MASS CAS + HAZ SUB 2014

MASS CASUALTY HAZARDOUS SUBSTANCES PROCEDURESDR CHRIS CRESSWELL

EMERGENCY PHYSICIAN

WANGANUI HOSPITAL

Acknowledgements

Michelle Batterbee

Katie Edmonds

Simon Ward

Christie King

Whole of hospital response to a mass incident

ED response

PPE and Decontamination procedures in ED

Procedures revised based on Tasman Tanning Hydrogen Sulphide incident

2 patients GCS 3

Multiple other exposed factory staff

Multiple exposed emergency services staff

Potentially contaminated ED

HS: Volatile toxin with little risk of secondary exposure

Multiple potential toxins in our city

Including allegedly the southern hemisphere’s largest stockpile of cyanide …

with a munitions factory nearby

Hypothetical scenario

Ambo call:

National Party conference in the city

A package explodes releasing unknown white powder

A few people have blast injuries

~150 people inhaled the powder and are now coughing

First patients will arrive in 5 minutes

First action?

Lock Down

The hospital will be inundated with patients, relatives, worried people from 3 blocks away from the incident …

and paparazzi

“not pond scum, rather the scum that feed on the pond scum”

Lock all the door

Then get orderlies, then security, controlling ingress and egress

Only staff with ID badges allowed in

Anyone is allowed out

Declare a Mass Casualty Event

Senior ED nurse + duty nurse manager +/- ED senior doc decide if need to declare a Mass Casualty Event and if so what level. DNM is only one who can activate Mass Casualty Plan

Stage 1: ED only. Call in extra ED staff, lab, Xray etc. Managed by ED

Stage 2: ED + Hospital.

Stage 3: ED + DHB + EOC +/- regional or national support.

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Mass Casualty Plan

DNM talks to switchboard

Telephonist phones …

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STAGE 2   CALL Senior Manager on duty as directed by Duty Nurse Manager  

DNM to advise on following contacts with correct message:1. TEXT PAGE ALL RMOs / Registrars on duty covering specialities: MSG “Stage 2 Mass Casualty Emergency

– expedite discharges and admissions from ED, report to senior doctor in ED” Surgical RMO Ortho RMO Medical RMO Surgical Reg Ortho Reg

 2. CALL IN THEATRE STAFF: MSG “Stage 2 Mass Casualty Emergency, please report to the hospital”

0800 – 2200 hrs: Theatre Control Room / Theatre Manager 2200 – 0800 hrs (After Hours): Use On Call Theatre Call Back Procedure

 SWITCHBOARD to anticipate staffing needs and liaise with Switchboard Manager / DNM / Manager of

emergency to authorise extra staff – (consider 2 extra to start?) 

Follow direction from ED or DNM -Contact or CALL IN “Stage 2 Mass Casualty Emergency, please report to the hospital”

Clinical Nurse Manager ED (if not already on site) Clinical Director of Emergency Department (or delegate)

On Call Physician On Call Surgeon

On Call Ortho Surgeon On Call Anaesthetist On Call Paediatrician

Lab (on call) XRay (on call) CT (on call)

USS (on call) Pharmacy (on call)

Consultant Medical Staff – not on call 

Follow direction from Nurse / Business manager (a/h on duty)-CALL IN “Stage 2 Mass Casualty Emergency, report to ED Coordinator, Red Vest ED, Room 3”

Media Liaison – immediate report required- Advise switchboard of message for public

- Advise switchboard number to transfer all media calls Manager of Social Workers – 0276887095 Page 117 Spotless 24 hour help line – 027 288 7451 Page 041

1. Orderlies x 2 to ED – via SPOTLESS as above2. Security (ON / OFF site) – via SPOTLESS as above

3. Kitchen/cleaning manager alerts as requestedNotify WDHB Emergency Phone “Stage 2 Mass Casualty Incident” (Single Point of Contact – DNM 027 222 0926 or

page 085) 

You may be requested to call in specific personnel / services: Supply Department

Centre for Patient Safety Manager – stand by / set up EOC Director Maori Health – Maori Liaison to ED / Mauri Ora

Chaplain Facilities Management – 0274918385 Page 144

ICT Service ManagerIN and OUT OF HOURS - INFORM as directed by DNM “Stage 2 Mass Casualty Emergency – please report to

the hospital and follow your Mass Casualty Plan” ASSOCIATE DIRECTOR OF NURSING

MANAGER OF OPD – if space needed to overflow from ED MANAGER OF WAM (Lu Gribble – 0277171665)

MANAGER OF HEALTH RECORDS – send admin assistance to ED if required 

SWITCHBOARD TO EXPECT INCREASED EXTERNAL CALL LOAD Direct families / whanau to info point in staff café, tunnel access

Direct volunteers / staff called back to main entrance, signs to Medlab, on left, door marked “Training Room” – HR check in

STAGE 2   CALL Senior Manager on duty as directed by Duty Nurse Manager  

DNM to advise on following contacts with correct message:1. TEXT PAGE ALL RMOs / Registrars on duty covering specialities: MSG “Stage 2 Mass Casualty Emergency

– expedite discharges and admissions from ED, report to senior doctor in ED” Surgical RMO Ortho RMO Medical RMO Surgical Reg Ortho Reg

 2. CALL IN THEATRE STAFF: MSG “Stage 2 Mass Casualty Emergency, please report to the hospital”

0800 – 2200 hrs: Theatre Control Room / Theatre Manager 2200 – 0800 hrs (After Hours): Use On Call Theatre Call Back Procedure

 SWITCHBOARD to anticipate staffing needs and liaise with Switchboard Manager / DNM / Manager of

emergency to authorise extra staff – (consider 2 extra to start?) 

Follow direction from ED or DNM -Contact or CALL IN “Stage 2 Mass Casualty Emergency, please report to the hospital”

Clinical Nurse Manager ED (if not already on site) Clinical Director of Emergency Department (or delegate)

On Call Physician On Call Surgeon

On Call Ortho Surgeon On Call Anaesthetist On Call Paediatrician

Lab (on call) XRay (on call) CT (on call)

USS (on call) Pharmacy (on call)

Consultant Medical Staff – not on call 

Follow direction from Nurse / Business manager (a/h on duty)-CALL IN “Stage 2 Mass Casualty Emergency, report to ED Coordinator, Red Vest ED, Room 3”

Media Liaison – immediate report required- Advise switchboard of message for public

- Advise switchboard number to transfer all media calls Manager of Social Workers – 0276887095 Page 117 Spotless 24 hour help line – 027 288 7451 Page 041

1. Orderlies x 2 to ED – via SPOTLESS as above2. Security (ON / OFF site) – via SPOTLESS as above

3. Kitchen/cleaning manager alerts as requestedNotify WDHB Emergency Phone “Stage 2 Mass Casualty Incident” (Single Point of Contact – DNM 027 222 0926 or

page 085) 

You may be requested to call in specific personnel / services: Supply Department

Centre for Patient Safety Manager – stand by / set up EOC Director Maori Health – Maori Liaison to ED / Mauri Ora

Chaplain Facilities Management – 0274918385 Page 144

ICT Service ManagerIN and OUT OF HOURS - INFORM as directed by DNM “Stage 2 Mass Casualty Emergency – please report to

the hospital and follow your Mass Casualty Plan” ASSOCIATE DIRECTOR OF NURSING

MANAGER OF OPD – if space needed to overflow from ED MANAGER OF WAM (Lu Gribble – 0277171665)

MANAGER OF HEALTH RECORDS – send admin assistance to ED if required 

SWITCHBOARD TO EXPECT INCREASED EXTERNAL CALL LOAD Direct families / whanau to info point in staff café, tunnel access

Direct volunteers / staff called back to main entrance, signs to Medlab, on left, door marked “Training Room” – HR check in

Calling back staff

Don’t call in people who are due on the next shift – you are going to need them fresh

ED nurses call in ED nurses

ED doctors call in ED doctors

If the telephonist calls you

Don’t ask questions! The telephonist does not have time!

Say “Yes I can come in” or

“I can’t come in, I will find someone else, and I will let …… know who I have found” or

“I can’t come in, sorry I don’t have any phone numbers, please call ….”

Send out the teletubbies

A triage nurse outside front door and in ambo bay

In PPE if a HAZ SUB event

+ an assistant with a phone/radio

+ security

Triage non-emergency patients away, and stable patients to a holding area eg chairs/ stretchers/bus outside

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Minimise the number of people getting into ED

And once they leave ED (eg CT) they don’t come back

Inpatient teams

Cancel elective procedures

Get your patients out of ED

Discharge as many patients as you can from wards

Send a few docs, nurses, HCAs down to ED if possible

ED

Appoint nursing coordinator

Open the Mass Cas box

Follow coordinators instruction sheet

Give out vests and job cards

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Mass Casualty Box

Folders with ED cards, Xray and lab forms, ID bracelets

Some “unidentified” labels

Try to identify all patients and use usual patient registration processes

(Later boxes are more useful eg automatic arrival of LOTS of drugs, linen other consumables)

If several unconscious or unknown patients

Vests are for ED staff only

Helpers from other wards wear usual uniforms + lanyard

Makes it easy for all to recognise the “locals” who tend to know where things live and how things work in ED

Task cards

Back door triage nurse based outside fishbowl closest to ambo door with ED

cards

ED coordinator based outside the fishbowl, outside room 3

+ orderly

+ transport nurse

Red folder has an excellent list of tasks

+ patient log

+ staff log

Eg Outpatients or SDU

Eg multiple chairs in AAU

Eg WAM

Eg GP

Maximise cohort care

Minimise one-on-one care

Allocate areas/rooms to ED staff and further dividing as more staff arrive

Allocate extra help to ED teams as needed

= Small teams with ED staff + helpers from elsewhere

Corral extra staff eg in fish bowl or whanau room

You may get more help than you can use

They may get in the way / make inappropriate decisions

ED teams in resus bays

other senior staff by invitation

Eg Christchurch: ED and anaesthetists in bays, other consultants corralled in fishbowl and Dr Jan Bone summoned as needed

Eg Kandahar: ED + military medics in bays. Stabilise give to anaesthetist and surgeon when ready

for surgery => increased survival

Intra-department communication

Public address system

OK, we’re ready for some HAZSUB

Get in the Zone

General principle: no potentially contaminated person gets into hospital

Otherwise we might have to shut down the hospital

Hot zone: outside

Warm zone: decontamination shower

Cold zone: inside hospital

Teletubbies to the shower

Tape over cuffs

Patients who have been decontaminated,

or considered not contaminated, by the Fire Service

can enter ED by front door or ambulance door

Everyone else gets washed

“All Hazards Approach”

Detergent

Sponge

Lots of water

Preserve clothing

Strip ‘em

Put clothing in biohazard bag

Label the bag with a patient ED sticker, date, time, clinician name and signature (if possible/time) Police may want it

Non ambulatory patient

Wash on ambulance stretcher

Wash stretcher

Patient and stretcher go through into cold zone

Ambulance officer in ED to help work the stretcher

Don’t drown the patient

Has a PhD in stretchero-logy

No clothes, used towels, PPE or teletubbies to go from warm zone (shower) into cold zone (ED)

Ambulant patients get a poncho

Put a clean sheet or towel over stretcher patients

Decontaminated patient enters ED

Medical treatment continues as needed

Complete the cycle

Treat all patients

Track all patients

Ensure staff are fed and watered and get a break

Support and reconcile with families

Declare end of emergency

Restock

Debrief

Learn and improve

Prevention

Exercises / test the system

Educate staff