull CommunicationamonghospitalshealthsystemsEMSEOCandpublichealthcannot belostorinterrupted
bull Hospitalsusetheincidentcommandsystemandhavestaffwhocanimplementit
bull Hospitalslong-termcarefacilitiesofficesandclinicshaveMemorandaof Understanding(MOU)toshareresources
bull TheEOCincludeshealthcarerepresentativestocoordinatemedicalresources
bull Patientswhodonotneedacutecareservicesshouldbetreatedatalternatecare facilities
bull Theinstitutionmust
ndash EstablisharesponseplanbasedontheIncidentManagementSystem(egHospital IncidentCommandSystem(HICS)model)
ndash Includeclinicsandofficeswithemergencypreparednessplansconsistentwiththe hospital
ndash Includemedicalnursingdentalandpharmacystaffrespiratorystudentsandhouse staffandfellowsifavailable
ndash Determinethelocationofthecommandcenter(notintheED)andbackupsites
ndash Establishwrittenplanstosecuretheperimeterofthefacilityandaccesspoints
ndash Identifyaspokespersonforthehospital(publicinformationofficer)
bull Thepreparednessplanshouldincludemechanismsformodifyingadmissiondischarge andprocedureschedules
ndash Deferadmissionsthatarenotemergent(developcriteriaandputintopolicy)
ndash Notifyoperatingroommanagertodeferorcancelinpatientandoutpatientnonshyemergencysurgeries
bull IncorporateintensivisthospitalistorChiefofStaffrsquosdesigneeintoplanfordischarging patientsduringemergencyoperations(SeetemplateonHospitalistResponse)Setup MOUswithhospitals
Additionalstaffingissuestoconsider
bull Haveavailablestaffaddressthementalhealthofvictimsfamiliesandstaff(eg psychiatristspsychologistslicensedmentalhealthpractitionersandvolunteers)
bull EmployworkerstrainedbytheAmericanRedCrossespeciallythosewhocan providementalhealthservices
bull Providechildcareservicessothatstaffarefreetoattendtopatients
bull Compilealistofqualifiedtranslatorsforthedisaster
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 9
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
ACTIONSTEPS Thesolutionslistedbelowincludeestimatedhoursforeachtask 1 Control of the External Environment
Theexternalenvironmentwillchangerapidlyduringalarge-scalemasscasualtyevent ThehospitalmustbesecuredandcampustrafficmustbecontrolledSuchcontrolof theexternalenvironmentincludesclearingbedstoaccommodateincomingcasualties redirectingnon-emergencypatientstootherresourcesandmanagingthecomingsand goingsofstaffManagingmediarelationscanbechallengingwhentryingtoprovide safeandeffectivecareTheinstitutionrsquossecurityandpublicaffairsofficesmustwork togetherandbeinplacebeforethemediaarrives
2 Activation of Hospital Incident Command System (HICS)
HICSawidelyusedemergencymanagementsystemisknownforprovidingachain ofcommandwiththeabilitytoeffectivelymanageanincidentprovideaccountability ofpositionfunctionsallowforaflexibleresponsetospecificemergenciesimprove documentationoffacilityactionsprovideacommonlanguagetofacilitateoutside assistanceanddevelopprioritizedresponsechecklistsforseniorleadershipIdentifying theappropriatepeopletomakedecisionsispivotalinafast-paceddisastersuchas intheMadridbombingsThereislittletimeformeetingsanddiscussionaboutthe appropriateuseofsupportfunctionsandpersonnelStaffshouldbetrainedanddrilled regularlytoingrainthedifferencebetweenincidentstructureandnormaloperations
3 Logistics and Supplies
Coordinatingwithkeysuppliersandmaintainingcurrentinventoriesthroughoutthe healthsystemwillmakestockingeffortseasierWhenresourcesarelimitedproviders mustbepreparedtorespondtocareneedswithwhateverisavailable
LogisticsincludebutarenotlimitedtopatienttransportationForexamplehousing evacueesandthewalkingwoundedandtheirfamiliesisafunctionoftheemergency managementprogramKnowingthelocationsofdesignatedsheltersthroughoutthe vicinityandtransportationresourcesforlow-acuitypatientsandtheirfamilieswill hastendischargeplanningandpatientflowinacutecarefacilities
4 Alternate Care Sites
Ahospitalrsquosabilitytomobilizeemergencycareunitsandtoextendcaretothecityrsquos walkingwoundedaddstoitseffectivenessTriagesystemsareusedtoprioritizepatients sothatlow-prioritypatientscanbedirectedfromthemainhospitalallowingambulances andhospitalstafftofocusonhigh-prioritytraumapatientsinneedofmedicalassistance AlternatesitesliketheonesusedduringHurricanesKatrinaandRitaallowlargehealth systemstofacilitatetriageanddirectpatientstoappropriatesourcesofcare
5 Credentialing
TheJointCommissionontheAccreditationofHealthcareOrganizations(JCAHO) emergencycredentialingsystemmustbetestedwithinanorganizationbeforeitis reallyneededStateEmergencySystemsforAdvanceRegistrationofVolunteerHealth Professionals(ESARndashVHP)reflectJCAHOrequirementsandprovideastandardized setofverifiedcredentialsforvolunteerswhomaybecalledtoassisthospitalsduring emergencysituations
40 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
6 Patient Tracking
SuccessfulpatienttrackingbeginsassoonastheyenterthehealthcaresystemWhen moretimeisspentidentifyingandtrackingpatientstheprospectofreimbursementfor relatedcostsisbetterTheabilitytotrackpatientsidentifytheirsupplyconsumption andmonitorbeduseenablesseniormanagementtoproactivelymeettheneedsof healthcareprovidersonthefrontlinePatienttrackingsystemsmustbeflexibleenough toaccommodatesuchneeds
7 Identify gaps
bull Ensurecoordinationbetweenon-scenemanagementandavailablecommunity resourcessothatspecificfacilitiesarenotoverloaded
bull Communicationamongfacilitiesatclinicalandadministrativelevelsisessential
8 Identify additional sources of community support
Additionalsourcesofsupportcanincludelocalshelterslocally-developedstockpiles communitypharmaciesdrugwholesalerswarehousespublichealthauthoritiesetc Accesstotheseresourceswillbeimportantiftheeventdisplacesmanyresidentsdueto contaminationpropertydamageutilityfailureetc
9 Establish communication and relationships
bull Developcommunicationswithlocalemergencymanagement
bull Establishcommunicationswithlocalregionalandstatehospitals
10Exercise plans
bull Establishregularschedulestodrilleveryaspectofaresponsetoensurethatallstaff understandstheirroles
bull Evaluatethedrillsandmodifyplansbasedonafter-actionreports
bull Drillthenewplan
EVALUATION 1 Planconductandevaluatefacility-widedrillsTheevaluationshouldidentifystressors
onclinicalandadministrativeactivities
2 Planconductandevaluatecommunity-widedrillsTheevaluationshouldidentify stressorsonclinicalandadministrativeactivities
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 41
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Drugs and Pharmaceutical Supplies
PURPOSE Withinfourhoursofanexplosionacquiretheadditionaldrugsand pharmaceuticalsuppliesneededtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION
TheMadridterroristbombingswereusedasamodeltohelpdevelopsolutionsfor
Emergency Medical managingrapidsurgeproblemsduringamasscasualtyevent Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the
Administration Response time of the explosion Resources can be delayed by the time taken to deploy them
Drugs and Pharmaceutical Supplies and by responding to multiple communities Nursing Care
GOAL Withinfourhoursofanexplosionacquireappropriateandadequatedrugsto treat00injuredpatientsforupto72hours
RESOURCESREQUIRED Thelistbelowincludestherapeuticcategoriesadministrationrouteand recommendeddrugorpharmaceuticalsupplyForsimplicitypurchaseand stockpileasingleorfewdrugsfromeachtherapeuticcategoryCareproviders mayhavelittleornopriorexperiencewithadrug
This document is a resource guide Local needs preferences and capabilities of the affected communities may vary bull Analgesics
pohydrocodoneacetaminophen(onestrengthmdash5500)IVmorphine
bull Anxiolytics poandIVlorazepam
bull Antipsychotics poandIVhaloperidol
bull Antibioticsbroadspectrumwithlowallergyrisk poandIVciprofloxacin
42 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Intravenousfluids salineandD5W
bull Blood(seeBloodBankResponse)
bull Drugsforintubation IVetomidatesuccinylcholineandvecuronium
bull Topicalburncareagents Silversulfadiazine(Silvadene) Bacitracin
bull ENTmedsforTMperforation Cortisporinoticsuspension
bull Ocularmeds Proparacaine Erythromycinophthalmicointment
bull Tetanustoxoid
ASSUMPTIONS 1 Theremaybeademandforcertainpharmaceuticalsfollowingabombingeventwith
multiplecasualties
ACTIONSTEPS 1 Identifycommunitymedicalleadershipandacommitteetoaddressnear-termsolutions
DiscussionanddecisionbyEMSemergencymedicinetraumasurgeryhospital pharmacy(PharmD)bloodbankhospitalleadershiphospitalnursingemergency managementpublichealthandlawenforcementabouttransportofpharmaceuticals
2 Inventorydrugsandquantitiesavailableatpointsofcare(prehospitalandhospital)
Assuming4hospitalsand10ambulancescommitteeshoulddelegateapointpersonto contacthospitalpharmacistsandEMSleadershipandinquireaboutinventory
Identifygapsbetweendrugsonhandandgoal
4 Identifypotentialsourcesofdrugsinthecommunitybesidesprehospitalandhospital supplies(eglocallydevelopedstockpilescommunitypharmaciesdrugwholesalers warehousesphysiciansrsquoofficesviamedicalsociety)Identifyingadditionalsources shouldincludedailyroutineneedsofthecommunity
5 Developrelationshipswithleadershipfromadditionalsourcesaskforldquosnapshotrdquo inventoryofdrugsandestablishldquomutualaidrdquoagreementstorapidlyacquiredrugs
6 Assessdrugsavailableinthecommunitybyaddingprehospital+hospital+community pharmacies+drugwholesalerswarehouses+physiciansrsquooffices(throughmedical society)
7 Ifthedrugsupplyislowdevelopaplanforintercommunitymutualaidorrationing
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 4
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
8 Developaplantorapidlyacquiredrugsfromadditionalsourcesanddeliverproducts topointsofcareThisplanshouldincludecommunicationsbetweenpoint(s)ofcare andadditionalsourcesmutualaidagreementswithadditionalcommunitysources transportofdrugsandreimbursement
EVALUATION 1 Planconductandevaluateacommunity-widedrillTheevaluationshouldinclude
measuringquantityandnamesofdrugsandpharmaceuticalsuppliesacquired distributedandadministeredtimeswhendrillstartedtimedrugswereacquiredfrom distributionpointsdurationoftransporttimeofdistributiontopointsofcareand timeofadministrationtopatients
2 Refineplanbasedondrillexperience
44 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Managing Surge Needs for Injuries Nursing Care
PURPOSE Tooperationalizeadditionalnursingresourcesinacommunitywithinfourhours ofaterroristbombexplosionandtotreat00injuredpatientsforupto72hours
BACKGROUND INJURY PREVENTION TheexperiencesoftheMadridterroristbombingswereusedasamodeltohelp
developsolutionsformanagingrapidsurgeproblemsduringamasscasualtyevent Emergency Medical Service Response
Emergency Department Response On March 11 2004 10 terrorist explosions occurred almost simultaneously on
Surgical and Intensive commuter trains in Madrid killing 177 people instantly and injuring more than Care Unit Response 2000 That day 966 patients were taken to 15 public community hospitals More Radiology Response than 270 patients arrived at the closest facility between 0800 and 1030 hours Blood Bank Response
Hospitalistsrsquo Response Federal resources should not be expected to arrive sooner than 72 hours from the Administration Response
time of the explosion Resources can be delayed by the time taken to deploy them Drugs and Pharmaceutical Supplies and by responding to multiple communities
Nursing Care
GOAL Withinfourhoursofanexplosionmobilizetheappropriatenumberoffacilitiesandbeds nursingstaffandresourcesneededtotreat00injuredpatientsforupto72hours
RESOURCESREQUIRED Theworkloadwillrequireadequatestaffingandbackuppersonnelforthe initialresponseandmechanismsfornotificationandactivationcredentialing volunteersandforensuringthesafetyandwelfareofresponders
This document is a resource guide Local needs preferences and capabilities of affected communities may vary
ASSUMPTIONS 1 Nursingpersonnelareessentialforaneffectiveresponsetoabombing
includingpatientcarepatienttrackingandinformationmanagementand logisticalsupport
ACTIONSTEPS Thesolutionslistedbelowinvolveprovidingclinicalnursingfor00patientsover a72-hourperiod bull Makeallphysicalbedsavailableforcareincludingthoseinstorageandthose
thatcanberentedonshortnoticePlacecotsinroomsorhallways
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 45
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
bull Developcriteriaandpolicytodischargepatientswhocangohomeorbequickly transferredtolong-termcare
ndash MakesureeachdepartmenthasaprocedureformasscasualtycareThese proceduresneedtobereviewedandbeaccessibletothecommandcenter
ndash Departmentsneedtodetermineproceduresforwhatwillbedoneimmediately(0ndash 120minutes)intermediately(2ndash4hours)andlongterm(4ndash24hours)
bull Notifyalldepartmentsofincidentandofemergencyplanactivation
bull Requestthatpoliciesbeapprovedbyacentralizedcommitteethatoverseesthe emergencyoperationsandplan
bull UpdatecalllistsEverydepartmentshouldhaveacurrentlistthatidentifiesstaffbytheir proximitytothehospital
bull Makestaffawareofwheretoparkwheretoreporthowtorespondetc
bull MaintainacentralizeddatabasewithstaffcompetencyskillslikeACLS(Advanced CardiacLifeSupportreg)TNCC(TraumaNurseCoreCourse)ENPC(EmergencyNurse PediatricCourse)andPALSIdentifywhoiscompetenttocareforcriticallyillpatients
bull Addon-callstafftothedisastercalllist
bull Maintainnamesofretiredorunemployedstaffinahospitalorhealthsystemdatabase
bull IncludeMedicalReserveCorpinformationlistsintheemergencyresponseplan
bull Preparebadgesinadvanceforcredentialedprofessionalstaff
bull CredentialvolunteersinadvanceCommunityagenciestypicallymanagevolunteers
bull Setupasystemsothatthehospitalcanverifycredentials(ieStateESARndashVHP)
bull Ensurethatstaffisassignedtotaskswithwhichtheyaremostfamiliarandperform dailydonotchangeroutineprocedures
EVALUATION HospitalshealthsystemsshouldplanandexecuteadrillwithEMSatleastonceayear Thedrillshouldincludeobjectivestoaccommodate00patientswithbedsstaffingand resources
Critiquethecompleteddrillwriteareportandsharethefindingswithparticipants Hospitaladministratorsshouldanalyzethereportandmakerecommendationstothe disasterplanAnydeficienciesshouldbetestedinthenextdrill
PlanningadrillisexpensiveExercisesmustbedoneinconjunctionwithstateorcounty cityemergencymanagementagencystaffwiththeresourcestoconductthem
46 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
Conclusion Worldwidebombingsoccuralmostdailyandareescalatingincomplexityand sophisticationAsnotedthroughoutthisreportweknowtheUShealthcaresystemwill beoverwhelmedbyaterroristbombingTheproposedsolutionsoutlinedinthisreport providestrategiesthatcanbeputinplacenowmdashbeforeacrisisstrikesmdashtoaddressthe systemwideanddiscipline-specificsurgecapacitychallengestoprovidinganeffective response
Acknowledgments CDCrsquosInjuryCenterwouldliketothankthemanymedicalcareandadministrativeexperts whocontributedtotheconceptualizationandcontentofthisreportbyparticipatingon theSurgeCapacityExpertPanelwritingsectionsofthisdocumentreviewingtextand providingvaluablecomments
BobBaileyMA KevinGeroldDOJDMA(Ed) SeniorAdvisortotheDirector Director DivisionofInjuryResponse CriticalCareMedicine NationalCenterforInjuryPreventionand DepartmentofAnesthesiology Control JohnsHopkinsMedicine CenterforDiseaseControlandPrevention BaltimoreMD AtlantaGA
JoeHendersonMPA PalmerBesseyMDFACS AssociateDirector Professor OfficeofTerrorismPreparednessand DepartmentofSurgery EmergencyResponse CornellUniversity CentersforDiseaseControlandPrevention AssociateDirector AtlantaGA WilliamRandolphHearstBurnCenter NewYorkNY RichardCHuntMDFACEP
Director SteveCantrillMD DivisionofInjuryResponse AssociateDirector NationalCenterforInjuryPreventionand DenverHealthMedicalCenter Control DenverCO CenterforDiseaseControlandPrevention
AtlantaGA AlexanderDuncanMD AssistantProfessor MarkJohnsonMPA EmoryUniversityHospital RetiredChiefCommunityHealthand AtlantaGA EmergencyMedicalServices
AlaskaDepartmentofHealthampSocial Services JuneauAK
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 47
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
ArthurKellermanMDMPH WayneMeredithMD ProfessorandChair ProfessorandChairman DepartmentofEmergencyMedicine DepartmentofGeneralSurgeons EmoryUniversitySchoolofMedicine WakeForestUniversity AtlantaGA Winston-SalemNC
RobertMKellmanMD StuartMirvisMD ProfessorandChair Professor StateUniversityofNewYork UniversityofMarylandRadiologyamp UpstateMedicalUniversity ShockTreatment SyracuseNY BaltimoreMD
JonKrohmerMDFACEP LCDRJMorrisMPH MedicalDirector USPublicHealthService KentCountyEMS NationalBioterrorismHospital GrandRapidsMI PreparednessProgram
HealthResourcesandServices DavidLehmannMDPhD Administration ProfessorofMedicineandPharmacology RockvilleMD StateUniversityofNewYorkUpstate MedicalUniversity BrentMyersMD SyracuseNY WakeCountyEMSMedicalDirector
RaleighNC PatriciaLenaghanRNMSCENFAAN DirectorBiocontainmentUnitampMagnet RobertNovellineMD Program ProfessorofRadiology TheNebraskaMedicalCenter HarvardMedicalSchool NebraskaMedicalCenter BostonMA OmahaNE
RichardOrrMD LTCJohnMcManusMDMCRFACEP Physician ResearchPhysicianUSArmyResearch ChildrenrsquosHospitalofPittsburgh ProgramforCombatCasualtyCare PittsburghPA USArmyInstituteofSurgicalResearch TransitionalProgramDirectorSanAntonio ThomasAPetersMBAMHA UniformedServicesHealthEducation VicePresident ConsortiumMedicalDirectorFortSam UniversityHealthSystem HoustonandCampBullisFireAdjunct SanAntonioTX AssistantProfessorEmergencyMedicine OHSUandUSUHS SallyPhillipsRNPhD
DirectorBioterrorismPreparedness NormanMcSwainMDFACS Research TraumaDirectorCharityHospital AgencyforHealthcareResearchandQuality TulaneUniversitySchoolofMedicine RockvilleMD NewOrleansLA
48 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
EdwardRachtMD RichardSerino MedicalDirectorClinicalAssociate Chief ProfessorofEmergencyMedicine BostonEmergencyMedicalServices CityofAustinTravisCountyEmergency BostonMA MedicalServicesSystem UniversityofTexas-Southwest JasonSteinMD MedicalCenter DirectorQualityImprovement AustinTX EmoryHospitalMedicine
EmoryUniversityHospital ScottMSasserMD AtlantaGA DepartmentofEmergencyMedicine EmoryUniversitySchoolofMedicine GamWijetunge DivisionofInjuryResponse HighwaySafetySpecialist NationalCenterforInjuryPrevention NationalHighwayTrafficSafety andControl Administration CentersforDiseaseControlandPrevention WashingtonDC AtlantaGA
JanetWilliamsMDFACEP RichardSattinMD Director AssociateDirectorforScienceActingTeam CenterforDisasterMedicineand Lead(Research) EmergencyPreparedness CentersforDiseaseControlandPrevention UniversityofRochester AtlantaGA PittsfordNY
PaulSchmidtMD Professor DepartmentofPathologyandCellBiology TampaFL
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 49
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
References
1Patternsofglobalterrorism2001UnitedStatesDepartmentofState[online]May2002[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1019pdf
2Patternsofglobalterrorism2002UnitedStatesDepartmentofState[online]April200[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization20177pdf
Patternsofglobalterrorism200UnitedStatesDepartmentofState[online]April2004[cited 2005Feb4]AvailablefromURLwwwstategovdocumentsorganization1912pdf
4Terrorism20002001UnitedStatesDepartmentofJusticeFederalBureauofInvestigation (FBI)CounterterrorismDivisionPublication008[FBIwebsite][cited2005Feb4] AvailablefromURLwwwfbigovpublicationsterrorterror2000_2001htm
5GadsonLOMichaelMLWalshNeditorsFBIBombDataCenter1998bombing incidentsWashington(DC)DepartmentofJustice(US)FederalBureauof Investigation1998GeneralInformationBulletin98-1
6TerrorismResearchCenterIncAvailableatURLwwwTerrorismcom
7CushmanJGPachterHLBeatonHLTwoNewYorkCityhospitalsrsquosurgicalresponseto theSeptember112001terroristattackinNewYorkCityJTrauma20054(1)147ndash55
8RodopluUArnoldJLYucelTTokyayRErsoyGCetinerSImpactoftheterrorist bombingsoftheHongKongShanghaiBankCorporationheadquartersandthe BritishConsulateontwohospitalsinIstanbulTurkeyinNovember200JTrauma 200559(1)195ndash201
9FrykbergERTerroristbombingsinMadridCriticalCare2005920ndash2
10FrykbergERMedicalmanagementofdisastersandmasscasualtiesfromterrorist bombingshowcanwecopeJTrauma20025201ndash12
11FrykbergERTepasJJTerroristbombingslessonslearnedfromBelfasttoBeirutAnn Surg1988208569ndash76
12NationalStrategyforCombatingTerrorismUnitedStatesGovernment200Available atURLhttpwwwwhitehousegovnewsreleases20002counter_terrorism counter_terrorism_strategypdfsearch=22national20strategy20for20combating 20terrorism22
1LesserIOHoffmanBArquillaJRonfeldtDFZaniniMJenkinsBMeditorsCountering thenewterrorismSantaMonica(CA)RANDCorporation1999
14GutierrezdeCeballosJPTureganoFuentesFPerezDiazDSanzSanchezMMartin LlorenteCGuerreroSanzJECasualtiestreatedattheclosesthospitalintheMadrid March11terroristbombingsCritCareMed2005(1Suppl)S107ndash12
15BazermanMHWatkinsMDPredictablesurprisesthedisastersyoushouldhaveseen comingandhowtopreventthem(leadershipforthecommongood)Boston(MA) HarvardBusinessSchoolPress2004
50 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
In a Momentrsquos Notice Surge Capacity for Terrorist Bombings 51
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
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16BurtCWandMcCraigLFStaffingCapacityandAmbulanceDiversioninEmergency DepartmentsUnitedStates200ndash04Advancedatafromvitalandhealthstatistics September27200676
17VisitstoUSemergencydepartmentsatall-timehighnumberofdepartmentsshrinking [onlinepressrelease]26May2005[cited10Apr2006]Atlanta(GA)Centersfor DiseaseControlandPreventionOfficeofEnterpriseCommunicationMediaRelations AvailablefromURLwwwcdcgovodocmediapressrelr050526htm
18AmericanCollegeofEmergencyPhysiciansAmbulancediversionandEDovercrowding AvailablefromURLwwwaceporgwebportalPatientsConsumerscritissues overcrowdingFactSheetAmbulanceDiversionandEhtmCited12October2006
19DerletRWRichardsJROvercrowdinginthenationrsquosemergencydepartments complexcausesanddisturbingeffectsAnnEmergMed20005(1)6ndash8
20EcksteinMIsaacsSMSlovisCMKaufmanBJLoflinJROrsquoConnorREetalFacilitating EMSturnaroundintervalsathospitalsinthefaceofreceivingfacilityovercrowding PrehospEmergCare2005Jul-Sep9()267-75
21SchafermeyerRWAsplinBRHospitalandemergencydepartmentcrowdinginthe UnitedStatesEmergMed(Fremantle)20015(1)22ndash7
22GeneralAccountingOffice(US)Hospitalemergencydepartmentscrowdedconditions varyamonghospitalsandcommunitiesWashington(DC)GovernmentPrintingOffice 14Mar200ReportNoGAO-0-460
2AmericanHospitalAssociationPreparedtoCareThe247roleofAmericarsquosfull-service hospitals2006Cited12October2006httpwwwahaorgahacontent2006pdf PreparedToCareFinalpdfAvailablefromURLhttpwwwahaorgahacontent2006 pdfPreparedToCareFinalpdf(February2004)
24InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareemergencymedicalservicesatthe crossroadsWashington(DC)TheNationalAcademiesPress2006
25InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycarehospital-basedemergencycareatthe breakingpointWashington(DC)TheNationalAcademiesPress2006
26InstituteofMedicine(US)CommitteeontheFutureofEmergencyCareintheUnited StatesHealthSystemFutureofemergencycareEmergencycareforchildrengrowing painsWashington(DC)TheNationalAcademiesPress2006
27NiskaRWBurtCWBioterrorismandmasscasualtypreparednessinhospitalsUnited States200AdvancedatafromvitalandhealthstatisticsNationalCenterforHealth StatisticsSeptember27200564
28AufderHeideETheimportanceofevidence-baseddisasterplanningAnnEmergMed 2006Jan47(1)4ndash49
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29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
29RubinsonLNuzzoJBTalmorDSOrsquoTooleTKramerBRInglesbyTVAugmentation ofhospitalcriticalcarecapacityafterattacksorepidemicsrecommendationsofthe WorkingGrouponEmergencyMassCriticalCareCritCareMed200510(Suppl)
0SchmidtPJBloodanddisastermdashsupplyanddemandNEnglJMed200246(8)617ndash20
1Disasteroperationshandbookcoordinatingthenationrsquosbloodsupplyduringdisasters andbiologicaleventsAmericanAssociationofBloodBanksAvailablefromURLwww aabborgDocumentsPrograms_and_ServicesDisaster_Responsedohdbk0050pdf
2DisasteroperationshandbookoverviewofresponseplanAmericanAssociationof BloodBanksAvailablefromURLwwwaabborgDocumentsPrograms_and_Services Disaster_Responsedohdbkoview0050pdf
Disasteroperationshandbookmdashhospitalsupplementcoordinatingthenationrsquosblood supplyduringdisastersandbiologicaleventsAmericanAssociationofBloodBanks AvailablefromURLwwwaabborgDocumentsPrograms_and_ServicesDisaster_ Responsedohdbksupp0050pdf
4AgencyforHealthcareResearchandQualityAlteredstandardsofcareinmasscasualty eventsRockville(MD)DepartmentofHealthandHumanServices(US)Preparedby HealthSystemsResearchInc2005ContractNo290-04-0010AHRQPublicationNo 05-004AvailablefromURLwwwahrqgovresearchaltstandaltstandpdf
52 In a Momentrsquos Notice Surge Capacity for Terrorist Bombings
CS109858
CS123209
CS123209