Chapter 15

Chapter 15
Emergency Preparedness and
Response for Today’s World
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 All hazards approach
 Emergency plans to address adequate response systems to a
variety of hazards
 Most serious knowledge deficit: bioterrorism attacks and
pandemic flu events
 Place health care providers in a different position of being “first
responders”
 Victims will first appear in emergency departments, physician
offices, nurse-managed clinics, or even school health settings
 Health care professionals must identify symptoms, patterns of
similar events, and other irregularities
The Basics of Emergency
Preparedness and Response
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. 2

 Disaster condition
 Significant natural disaster or man-made event that
overwhelms the affected area
 Necessitates both federal public health and medical
care assistance
 Large number of victims may require response of
multiple organizations
(cont'd)

 Nursing fundamentals during crisis
 Nursing fundamentals practiced during smaller crises
will still be applicable
 Triage priorities change
• With large numbers of victims, priority shifts to doing the
greatest good for the greatest number of people
• Care is given to those patients who have the greatest chance
of survival
 Nurses may have to use creative solutions in
response to a lack of commonly available resources
(cont'd)

 Terrorist attacks
 Terrorism has created the need to prepare against a
variety of different agents
 Standardized nomenclature for potential agents
(known as CBRNE):
• Chemical
• Biologic
• Radiologic
• Nuclear
• Explosive
(cont'd)

 Kill through a variety of means: nerve, vesicant, blood,
and choking
 Spread easily through air and cause immediate effects
 Require decontamination
 Require trained hazardous material (Hazmat) teams
 Treatment
 Depends on agent used; may require agent-specific medications
 Decontamination
 Use of personal protective equipment (PPE) by personnel
Chemical Agents

 Small quantities can have a large effect
 Difficult to prepare for
 Treatment
 Depends on agent used
 Most cause flulike symptoms
 Plague and smallpox most contagious
 Timing of specific treatment critical
Biologic Agents

 Expression may be delayed; depends on time, distance,
shielding, quantity of radioactive material
 Psychological effect likely to be substantial
 Often used in conjunction with explosive devices (“dirty
bomb”)
 Treatment
 Immediate effects: radiation burns/acute poisoning
 Long-term effects: cancer/contamination of drinking water
 Decontamination must occur before patient care can begin
Radiologic Agents

 Damage consists of blast range effects, thermal
and nuclear radiation, and radioactive fallout
 Contamination can remain for many years
 Psychological effect likely to be substantial
 Treatment
 Symptomatic: thermal burns, shrapnel injuries, and
radioactive fallout
 Decontamination is required
Nuclear Agents

 Most common method for terrorists
 Cause violent decomposition and
pressure/temperature changes; propellants
cause injury and/or death
 Treatment
 Symptomatic
 Many may require treatment for burns
Explosive Agents

1. A nurse is conducting a community awareness
class for the preparedness phase of a terrorist
attack and states, “The most common agent used
by terrorists is:
A. Chemical because it can be dispersed by the
wind.”
B. A ‘dirty bomb’ because of its immediate effect.”
C. Nuclear because contamination can remain for
years.”
D. Explosive because the materials are easy to find
and conceal.”

 Preparedness
 Relief response
 Recovery
Stages of Disaster
12Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

 Focused on planning, preparedness, prevention,
and warning
 Every disaster begins as a local event
 Heaviest burden falls on the local community
 State and federal assistance is appropriated
when the local system is overwhelmed
Preparedness

 Community preparedness
 Assess the community for risks
 Plan for a coordinated response effort by local
agencies/services (e.g., law enforcement, fire, health
care, emergency medical services [EMS]).
 Build capability to respond to consequences (e.g.,
shelter, supplies, handling mass casualties)
 Local agencies must have an emergency operating
plan (EOP)
• Identified chain of command
• Plan for interaction with other agencies
Preparedness (cont'd)

 Metropolitan Medical Response System (MMRS)
 Funded by Department of Homeland Security
 Coordinates with statewide response plans
 Response
• Expanding hospital-based care
• Enhancing emergency medical transport and emergency
department capabilities
• Locating specialized pharmaceuticals
• Managing mass fatalities
• Providing mental health care
Federal Programs to
Assist Communities

 National Disaster Medical System (NDMS)
 Lead federal agency for medical response
 Supplements state and local resources
 Activated when local/state resources are insufficient
 Major components include:
• Teams of health care providers with supplies and equipment
• Patient evacuation
• Arrangements for hospitalizations
Federal Programs to
Assist Communities (cont'd)

 Commissioned Corps
 Led by the Surgeon General
 Responds in times of extraordinary need
 Made up of more than 6000 health care professionals
Federal Programs to

 Strategic National Stockpile (SNS)
 Jointly managed by the Department of Homeland
Security and Health and Human Services
 National repository of antibiotics, chemical antidotes,
antitoxins, IV administrations, airway supplies, and
other medical-surgical items
 Serves to resupply and enhance the supplies of local
and state agencies
Federal Programs to

 Response activities
 First emergency response to victims
 Stabilize the situation
 Require the interaction of emergency responders
• Fire and police
• Emergency medical services
• Hazmat teams
• Health care agencies and departments
Relief Response

 Incident Management System (IMS)–National
Incident Management System (NIMS)
 Designed to expand from one person or agency
performing all roles to a process involving hundreds of
people
 Hierarchic chain of command led by the incident
manager
 Job assignments consistently followed
 Includes representatives of all agencies needed to
provide emergency services
Relief Response (cont'd)

 Hospital Incident Command System (HICS)
 Defines responsibilities, reporting channels, and
common terminology
 Customized for organizations of varying sizes
 Successful use of incident command principles
depends on a unified command structure
 In the aftermath of Katrina and Rita, multiple hospitals
reported that the HICS was one of the most important
aspects of the disaster response

 Event recognition
 The causative agent may not be known immediately
 Responders assess for contamination potential
 Field decontamination is performed before victims are
transported
 Responders must use PPE
 Health care facilities should be notified of the
possibility of contamination as soon as possible

 Health care facilities’ priorities when receiving
contaminated victims
 First: protect patients, staff, and facility
 Second: provide medical care for contaminated
victims
 Third: protect the environment from decontamination
waste runoff

 Personal protection and safety
 Protecting emergency responders takes precedence
over other issues
 Being familiar with the routes of exposure is important
 PPE
• Level A: totally encapsulated chemical-resistant suit,
including supplied air
• Level B: chemical splash–resistant suit with hood and self-
contained breathing apparatus (SCBA)
• Level C: chemical-resistant clothing with a hood and an air-
purifying respirator
• Level D: uniform or scrubs; appropriate when no respiratory
or skin hazard is identified

 Communication within the health care facility
 Initiate plan to communicate to the public and within
the health care facility
 Communication officers need to do the following:
• Determine the effects the crisis will have on the audience
• Speak clearly and simply about the facts
• Be direct, honest, and to the point
• Calm and reassure the audience

2. A triage nurse becomes concerned and notifies the
nursing supervisor when several individuals come to the
emergency department within a 30-minute period with
pinpoint pupils, decreased levels of consciousness, and
respiratory distress. Each patient’s condition deteriorates
rapidly, and respiratory failure ensues. The nursing
supervisor instructs all staff members to don personal
protective equipment (PPE). What is the rationale for the
level of PPE the staff should use?
A. Level A, because the agent is unknown.
B. Level B, given that a nuclear agent is suspected.
C. Level C, because biologic agents are the probable cause.
D. Level D, because higher-level protection is not needed until
the agent has been identified.

 Begins 72 hours after the disaster
 May continue for 2 to 3 years
 Activities to enhance recovery, rehabilitation,
and reconstruction
 Evaluation of the disaster preparedness and
response plan
Recovery

 Preparation necessary for all types and causes
of mass casualty incidents (MCIs) (natural or
man-made)
 Issues to include in emergency preparedness
plans:
 Use of personnel, rotation and resting of personnel
 Use of family/volunteers
 Methods of evacuation
 Care of hospital staff and families
 Power outages and damage to the institution
Lessons Learned from
Recent MCIs

 Alternate standard of care to be able to serve the
greatest number of people (see report online at
www.ahrq.gov/research/altstand)
 Examples of decisions that had to be made
 Delivering medications when pumps were not functioning
 Deciding what meds would be given when the medication supply
was depleted
 Providing ventilation and suctioning without electricity
 Preparing unit-based scenarios can be helpful in
preparing for an MCI
Recent MCIs (cont'd)

 Develop plans for evacuation of patients
 Research suggests that evacuation plans should be
discussed at shift report at least once a week
 Suggest a 3-minute plan
• Which patients should be evacuated first
• How each patient would be evacuated
• What personnel/equipment would be needed
• Assess the evacuation route to ensure that no impediments
are present
Recent MCIs (cont'd)

 Pandemic influenza
 Global outbreak that occurs when a new influenza
virus “emerges” in the human population, causing
serious illness and death as it spreads worldwide
 Previous pandemic flu experiences
 1918: 50 million died worldwide/675,000 in the U.S.
 1957: 1 to 2 million worldwide/70,000 died in the U.S.
 1968: 700,000 worldwide/34,000 died in the U.S.
Biologic Causes of Mass Casualty:
Pandemic Influenza

 World Health Organization (WHO) phases of pandemic
alert
 Level 1: low risk of human cases
 Level 2: higher risk of human cases
 Level 3: no or very limited human-to-human cases
 Level 4: evidence of increased human-to-human
transmission
 Level 5: evidence of significant human-to-human
transmission
 Level 6: efficient and sustained human-to-human
transmission
 2009 alert is at Level 6
Pandemic Influenza (cont'd)

 Vaccines
 Influenza strains are capable of mutating so rapidly that
producing vaccines is like “shooting a moving target”
 Most likely will not be available in the early stages of a pandemic
 Planning aimed at saving the largest number of people
with control methods
 Isolation, quarantine, and restrictions
 Suspension of large public gatherings, school closure, and
“social distancing” (keep people as far apart as possible)
 Become familiar with your institution’s plan
 Know what your role is, how you would be notified, and where
and how you would report if an emergency were declared
Pandemic Influenza (cont'd)

 Practice good health hygiene and follow the
general principles of sound public health
 Teach family to cover mouths when coughing,
dispose of used tissues, wash hands
 Develop contingency plans for school and
business closures, unavailability of public
transportation, and disruption in social activities
 Personal stockpiling of food and medications
may help
Individual and Family Preparation

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Chapter 15

Editor's Notes