What should the administrator of a community hospital do during a mass casualty event

Mo Med. 2018 Sep-Oct; 115(5): 451–455.

Abstract

A mass casualty incident (MCI) by definition can overwhelm local and regional resources. Preparation and training is required by any health system to minimize the loss of life and maximize patient recovery. This update will review lessons learned from recent events and discuss current research that healthcare providers should be familiar with when managing MCI’s.

Introduction

The Hospital Preparedness Program (HPP) was established after September 11, 2001 to “enhance the ability of hospitals and healthcare systems to prepare for and respond to bioterror attacks…and other public health emergencies, including pandemic influenza and natural disasters”.1 An interim 2007 progress report on the state of U.S. hospital preparedness highlighted considerable progress made in the area of healthcare coalitions contributing to collaboration and networking between all levels of providers from first responders to hospitals and public health agencies. Evolving areas for improvement include planning for catastrophic emergencies requiring drastic changes in infrastructure and response systems, and their ability to respond to unconventional mass casualty incidents (MCI) as measured by surge capacity.1 In 2015 the federal government updated its National Preparedness Goal, “A secure and resilient Nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to, and recover from the threats and hazards that pose the greatest risk”.2 The document outlines core capabilities which include quick disaster response in the aftermath of an incident. It also emphasizes the mitigation of risk at the local level with preparation and coordination.

Lessons Learned from Recent Events

In 2011, the deadliest single tornado recorded in the U.S. since the beginning of recordkeeping in 1950 struck Joplin, Missouri. It destroyed 7,000 homes, resulted in 162 fatalities and over 1,000 injured, and cost an estimated $3 billion in insured losses. In their review of the MCI, Bimal Paul and Mitchel Stimers collected data from first responders, survivors and the Federal Emergency Management Agency (FEMA) to determine reasons for the high fatality rate.3 They concluded that in addition to the intensity of the tornado and the large size of damage area, other contributing factors included ignoring the warning sirens or having less than 15 minutes to seek shelter, structural weakness in area homes and disproportionate damage to a hospital and area business where more people were gathered. A component of delayed recognition of a rare fungal infection also contributed to late deaths.4 Some of these patients were transferred to our institution only to succumb to the widely disseminated infection.

An after-action review published by the Boston Trauma Center Chief ‘s Collaborative discusses key lessons learned from the 2013 Boston Marathon bombings’ MCI response, the scale of which had not been seen since the Cocoanut Grove fire.5 Representing six area trauma centers that cared for the injured, the review credits the work of first responders and healthcare providers for the 100% survival rate for any patient that arrived at a trauma center. Field triage only tagged 50% of patients arriving at trauma centers and patients in extremis were unevenly distributed among the six area trauma centers, where one level 1 center received none of these patients. Multiple transport mechanisms were used including ambulances, police vehicles and private automobiles. A central EMS Command Center coordinated triage among area hospitals but law enforcement occasionally redirected ambulance traffic. Several first responders and healthcare providers were already staffing the marathon to render medical assistance and proved invaluable after the bombing in providing bleeding control with tourniquets and stabilizing victims prior to transport. While most trauma centers were already aware of the event via the media before Boston EMS radio contact, all sites reported difficulty with communication among their own staff members, reflecting shortcomings with their center’s MCI communication plan. Key lessons learned are summarized in these points:

• Resist complacency and perform ongoing MCI training to enhance preparedness.

• Establish robust communication systems that utilize the modern cellular telephone network and insure reliable backup systems.

• Enhance situational awareness of the scene to provide closed-loop feedback between first responders, law enforcement and trauma centers to ensure appropriate triage and victim allocation.

• Military-grade tourniquets should be standard issue on all emergency vehicles and incorporated into the national first-aid curriculum.

• Improve planning of system-wide resource sharing during MCI and non-MCI emergencies.

Boston Marathon Finish Line Bombing.

Source: Time, Inc.

Current Research

In 2009 the Institute of Medicine (IOM) sponsored a workshop on medical surge capacity.6 Participants defined standard terminology and metrics, discussed the state of the art in MCI management and offered strategies for the future. Surge or crisis capacity was defined as a “systematic change into a system in which standards of care are significantly altered…”, prompting “…the institution to either get the right resources in, transfer the excess patients out, or look for additional relief.” The IOM workshop also discussed several legal issues including suspension of EMTALA and state licensing and credentialing requirements during MCI’s, allowing for reciprocity of out-of-state responders and healthcare providers as well as drafting of mutual medical aid agreements. One of the most critical themes in their executive summary is the integration of care. Captain Deborah Levy from the CDC described the “…preferred framework [as] one in which the established healthcare system (hospital administrators and emergency departments, physicians, emergency medical services, community health clinics, pharmacists, and other caregivers) works closely with the public health community (local departments of public health), then explicitly brings the local emergency management agency into the process…”, while the alternative of silo-based independent goals and objectives is ineffective and inefficient.6 They also briefly shared the Israeli example of alternative sites of triage for minor injuries, reserving the hospital for the most severely injured that require the highest level of medical care. Given its size at just slightly smaller than the state of New Jersey, Israel’s MCI model is analogous to a state-level trauma system. In a prospective study during live simulation exercises in Israel, using de-identified real trauma patient data facilitated more accurate triage knowing the exact resources that were required for successful treatment of those patients.7 Their experience emphasizes centralization of hospital triage and delegation of leadership roles to nursing and other staff. Prehospital triage includes identification and documentation and reliance on ultrasound over CAT scanning to rule out intraabdominal hemorrhage. Israeli trauma hospitals also establish an emergency public information site (EPIS) headed by social workers to communicate with the public about their loved ones. Hospital security in controlling access is also paramount for the safety of patients, staff and family.8

Using federal grant funding, a coalition of eight counties in south central Pennsylvania, with a catchment population of 1.9mil, engaged seventeen hospitals and healthcare systems in a prospective performance improvement project.9 Their coalition’s goals were to demonstrate improvements in six areas:

• Situational awareness of capabilities and assets.

• Development and testing of advanced regional planning and exercise events.

• Augment mutual medical aid agreements (MMAA) between regional healthcare facilities especially hospitals.

• Strengthen partner relationships through joint planning, communication, simulation and evaluation of preparedness.

• Ensure compliance with the National Incident Management System (NIMS).

• Develop and test plans for more effective utilization of the state’s emergency volunteer registry.

The coalition expanded these goals to 59 specific, measurable, achievable, realistic and time-framed (SMART) objectives they used as performance metrics. Their interventions included teleconferences and webinars, enhancement of the radio-based emergency response system to include the internet, creation of a web-based portal to catalogue real-time available resources across the coalition and brief web-based surveys to assess changes in measured variables. After a 24-month evaluation period, the coalition reported improvements in all measured goals including a 100% response rate to emergency notifications, 16 training exercises performed, 14 out of 17 mutual medical aid agreements formulated, 4,651 trained employees available 24/7 at each facility and near universal registry tracking of volunteers with an overall 97% SMART objective completion rate.9

In their recent editorial response to MCI’s, Knudson et al. connected lessons learned from the battlefield to contemporary civilian experience.10 They emphasized the evolution of damage control resuscitation, formerly the massive transfusion protocol, in treating life-threatening hemorrhage. Recent MCI’s were highlighted from the Boston Marathon bombing to the crash of Asiana Airlines Flight 213 in San Francisco with take home lessons including dual command triage, communications and CAT scanning for triage, the latter acknowledged as contrary to the standard practice of ultrasound triage for intraabdominal hemorrhage. They concluded with the Hartford Consensus on providing the public with the skills and tools needed to control hemorrhage as bystander first responders through the “Stop the Bleed” program at www.bleedingcontrol.org (see Sidebar next page).11

SIDEBAR

by John C. Hagan III, MD

Stop the Bleed Program

Public education directed by physicians has been enormously successful in the past. Especially notable were the efforts to teach the general public to perform cardio-pulmonary resuscitation and the Heimlich maneuver to clear blocked airways.

Launched in October of 2015 by the White House, Stop the Bleed is a national awareness campaign and a call to action. Stop the Bleed is intended to cultivate grassroots efforts that encourage bystanders to become trained, equipped, and empowered to help in a bleeding emergency before professional help arrives.

Background

No matter how rapid the arrival of professional emergency responders, bystanders will always be first on the scene. A person who is bleeding can die from blood loss within five minutes, so quickly stopping the bleeding is critical. Those nearest to someone with life threatening injuries are best positioned to provide immediate care if they are equipped with the appropriate training and resources.

What’s Happening Now

The Stop the Bleed initiative brought together a number of Federal agencies, non-profit organizations and corporations to develop and disseminate resources to train the public in bleeding control. Hosted by the Department of Homeland Security, the Stop the Bleed website (https://www.dhs.gov/stopthebleed) offers posters and other materials that explain how to control life-threatening bleeding and links to information, such as where to find courses on bleeding control and how to offer them in your community.

Who’s Involved?

The Stop the Bleed initiative began as a collaborative effort headed up by the White House that included a number of Federal agencies, including the NHTSA Office of EMS, as well as national organizations and corporations. Missouri organizations teaching Stop The Bleed Courses include: University of Missouri SO M, Washington University SO M, Kansas City Medical Society, a large coalition of partners in Springfield and many others.

What You Can Do?

Offer training on bleeding control in your community to increase bystander engagement and willingness to act during an emergency. The Stop The Bleed website has information on offering courses, training medical personnel to be instructors, educational material and kits to stop bleeding.

Reference: Some of this material is taken verbatim from the Stop The Bleed Website.

Ongoing research is also improving MCI communication systems. Jokela et al. described their incorporation of RFID tagging systems with conventional cellular networks to improve situational awareness in a military training exercise.12 Their initial results encouraged civilian adoption and testing. More recently, the University of Washington Harborview Medical Center in Seattle described their novel approach in staff notification in the setting of difficulties with cellular networks during the Boston Marathon bombing.13 Leveraging their unique Disaster Management Control Center (DMCC), researchers created a system that utilized a combination of text, voice and e-mail coupled with conference calls to communicate with staff in their system. Their premise behind using text messaging was the higher likelihood of successful transmission than voice calls.

Since 2014, our institution has been testing an MCI triage communication platform called Panacea’s Cloud©. A collaboration between the Acute Care Surgery Division and the Department of Computer Engineering, Panacea© is being developed as a situational awareness operating system whose common operating picture (COP) includes communication with and tracking of patients, first responders, healthcare providers and incident commanders. The prototype system consisted of an ad-hoc resilient and self-sustaining battery-powered Wi-Fi™ mesh network covering a two-scene lake boating crash simulation.14 The original dashboard provided video calling capabilities for the incident commander with both scenes via Google Glasses™ donned by the paramedics over the mesh network and has recently been enhanced to include staff and victim tracking capabilities15–17 (Figure 1). Our latest experiment was conducted with Missouri’s Task Force One search-andrescue team during a training simulation. We compared Panacea© with their standard of care Iron Sights© GPS system used for geotracking of incident markers and found our system to be more efficient in providing real-time actionable intelligence for remote commanders18 (Figure 2). Our goal is to enhance Panacea’s capabilities through realworld testing with collaborative city-wide exercises.

MCI triage communication platform called Panacea’s Cloud©.

Conclusion

Take advantage of the lessons learned from recent MCI’s in developing, implementing and testing your own MCI disaster plan. Sponsor integrated live-action exercises with the intention of breaking the system, finding weaknesses and improving your plan. Statewide initiatives can improve integration of care and raise the state of preparedness for MCI’s. Research continues into novel systems-based solutions to MCI management.

Footnotes

Salman Ahmad, MD, FACS, is Assistant Professor of Surgery, Medical Director Surgical Intensive Care Unit, Acute Care Surgery Division, Department of Surgery, University of Missouri Healthcare, Columbia, Missouri.

Contact: ude.iruossim.htlaeh@asdamha

Disclosure

None reported.

References

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