Preparations for Mass Casualty Care

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Preparations for Mass Casualty Care

• John G. Benitez, MD, MPH
• Managing and Associate Medical Director
• RA Lawrence Poison and Drug Information Center
• Center for Disaster Medicine and Emergency
  Preparedness
• University of Rochester

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Acknowledgement

• Material fromBioterrorism and Other Public
  Health Emergencies Altered Standards of Care in
  Mass Casualty Events
• Agency for Healthcare Research and Quality
• US Department of Health and Human Services
• 2005
• (AHRQ Publication No. 05-0043)

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Assumption

• Health care will be delivered according to
  established standards of care

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Reality

• Compromised health care
• Short term(?)
• Local
• Regional
• Therefore we need to make plans

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Key Issue

• Save as many lives as possible
• Typically we want to save everyone
• This is a change from the usual standard of care!

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Set of standards

• What- interventions, protocols, orders?
• To whom- medical care, likelihood of response?
• When- what level of urgency?
• By whom- who is certified/licensed?
• Where- what facility and standards (pre-hospital,
  hospital, alternate care site) should be in place?

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Scenario 1

• A series of multiple, simultaneous explosions
  (dirty bombs) throughout a city. Some city
  hospitals targeted and 40 of hospitals are no
  longer operational. There are an estimated
  10,000 victims.

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Scenario 2

• A highly lethal communicable biological agent
  with a set but initially unknown incubation
  period has been released in a heavily populated
  area. Diagnosis is dependent on laboratory
  tests. Medical staffs are required to use PPE.
  Treatment requirements include isolation and use
  of ventilators however, impact and effectiveness
  of treatment is unknown.

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Requirements of both scenarios

• Triage aimed at saving most likely to survive
• Triage decisions that will allocate resources
• Immediate need EDs
• Ambulatory alternate care sites
• ICUs may become surgical suites
• Regular wards may become isolation areas

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Requirements of both scenarios

• Needs of current patients
• Elective procedures cancelled
• Current patients discharged or transferred
• Certain lifesaving efforts discontinued
• Usual scope of practice standards changed
• Nurses may function as physicians
• Physicians practicing outside own specialty

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Requirements of both scenarios

• Equipment rationed
• Not enough trained staff
• Backlogs of patients causing delays
• Treatment decisions based on clinical judgment
• Psychological impact on providers
• Documentation standards
• Backlog for processing fatalities

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Scenario 1 Specific

• Pre-hospital
• Physicians not at scene. Triage per
  EMS/first-responders
• Anyone at scene who can help medical staff
• Triage protocols may not apply
• Alternate transport buses, etc
• Shortage of EMS equipment (backboards,
  immobilization, etc)

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Scenario 1 Specific

• Hospital
• Water, heating and cooling, electricity, and
  communication shortages
• Reserve medical supplies and equipment lag phase
• Provider-patient relationship severed
• Strict control of access to hospital
• Decontamination practices
• Only lifesaving surgery
• Just in time ordering practice stressed

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Scenario 1 Specific

• Alternate Care Sites
• Ambulatory patients redirected
• Within hospital
• Outside hospital

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Scenario 2 Specific

• Pre-hospital
• No initial scene. Done at MD offices, EDs,
  pharmacies
• Communication important
• Public health surveillance
• EMS used to transport to quarantine, isolation or
  alternate care sites

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Scenario 2 Specific

• Hospital
• Emphasis on prevention and contagion control and
  treatment. Group isolation may be necessary
• Suspected exposure patients quarantined. If
  diagnostic tests not available, may be treated.
• Staff shortages
• Protection of all staff and families
• Early treaters/responders need to be
  quarantined and treated. Increased staff
  shortages

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Scenario 2 Specific

• Hospitals
• Demand for pharmaceuticals likely to outstrip
  supply. Experimental or expired drugs may need
  to be used.
• Standards of care will worsen with increasing
  number of patients.

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Scenario 2 Specific

• Alternate Care Sites
• Triage
• Distribution of vaccines/prophylaxis (POD)
• Quarantine
• Minimum care
• Hospice care

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Guideline needs

• Adequate number of providers/staff
• Triage by condition, probability of response to
  Rx and resources available
• How to maintain infection control/safe
  environment
• How to use/reuse common supplies/equip.
• Allocate resources beds, surgery, lab, etc.

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Guideline needs

• Allocate scarce/highly specialized resources
  decon units, isolation units, ventilators, burn
  beds, ICUs
• How to treat specific conditions
• How to protect providers/staff and families
• Modification of documentation standards
• Managing excessive fatalities
• All need to be scalable to the disaster

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Medical Care Response Plans

• Compatible with or integrated with day to day
  operations
• Applicable to broad spectrum of event types and
  severities
• Flexible, graded response, based on changing
  circumstances
• Tested to determine where gaps exist

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Medical StandardsModified by Event and Stage of
Disease
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Guiding Principle 1

• In planning for a mass casualty event, the aim
  should be to keep the health care system
  functioning and to deliver acceptable quality of
  care to preserve as many lives as possible.

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Guiding Principle 2

• Planning a health and medical response to a mass
  casualty even must be comprehensive,
  community-based, and coordinated at the regional
  level.

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Guiding Principle 3

• There must be an adequate legal framework for
  providing health and medical care in a mass
  casualty event.

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Guiding Principle 4

• The rights of individuals must be protected to
  the extent possible and reasonable under the
  circumstances.

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Guiding Principle 5

• Clear communication with the public is essential
  before, during, and after a mass casualty event.

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Issues

• Legal and Regulatory Issues
• EMTALA
• HIPAA
• OSHA
• 80 hour work week for medical residents
• Financial Issues
• Costs, normal and at alternate sites
• Training

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Issues (continued)

• Communicating with the public
• Ensuring and adequate supply of health care
  providers
• Retired or unemployed
• Reserve military
• Modifying State certification/licensure
• Provider Training and Education Programs

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Issues (continued)

• Protection of health care providers and
  facilities
• PPE, prophylaxis
• Rotation
• Malpractice
• Mental health
• Families

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Issues (continued)

• Caring for Populations with Special Needs
• Children
• Persons with physical or cognitive disabilities
• Persons with preexisting mental health and/or
  substance abuse problems
• Frail or immunocompromised adults or children
• Non-English speakers

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Issues (continued)

• Transportation of Patients
• Who will accompany?
• How should services be mobilized?
• What kind of prior agreements can be established?

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Summary

• Need plan
• Need to practice plan
• Need to realize alteration in standards may be
  needed, depending on incident
• Coordination with and regional plan