Manuell powerpoint submitted on 5-28-12

6/1/2012

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T i d B i C i Triage and Basic Care in Emergency Shelters

Mary‐Elise Manuell, MD, MA, FACEP

University of Massachusetts Medical School

UMass Memorial Medical Center

Disclosures

• I receive funding from the Assistant Secretary for g y

Preparedness and Response (ASPR) Hospital

Preparedness Program through a contract with

the Emergency Preparedness Bureau at the

Massachusetts Department of Public Health to Massachusetts Department of Public Health to

serve as Director of the CEEPET Training Center

at UMass Medical School.

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Two key resources

http://www.emd.wa.gov/plans/documents/Planning_MedicalNeedsShelterPlan.pdf

http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/Emergency_Preparedness/Shelters_Disasters.

pdf

Objectives

• Identify the best methods of treatment for the most

common medical problems seen in emergency

shelters

• Explain the level of care that emergency shelter health

care volunteers should be prepared to providecare volunteers should be prepared to provide

• Review the use of appropriate infection prevention

measures to reduce the spread of infectious diseases

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Key questions …

• What are you going to see?

• How are you going to treat it?

• Should it stay or should it go?

• How prevent spread of disease?

http://www2.ljworld.com/photos/galleries/hurricane_katrina/http://www.wunderground.com/blog/NEFLRedCross/comment.html?entrynum=1

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We need to plan for all aspects of the spectrumWe need to plan for all aspects of the spectrum

What are you going to see?How are you going to treat it?Should it stay or should it go?

How prevent spread of disease?How prevent spread of disease?

We need to plan for all aspects of the spectrume eed to p a o a aspects o t e spect u



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Medical Assistance NeededHCP: identify & respond

Medical care that

is provided

Acute conditions or

decompensation of chronic

Self‐sufficient

at home conditions

Medical Assistance

• Identify

• TriageTriage

http://www.majiroxnews.com/2011/06/19/disaster‐victims‐now‐confronting‐a‐menace‐of‐the‐mind/

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Identify

ARC; UASI

Identify

Identify:

• Acute need

• Ongoing assistance

• +/‐ caregiver

• Medications

Can this shelter provide the

assistance and support

needed?

ARC; UASI

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Identify

UASI

Identify

• Completed mostly by p y y

individual

• Medical history, needs

• Vital signs

UASI

• +/‐ caregiver

• Dispo

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Identify

• Medical needs of people in the shelter

• Who needs (or may need) to be transported

hi h l l f to higher level of care

Typical Medical Assistance Rendered

• Basic first aid

• Sustained assistance or medical care

• Not to level of acute care

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Shelter staff training

Basic First Aid, CPR & AED

• Choking, breathing problems

• Unconscious

• Stroke, chest pain, heart attack

• Seizure

• Allergic reactions, etc

• Pregnancy complications, delivery

• Injuries, bites, stings

• etc

Things you might see

• Diabetes

People with chronic well‐maintained

conditions who decompensate

without medications or when their

routines are changed …

• Asthma / COPD

• Heart disease

• Hypertension

• Psychiatric illness

• Seizure disorderg

• Renal Failure / Dialysis

• People on chronic steroids

• Drug / alcohol abuse

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People with acute conditions

• Acute illnesses

– n/v/d; dehydration

– URI, viral illness

– anxietyanxiety

• Injuries related to disaster / evacuation

– Soft tissue, fractures, frostbite


http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm251314.htm

http://lifepregnancy.com/tag/new‐born‐babies/

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• Increased rate of unexpected deliveries during

disaster; increase in premature deliveries

• Shelter planning:

– emergency birthing kit

b b– crib / bassinette

– health and hygiene products for post‐partum women

American College of Obstetricians and Gynecologistshttp://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Preparing_f

or_Disasters_Perspectives_on_Women




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Depends on …

• Experience of medical provider(s)• Experience of medical provider(s)

• Resources available

• Whether or not transfer to definitive care is

iblpossible

• Your local plans

We need to consider all aspects of the spectrum

• Experienced ff

• +/‐ Experienced ff

• Insufficient ffstaff

• Resources available

staff• Rationing resources

staff• +/‐ resources• No infrastructure

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Common issues

• OTC or person’s prescription medication*

• Increasing fluid intake, rest

• Assisting with daily care

• Comforting words

*Pedi: medication doses are weight‐based

Within scope of practice

Medication Management

• Diabetes

People with chronic well‐maintained

conditions who decompensate

without medications or when their

routines are changed …

• Asthma / COPD

• Heart disease

• Hypertension

• Psychiatric illness

• Seizure disorderg

• Renal Failure / Dialysis

• People on chronic steroids

• Drug / alcohol abuse

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Management of acute conditions

• Gastroenteritis / dehydration

• Infectious illness

• Minor injuries

Things to worry about …

• Abnormal vital signs

• Difficulty breathing

• Diaphoresis

• New confusion, neuro changes

http://www.instructables.com/id/Bright‐Idea‐USB‐drive/

• Severe, uncontrollable pain

• Active bleeding

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Management

• Depends on expertise

of staff and resources

available

• Likely transfer acute • Likely transfer acute

care cases http://allcoloringpictures.com/kids‐776_ambulance.php

Worst case scenario

• Left lateral decub position

• Position of comfort

• Keep baby warm and dry

• Hold a hand

• Food, coffee

• Keep people warm and hopeful

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Condition Ideal In between Last resort / austere

Deformed extremity To ER for x‐rays,d i d li

Splint in same i i b

Support with h hreduction and splint position, maybe

manipulate a bit firstwhatever you have around you ‐‐‐ pillow, box

http://www.hunter‐ed.com/az/course/ch8_first_aid.htm http://lifesaving.xomba.com/how_apply_splint

http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf

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http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf

http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf; Appendix 7

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http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf; Appendix 8

UASI Appendix 7

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x 6 pages

UASI Appendix 9


What are you going to see?How are you going to treat it?Should it stay or should it go?How prevent spread of disease?How prevent spread of disease?

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Depends on …

• What providers are

available

• Provider’s comfort level

• Resources available for

treatmenttreatment

• Access to definitive care

or medical site http://pediatrics.about.com/od/asthma/ig/Asthma‐Photo‐Gallery/Nebulizer‐Treatment.htm




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Got germs?

• Common cold

• Influenza

• Gastroenteritis

H titi • Hepatitis

• Tuberculosis

http://aroundtheworldblog.blogspot.com/2011/12/danger‐lurks‐for‐airline‐passengers.html

Infection Control

I d i k f di t i iIncreased risk of disease transmission:

• Close proximity (displaced individuals and staff)

• Overcrowding

D i l k f i i i• Decrease in or lack of routine sanitary services

• Environmental conditions

APIC

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Infection Control

• Universal precautions are to be followed at all times per

policy and procedure

• All staff members are to be trained in the proper handling

of patients and supplies

• Staff members are to take appropriate infection control

iprecautions

• Special patient precautions are to be noted at the patient’s

bedside

UASI

Infection Control

• Triage and surveillance:

– identify potentially contagious individuals

– identify people in need of medical care

prevent or limit the emergence or spread of

communicable diseases within the shelter

APIC

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Infection Control

• Ideal:

– standard infection control practices at all types of

facilities

R lit • Reality:

– limited resources and capabilities

ACIP

Infection Control

Planning:

• Equipment that is easy to clean / disinfect

• Involve infection control experts

APIC

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Infection Control

Infectious disease disaster

Non‐infectious disease disaster

APIC

Triage & Surveillance

APIC Appendix B & C

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Infection Control Triage

APIC Appendix D

Isolation Precautions

• Space

• Actions

• Equipment / Environment

APIC

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APIC APpendix G

Isolation Precautions

Designated area for potentially infectious individualsDesignated area for potentially infectious individuals

• Physically separated from rest of shelter by walls on all

sides and a door

• Create area using plastic, other barrier material

• Dedicated shelter staff

• Dedicated entrance / passageway

APIC

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Negative Pressure Rooms

• Controlled air

movement in isolation

areaarea

http://www.health.state.mn.us/oep/training/bhpp/airbornenegative.pdf

Educate

APIC Appendix F

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Hand Hygiene

• Hand washing

• Alcohol Based Hand

Rubs (ABHR)

• Antimicrobial wipes

APIC Appendix I

Hand Hygiene

• When

• Where

• Monitoring compliance

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Environmental Decontamination

Germs can be spread via hands and equipment

when items in environment become

contaminated

• Tables

• Doorknobs

• Toys

APIC


• Proper cleaning and disinfection: crucial

• Staff need to be trained

• Cleaning plan for each shelter area

• EPA‐registered disinfectant or alternative

APIC

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• Body Fluid Spills

• Environmental Surfaces

• Toys

APIC

Toys / Play area

• Important part of shelter

• Potential to spread

disease

• Hand hygiene before

entering and when entering and when

leaving area

• Two toy boxes

http://www.bt.cdc.gov/disasters/hurricanes/library/evacplayareas.pdf

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APIC Appendix N

PPE

• Gloves

• Gowns

• Masks and respirators

• Resource management critical

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“Simple Respiratory Mask”

http://wwwnc.cdc.gov/eid/article/12/6/05‐1468_article.htm

Other infection control measures

• Water management

• Food safety

• Waste management / Medical waste

• Pest management

• Pet management

• Post‐mortem care

APIC

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http://www.bt.cdc.gov/disasters/commshelters.asp

Animals

http://www.bt.cdc.gov/disasters/animalspubevac.asp

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What do you need?

APIC Appendix A

http://nursingcrib.com/nursing‐jobs/infection‐control‐nurse/

Key points

• Planning planning planning• Planning, planning, planning

• Expect the unexpected

• Practice in your scope – what you feel

f bl d icomfortable doing

• Keep hands clean

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Key questions …

• What are you going to see?

• How are you going to treat it?

• Should it stay or should it go?

• How prevent spread of disease?

Objectives

• Identify the best methods of treatment for the most

common medical problems seen in emergency

shelters

• Explain the level of care that emergency shelter health

care volunteers should be prepared to providecare volunteers should be prepared to provide

• Review the use of appropriate infection prevention

measures to reduce the spread of infectious diseases

6/1/2012

36

Thank you

Documents

Manuell powerpoint submitted on 5-28-12