DISASTER COMMAND Disaster command provides overall direction and coordination of the hospital disaster response activities. These activities include activation of the plan, coordination of hospital activities with those at the disaster site, opening up additional hospital wards or clinics, obtaining outside assistance, evacuation of endangered patients, assignment of staff to treatment areas, and adjustment of the plan as necessary. Good, reliable communication is essential.
TRIAGE Entry of all patients should be restricted to one location: the triage area. The primary function of a disaster triage area is rapid assessment of all incoming casualties, assignment of priorities for management, and distribution of patients to various patient care areas in the hospital. A senior emergency physician or resident should be responsible for triage.
PATIENT IDENTIFICATION, REGISTRATION, AND DOCUMENTATION Emergency department registration personnel are key components of the emergency department disaster response. Ideally, they should be part of the triage team. Prepared documents assigned to each patient should include a unique disaster number for each patient, the patient's name and key information if available, the triage designation, the patient's wristband identification and charting materials, and copies for postevent analysis. A system should be in place to quickly obtain more patient documents when the supply is depleted. A separate triage log should be maintained. Individuals must also be assigned to transfer registration information to the hospital computer system so that laboratory requests, admissions, blood for type and cross-match, and dispositions can be systematically recorded. Finally, if unique disaster numbers are used, a system for transferring to the hospital medical record number system should be in place.
PATIENT CARE STATIONS One suggested method of organizing patient care stations includes division into resuscitation, major illness and injury, and minor trauma/primary care.
A resuscitation area should handle all life-threatening problems. Seriously injured patients who do not require immediate airway management or resuscitation are sent to the major illness or injury area, located in the emergency department.
In most disaster situations, the majority of patients are not seriously injured. Such patients can be sent to the minor trauma/primary care area for splinting of fractures, primary closure of lacerations, and tetanus prophylaxis. This area can be established in the hospital's outpatient clinics.
PRESURGICAL HOLDING Most trauma patients stabilized in the major illness or injury area (emergency department) will be sent to the admission presurgical holding area.
SURGERY The number of operating rooms that can be staffed is the main limiting factor in the provision of definitive care for a large number of severely injured casualties.47 The most senior surgeon available must take the responsibility for prioritizing cases and assigning surgeons to them as rapidly as possible.
MORGUE Many disasters can result in a large number of fatalities. Morgue capacities may need to be expanded or outside facilities, such as a church or stadium, temporarily utilized.48
DECONTAMINATION JCAHO requires hospitals to have provisions for emergency treatment and decontamination of individuals who are radioactively or chemically contaminated.1 49 Some basic requirements for hospitals are (1) a safe area for decontamination, (2) a means of washing external contamination from patients, (3) a method of containing contaminated materials, (4) adequate protection for persons handling patients and for other hospital personnel, and (5) disposable and/or cleanable medical equipment.
The goals are to reduce external contamination, contain the contamination that remains, and prevent further spread of potentially dangerous substances. 1 50 After being decontaminated, the patient can be treated as a "normal" accident victim. To accomplish this, three things must be achieved: (1) termination of exposure to toxic material, (2) stabilization of the patient, and (3) initiation of proper definitive care.
PSYCHIATRY In the event of a disaster involving mass casualties and extensive property damage, it is common for patients to present with episodes of anxiety, depression, and psychosis. Hysterical persons, whether patients, visitors, or staff, can be extremely disruptive to hospital disaster operations. A separate, isolated area must be predesignated to receive individuals in need of psychological intervention.
FAMILY WAITING AND DISCHARGE AREA Families and friends will converge on the hospital seeking information about victims. A separate area must be predesignated for family members seeking information. This area may also be utilized to discharge in-hospital patients and victims of the disaster. It may be staffed by volunteers, chaplains, and members of the public relations staff.
PUBLIC RELATIONS COMMAND The medical disaster plan should include a section on the proper relationship with the media. Representatives of the media are present at all medical disasters. They may be a valuable resource for announcing hazards or the need for evacuation. In addition, they may be used to make a general announcement that hospital or rescue personnel should report to work. The plan should include a means of providing the media with adequate information both at the site and in the hospital. At the disaster site, regular briefings help prevent representatives of the media from becoming victims as they search for more information. At the hospital, regular briefings and a room with adequate telephone access will prevent members of the media from invading patient care areas. A hospital public relations officer should act as liaison to the media. His or her duties are to prepare the pressroom, hold regular briefings, and arrange appropriate photographic opportunities. These functions must be carried out while balancing the public's right to know with individual victims' rights to privacy.
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