Planning and Triage in the Disaster Scenario

Emergency Preparedness Planning

“Failure to plan is planning to fail.” This quote by Benjamin Franklin appropriately reflects the message of this module. Emergency preparedness planning is crucial to prevent or mitigate a disaster. As defined in Module 1, disasters occur when a natural or man-made event transforms a vulnerable human condition into a traumatic event causing needs to exceed the local capacity for response. Without adequate planning, the most common response to these types of incidents is confined to simply rescuing victims and transferring them promptly to a hospital facility (the “Scoop and Run” approach). This results in the transfer of the problem from the incident site to the hospital, overwhelming and disrupting the care capacity of the health facility.

Planning for Children and Vulnerable Populations

Some events occur suddenly, with little or no warning. Others, such as flood and hurricanes, usually provide advanced warning or have a gradual onset that allows for additional preparations before the critical stage ensues. In any case, specific planning and preparedness are especially important to reduce the suffering caused by disasters, particularly for children. Children are among the most vulnerable populations in disasters because they have unique physiological, psychological, and developmental needs. Pediatricians and the local community have a special responsibility to assess how local, regional, and national preparedness plans and response systems will actually function to protect children. Failure to consider the needs of children in disaster planning, preparedness, and response at all levels potentially jeopardizes this vulnerable population. Pediatricians must advocate for the health, safety, and well-being of infants, children, adolescents, and young adults who cannot advocate for themselves. Increasing our understanding of how children were affected by past disasters will inform and strengthen our response.

Multidisciplinary Planning and Coordination

The information provided in this module can assist in the design of an emergency preparedness plan that will increase coordination among the many disciplines involved in disaster response. Active participation of all relevant entities in plan development is crucial. Participation in planning among involved entities breaks down the silos that all too often isolate different disciplines, and promotes understanding and cooperation among them. The multidisciplinary, inclusive planning process is actually more important than the document itself. The planning process facilitates a collective understanding among all the key agencies and their personnel about the plan, which is indispensable for effective implementation of the plan when it is needed. Planning should include both short-term and more long-term ways of risk reduction from potential disasters, efforts to educate families and community organizations about preparedness, and methods of horizontal and vertical coordination involving multiple local entities as well as regional, national, and international assistance networks. Local planners need to have knowledge of the regional and national response systems and the means to coordinate local activities with these systems.

Disaster Planning and Response Phases

The phases of disaster response include preparedness during which time there should be a risk assessment and mitigation; disaster response (the rescue mission) that involves warnings, evacuations, and saving lives during the immediate post disaster period; and the post disaster recovery period. Disaster management is part of the social system responsible for planning, organizing, directing, and controlling during all the phases of emergency management: Preparedness, Prevention, Response, and Recovery. The disaster plan should define the objectives, strategies, and activities, including a detailed chronology and a proposed budget.

Emergency and Contingency Plans

The emergency plan will have different objectives depending on the phase. Disaster preparedness includes the design of the plan, the training and coordination of those who will execute it, and the availability of needed resources. The plan designed during this stage is generically named the response plan. A plan made for various adverse events is called an emergency or disaster plan, whereas a contingency plan is designed for a specific adverse event (e.g., tornado, flood, pandemic).

Prevention, Response, and Recovery

During the prevention phase, the ultimate goal is to avoid or mitigate the disaster, directing efforts aimed at reducing both the risk and the vulnerability of the population. In many events, damages will occur despite mitigation efforts, and this is defined as the remaining risk. To face these damages, the capacity for response must be improved through preparedness. If a disaster occurs, the plan will be implemented in order to provide medical and humanitarian assistance. The response phase consists of both implementation of previously derived preparedness plans, as well as any spontaneous actions felt to be needed even if not part of a formal plan. After the response phase, efforts will be directed towards repairing damaged services. This is known as the recovery phase. Reconstruction and recovery consists of restoring the goods and services back to pre-disaster levels if possible, and includes measures for future risk reduction.

Pediatricians’ Role in Planning

Pediatricians and other clinicians that care for children need to be involved in all local committees that are considering risk management, preparedness, and response. They should be familiar with the plans that exist in their region so that they can work in coordination with other members of the response system. In summary, emergency planning includes all the activities and actions done preemptively in order to prevent, mitigate, respond to, and recover from the damages that disasters can cause. All stages of a disaster (described in Module 1) include elements of planning that are important for the pediatrician. These involve various social agents and are performed at different levels: the family, local community organizations, emergency services, community physicians, hospitals, government, and other agencies especially the local red cross and red crescent societies. The town or district public health offices are usually the convening agents for disaster preparedness and response planning.

Planning Process and Implementation

This is not merely desk work. It involves obtaining and analyzing data, along with field visits and meetings with representatives from different institutions and the community. Preparation demands the active participation of the health-care sector and the community. These efforts should result in the production of operative and concise documents that clearly define the responsibilities of specific participants and the agreements reached among the participants. It is important to institute periodic drills to test the functionality of the system and the coordination among the different participants.

Risk Evaluation

Identify the possible natural events that threaten a particular community (e.g., earthquakes, torrential rains, volcanic eruptions, sliding soils, the overflow of rivers or lakes). In certain regions, the climatic events that endanger the population have a seasonal predisposition. Recognizing these climatic cycles can maximize preparedness before and during these periods.

Do not disregard disasters caused by human actions. These include incidents in factories, chemical or fuel storage plants, intentional or accidental fires, incidents with radioactive or nuclear materials, armed conflicts, wars, or terrorism.

In summary, risk evaluation involves identifying regions and communities that are most vulnerable to the threats under consideration, and describe the specific characteristics that make these communities susceptible to those threats.

Community Emergency Planning

Clearly define the responsibilities of each institution and methods of coordination and collaboration. Analyze the risks threatening the various sectors of the community and develop immediate interventions recognizing both geographic and climatic conditions for various regions. Obtain input from regional and national levels, involving national and regional health officers in the planning process.

Essential Characteristics of an Emergency Plan

The emergency plan should fulfill four essential characteristics: it should be clear, concise, complete and widely disseminated.

Responsibilities and Coordination

The plan describes the responsibilities of each participant, the risks involved, and the range of interventions. It is imperative to involve the organizations that will carry out the plan in the planning process itself. For a health-care agency, the emergency plan defines the objectives, the actions, and the organization of the hospital and its various departments with respect to the response activities and responsibilities of its staff members.

Analysis of the situation

The analysis of the situation includes:

Assumptions

Identify the type or types of phenomena that should be addressed in the plan and describe the probable magnitude, the expected intensity at the site where the community is located, and the time period during which it is likely to occur. Determine the potential damages and the maximal demand for health services by establishing a relationship between the threat and the vulnerability.

Objectives and goals

The objectives and goals describe the expected outcomes from executing the emergency plan given the human, economic, and material resources that will realistically be available. One of the most frequent mistakes when preparing an emergency plan is to include nonexistent resources with the hope of obtaining them in the near future. Since it is usually impossible to obtain all the desired resources, establish priorities for the actions based on the population and geographical area to be served. The plan should include an outcome prediction that describes the measurable impact of carrying out the emergency plan.

Organization

Organize the various sectors and departments of the institution so that authority, lines of responsibility, and methods of coordination and communication for plan activation are clear and well-defined. Establish an emergency operations committee to oversee and coordinate response actions.

Roles and responsibilities

The assignment of roles and responsibilities is meant to answer the following questions:

It is important to have a clear command chain for communications with backup systems to mobile cellular service such as radios, megaphones, and mobile sound systems.

Communication and coordination

The communication instructions describe a calling or notification chain from a central point until all the necessary individuals have been contacted. Establish the means of communication to be used, indicating the radio band and frequency, telephone numbers, and rendezvous locations. Each location should have a team leader identified. Team leaders can do household counts to determine who might be missing and need to be rescued. Appendices to the plan include an updated directory of all the participants, a map of threats, vulnerable areas, or locations, as well as the population database, a health profile, health centers included in the network, a directory of basic services (e.g., water, electricity, telecommunications, security), assistance agencies, and an inventory of the available resources.

Training

Once the emergency plan has been developed, conduct training. Training should enable the participants to describe the situation, expected damages, roles and responsibilities, and means of coordination. This training should include simulation exercises. The participants will have to solve theoretical (tabletop) exercises once they have been assigned one of the roles and responsibilities contemplated in the plan. This exercise allows participants to assess their knowledge of the technical and organizational aspects of the emergency plan.

At a later stage, disaster drills can be organized and enacted. Organize disaster drills with prior notice, promoting the participation of the staff and key members of the community. Use the experience gained in the simulation drills to update the emergency response plan. Enacting unannounced simulated disasters without previously training participants usually causes frustration and has unwanted effects.

Resources

Analyze the activities included in the emergency plan to determine the resources required. This listing of resources is called the requisite analysis. Contrast the listed resources with those actually available and define the resources that are yet to be obtained. Gather the resources needed to carry out the emergency plan. Remember that the emergency plan must be based on reality. Otherwise, it will become a mere listing of wishful ideas.

See Box 1 for useful planning resources.

Response Mechanisms and Command Structure

The response mechanisms will have specific characteristics depending on the size of each community and the particular risks that threaten it. The coordinators in hospitals, rescue services, and emergency medical services, as well as the participants processing the incoming information, should report to an incident commander who will direct the local emergency plan (Figure 1).

A coordinated emergency response between various levels of local, state, and federal government may be needed, in addition to non-governmental agencies providing humanitarian aid.

Planning in the family

Pediatricians should prepare themselves for a disaster as well as provide the families of their patients with information about creating a family emergency plan. The questions below serve as a planning guide. Families need to understand that they have to be prepared to evacuate before the area becomes inaccessible by rescue services, and if they choose to stay, they might not be helped immediately.

All family members should know contact telephone numbers outside the affected area and know where community shelters will be located. It is also a good idea to have a pre-established meeting point outside the risk area when possible. Family should also know the location of the command center or evacuation site during typhoons, floods and other natural disasters.

When professional duties (e.g., those of health-care professionals, policemen, firefighters, public officials) limit the ability to assist one’s own family, it is important to have a clear written plan that has been discussed and can be followed. An example would include having a retainer contract with a child care provider during a pandemic influenza outbreak.

Consider storing and periodically renewing medications and supplies needed by family members with special health-care needs for use in the event of a disaster. Consider having a small backup generator to keep a refrigerator operational to store medications when there is no electricity. Recognize that family members with special needs may require earlier evacuation to ensure a safe environment.

Provide families with information about making a contingency plan that will enable family independence for 3 days following a disaster.

A list of supplies needed for 3 days of self-sufficiency for a high income country are shown in Box 2. This list should be modified for what is appropriate and feasible for low and middle income countries. A local specialist can add other useful supplies based on the local situation. Box 3 lists online resources for families.

Planning for Pediatric Offices and Staff

In addition to having their own family plan and educating the families of their patients, pediatricians should address several issues for their offices and staff. These issues involve ensuring the safety of staff and patients, protecting equipment and material, and securing patient records.

School and Child Care Emergency Planning

Public and private schools also need emergency response plans. 

Reopening Schools After a Disaster

Following a disaster, children often need the security of a normal routine and support of teachers and peers. Closing schools for a prolonged period negatively impacts the functioning of children after a disaster. Every effort should be made to open schools as soon as possible after an event. Use of school buildings as emergency shelters may hinder or complicate their reopening. Therefore, coordination between schools and relief agencies such as the Red Cross or the local organization for emergency management will assist in the transition to normal operations. More information regarding school disaster planning can be found at the American Academy of Pediatrics website: http://www.aap.org/disasters/schools.cfm.

Child Care Centers

Child care centers also need a plan to ensure the safety of children, to coordinate with other community response agencies, and to provide a method for reuniting children with family members. Child care centers need to educate and train staff members to implement the emergency plan efficiently.

Children With Special Health-Care Needs

Families, schools, and child care centers must consider how to help children with special health-care needs in an emergency situation. The AAP and the American College of Emergency Physicians have published an emergency information form (EIF) for children with special needs. This document provides important medical information about the child to any person responsible for their emergency medical care.

Shelter Planning and Operations

Shelters should have an identifiable person who is available, accountable, and responsible for communicating with agencies or organizations for supplies and assistance. Emergency planning must consider the possibility of prolonged shelter use which would require additional supplies and greater attention to organizational details. Planning should include sources of supply and methods of transportation. The needs of pregnant women, infants, and young children must be considered with respect to formula, diapers, basic first aid, hygiene, and safety. Shelters also must consider children with special health-care needs. For example, children with asthma may need nebulizer treatments. Although their families are likely to have brought their own nebulizers, a source of electricity is needed for these devices to operate.

Similarly, a refrigerator is required to store insulin for children and adults who have diabetes. Families with very young or debilitated children may move temporarily to a shelter to protect them from the heat, cold, sun, wind, or rain. Whenever possible, shelter staff members should have direct telephone or radio access to emergency medical care services to obtain medical advice. Ideally, a shelter should have isolation protocols for highly contagious infections such as measles and chickenpox.

Child Supervision and Activities

Shelter life must also be organized so that children are supervised and have the opportunity for constructive play and entertainment. Supervised activities enable the staff to inform children and keep them safe, while allowing them to participate in activities and tasks. Drawing and other creative activities can help children express themselves and reduce stress. Activities engaging adolescents reduce the potential of adolescent violence and mischief.

Shelter Safety

Safe Hospital Framework

The WHO comprehensive safe hospital framework provides a guide for preparing hospitals for their role in disaster risk management.

Some guiding principles when applying the framework from the report are as follows:

Hospital Disaster Planning

Hospital planning for disasters should deal with hospital and pre-hospital events. Hospital events include accidental or non-accidental events such as the collapse of hospital structures, fires, explosions, pandemics or toxic exposures. Plans should include a detailed description of the measures taken to protect staff members, patients, and visitors. In cases of infectious diseases or toxic exposures, protective personal equipment and isolation procedures must be instituted immediately to protect staff or other patients. Hospitals may need to coordinate with government agencies to access stockpiles of necessary medicines, vaccines, or equipment. In cases of structural collapse, fire or explosions, rescue interventions attempted by hospital staff who have received no previous training can put them in serious danger. Educate staff about basic safety precautions, and knowing when to intervene or to wait for the arrival of trained rescue workers. During the past 25 years, natural disasters have destroyed dozens of hospitals and hundreds of health centers, resulting in the deaths of thousands of patients, physicians, nurses, and other people who were trapped in the debris.

Hospitals must determine if it is necessary to build their surge capacity. The ability to treat and manage a sudden influx of patients will be determined by a variety of factors including, but not limited to, the number of inpatient, ICU, or emergency beds available, surgical capacity, staffing needs for all departments, supplies, and other physical spaces available for expansion of treatment areas. It is important to ensure that existing inpatients also receive appropriate care and are discharged or transferred to other facilities if necessary. The plan should include a communication method to call in additional healthcare professionals and ancillary staff. Directors of hospitals and emergency departments should have a basic knowledge of the local disaster plans and the local command levels. Select one or more members of the hospital staff to serve as liaisons with other responding organizations and agencies to coordinate any activities undertaken outside the hospital environment. In certain situations, a hospital can also serve as shelter for staff members and their families, patients with special needs, and the general public.

Hospital Incident Command System

Some U.S. hospitals have adopted a modified system for mass casualty incidents or disasters that mirrors the external incident command system. Originally known as the Hospital Emergency Incidents Command System (HEICS), it is now known simply as the Hospital Incident Command System (HICS). The system was originally developed by California firefighters in order to establish a common command structure and nomenclature.

This allows for a greater integration with the external response plans (Figure 2 and Box 5) and provides a working command structure for the hospital. It also recognizes the necessity of many other ancillary services and functions that may not be initially considered a part of direct patient care, but are nonetheless vital to emergency hospital operations.

Hospitals can also offer physicians who have lost their offices a space in which to attend to patients or in turn, provide emergency credentialing to community physicians when additional help is need. These additional physicians can cooperate with the regular hospital physicians in the care of patients who have minor conditions, thereby allowing regular hospital staff to attend to more critical cases.

Hospital plans also need to address the management of stress. Frequent rotation of providers and staff during surge times enables efficient performance, and minimizes psychological and physical exhaustion. Hospital plans should also take into consideration the care of individuals with acute stress reactions, those who feel guilty for having survived or having abandoned their families, and those who have suffered considerable material losses or have other psychological sequelae during and after the disaster. Post-traumatic stress disorder and other stress-related syndromes are frequent after a disaster.

Emergency Medical Services

Emergency Medical Services (EMS) are a type of emergency service dedicated to providing out-of-hospital acute medical care and/or transport to definitive care to patients with acute illness and injuries. The US has a sophisticated system of EMS agencies that include different levels of providers. Each type of provider is an integral part of the system and the composition of providers is dependent on the needs and resources of the local area.

EMS “DISASTER” Response

Partnerships with federal, state, and local EMS agencies exist to ensure the common goal of protection and preparedness for the states and its citizens. The local community and state leaders are responsible for their own disaster management. The responsibility of the federal government is to provide support, a framework for organization, and resources.

Medical Care in a Mass Casualty Incident (MCI)

Mass casualty management, as may occur in a disaster situation, requires an adjustment of the traditional emergency care approach. In the traditional care approach, first responders are trained to provide victims with basic triage and health-care before evacuation to the nearest available receiving health-care facility. This approach juxtaposes two organizations that work independently with only weak linkages: the field (often involving non health sector responders), and the receiving health-care organization that is often totally divorced from the pre-hospital problem. In a mass casualty situation, this approach will quickly result in chaos. For this reason, a system that would allow an adequate response to mass casualty situations was developed.

Mass Casualty Management System

This system, known as mass casualty management, includes pre-established procedures for resource mobilization, field management, and hospital reception. It is based on specific training of various levels of responders and incorporates links between field and health-care facilities through a command post. It acknowledges the need for a multi-sector response for triage, field stabilization, and evacuation to adapted health-care facilities. The development of this approach is based on the availability of large amounts of human and material resources, so it should be adapted to the available resources to maintain the same effectiveness in its implementation.

Rescue Chain

The rescue chain, the essence of the mass casualty management system, involves the health department, private hospitals, police, fire department, nongovernmental organizations (NGOs), transport services, and communications (Figure 3). This chain starts at the disaster site (with activities such as initial assessment, command and control, search and rescue, field care), continues with transfer of victims to appropriate facilities (using procedures to regulate evacuation and ambulance traffic control), passes through hospital reception (with activation of the hospital disaster response plan), and ends only when the victims have received all emergency care needed to stabilize them.

The implementation of this rescue chain requires the following components:

The assignment and organization of resources in mass casualty management requires careful planning.

Organizing the Disaster Zone

These activities include the procedures needed to organize the disaster zone. The alert given by any observer sets the process into motion. Define exactly the location of the disaster event, the time of its occurrence, its type, the estimated number of victims, the risks, and the population threatened by these risks.

The initial assessment will establish what resources will be mobilized at the site of the disaster (Refer to Figure 3 in Chapter 5).

The initial evaluation unit identifies the zones to be set up at the incident site:

Appendix B in Chapter 11, displays a number of function cards that define in detail the basic activities of the professionals involved in the coordination and the care of victims in a MCI.

Safety

Rescue activities during a disaster should include measures to guarantee the safety of the victims, the members of the rescue units, and the general population.

Communication and documentation

When a disaster occurs, both ­landline telephones and cell phones could be overburdened. The communication method of choice for emergency organizations utilize ultra-high frequency (UHF) and very high frequency (VHF) waves. The former are used for communications within the area of the event, and the latter for communications with strategic centers for purposes of coordination or transportation. Patient referral information should be provided from the site to the Incident Command and from there to intervening agencies and the nearest hospital. Essential information to be collected includes:

Care of Victims

Search and rescue activities should be performed by individuals with specific capabilities including firefighters and specialized rescue units. Before allowing these individuals to enter the disaster area, verify whether they need special clothing or breathing equipment to protect them from environmental risks.

Once the search and rescue units have located the victims, they must take them to a risk-free casualty collecting point to be assessed (field triage).

After this initial triage, the victims receive first aid according to their status. When the number of victims or the distance from the place of the incident prevents the direct transportation of all victims to hospitals, an advanced medical post may be established adjacent to, but outside of, the impact zone.

Prior to the advanced medical post, all victims are medically triaged (see “Triage: Rationale” below), to identify those who require immediate care.

Following triage classification, victims are referred to the adjacent treatment areas within the advanced medical post where they are stabilized. Stabilization procedures may include advanced airway management fluid therapy to maintain circulation and treat shock, control of hemorrhage, and analgesics. Document the therapies given in the patient’s evacuation report that accompanies the patient to the hospital. In summary, goals of the advanced medical post are to stabilize patients, reassess their condition (retriage), and organize their transportation to the appropriate hospitals. All these tasks have been summarized as the 3 Ts principle: typifying (classifying), treating, and transporting.

Ideally, the advanced medical post should be staffed with trained emergency medicine physicians and nurses; additional physicians such as surgeons and anesthesiologists can be added if available and needed.

Triage - Rationale

Triage is a system that allows establishing priorities for care and transporting in order to save as many lives as possible. It is performed during the rescue phase, and uses priority criteria for the care of patients, distinguishing those requiring immediate stabilization and transport from those who can wait. In a more detailed analysis, triage also allows for identifying patients who need emergency surgery. The primary triage in a MCI consists of a quick evaluation so that all the victims can be examined in a short period of time and decisions can be made regarding treatment priorities.

Once the victims are brought to the collection point, the staff responsible for triage must quickly assess each and every victim, and refrain from providing treatment other than hemorrhage control and brief airway repositioning. Specific algorithms, such as the START (Simple Triage and Rapid Treatment, Figure 6) have been used to streamline this process using a color-coding system. START triage evaluates for respirations, pulse/perfusion, and mental status. All patients are triaged first prior to initial medical interventions. During this evaluation, each victim is identified with a specific color-coded tag, tape or marker to indicate the level of medical urgency needed. Primary triage is based on the premise that all the victims are equally important, regardless of age, gender, profession, or any other factor. Decisions are made exclusively based on the victim’s clinical condition. Patients are classified according to severity as green (uninjured or minimally injured), yellow (moderately injured or urgent), Red (severely injured or emergent), and Black (deceased).

Field triage is performed on three levels:

Pediatric triage

The JumpStart triage system is a modified triage algorithm of START based on physiological criteria adapted to the normal range of pediatric values (Figure 7).

Unlike the adult-based triage system, this system recognizes that an apneic child can still maintain a certain degree of perfusion before he/she develops an irreversible cardiac lesion secondary to anoxia. These children can survive if their respiratory function is sustained or restored, something that will not be identified by applying the START system (Figure 6), which does not include pulse palpation for patients whose apnea persists after the airway has been opened. Children who are not able to walk or are carried in arms by adults should always be categorized at the very least, as yellow.

Regardless of the triage system used, perform a careful secondary evaluation on all the victims on-site and then again at the emergency department. Triage is a dynamic process and continues until the patient arrives at a place where he/she is offered definitive evaluation and treatment.

SALT Triage

There is a newly proposed national for mass casualty triage called SALT for both adults and children (see Appendix B). SALT stands for “Sort, Assess, Life-saving interventions, and Treatment.” This guideline was developed due to the multiple triage systems, many of which have been inadequately guideline validated. This guideline was developed by an interdisciplinary committee of the AMA, the American College of Surgeons, the American College of Emergency Physicians, the National Association of EMTs, and various other representative organizations.

Global sorting is the first step to address the “walking wounded”. Those who are able to walk are prioritized last; those who cannot follow a command or have an obvious life threat are prioritized first; and those who can follow a command but are unable to walk are prioritized second. The next step of this triage system is to make lifesaving interventions before assigning a patient to a triage category. Lifesaving interventions include control of major hemorrhage, opening the airway and providing 2 breaths for child casualties, decompression of a tension pneumothorax, and use of autoinjector antidotes. Finally, triage categories are assigned to be Delayed, Immediate, or Expectant management based on breathing, peripheral pulses, respiratory distress, and hemorrhage control. This system of triage is different from the other systems in that there is a grey or “Expectant” category. This category means that the patient may have a life threatening injury, but current resources are not available to meet the demand. The “expectant” category of patients should be re-evaluated frequently as resources become available.

This system of triage does not assign “colors” to patients; therefore, it should not be confused with other triage systems. The SALT triage system is an attempt to take the best features of triage systems that have been tested. It is a different method of triage in that there is global sorting based on the ability to follow commands and walk, and a triage category assignment based on response to life-saving interventions. Children would likely be over-triaged to the “assess 1st category,” as many will not be capable to follow commands due to developmental stage. This over-triage is probably inherent in pediatrics and can not be avoided. This SALT system of triage should be tested against the most commonly used form of pediatric triage: Jump START.

Transfer Organization

The transfer organization includes those procedures implemented to ensure that victims of a mass casualty incident will be safely, quickly, and efficiently transferred by appropriate vehicles to a prepared healthcare facility.

Transfer is organized according to different principles such as strict control of the rate and destination of evacuation to avoid overwhelming the health-care facilities. One of the roles of on-scene mass casualty management is to stop spontaneous evacuation from by-standers of unstable victims or those minimally injured. This unmanaged transport is unsafe, ­endangers the lives of victims, circumvents field decontamination process, and disrupts the implementation of the mass casualty management system. Victims should not be removed from the advanced medical post to health-care facilities before:

Control of Victim Flow: The Noria Principle

Receiving Hospital Organization

The mass casualty management system needs specific organization at the receiving hospital. This organization allows the active mobilization and management of available or needed resources, communicates with pre-hospital providers, and facilitates the management of inpatients and the flow of incoming victims. Other management tasks include secondary evacuations, departments, operating rooms, laboratory, radiology, and intensive care unit, have to be reinforced. It is also important to prepare sequential reinforcements and allow a rapid rotation of the staff in those areas where the workload will be most demanding. This prevents overburdening the staff during an influx of casualties and ensures the prompt return to normal operations with an adequate staff.

Reception of victims

In order to accommodate the influx of new patients, discharge all patients that can be cared for on an outpatient basis. Adding hallway beds or opening up inhospital clinics can help with surge capacity. If victims bypass the on-scene medical triage and arrive at the hospital on their own, they should be triaged appropriately as with any other arriving victim. When prehospital management has been efficient, an experienced emergency nurse can do the triage. If this is not the case, triage should be performed by an experienced emergency physician, anesthesiologist or surgeon. All arriving victims, whether or not they’ve been previously triaged, should be re-triaged upon arrival to the hospital. 

Treatment Areas

Clearly establish the treatment areas in the hospital and provide the necessary staffing. Treatment area designation should reflect triage levels, e.g., red treatment area for victims triaged in the red category. An emergency medicine physician or an anesthesiologist should be in charge of the red treatment area and should be prepared to treat patients with extremely severe injuries. An additional triage can determine the order of these red patients that need operative interventions. Victims triaged as yellow should be reevaluated by a physician and provided care or observation as needed. If their condition worsens, transfer them to the red treatment area. Victims with no hope for survival require only supportive care. These patients should be kept in a separate ward. Have an area ready for deceased victims if the hospital morgue is overwhelmed.

Conclusion

References

Case Resolution

Review Questions

Emergency Support Functions

Function Cards for Mass Casualty Incident Response

PAHO has created a number of function cards that define in detail the basic activities of the professionals involved in the coordination and the care of victims in a MCI.