Page 89 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 9: Preparedness for Catastrophe 57

Hazardous material spills, power outages, or transportation accidents such as emergency airway management and intravenous (IV) supplies,
can occur as well, or in concert with naturally occurring events, as took but it does not include cardiopulmonary monitoring equipment, remote
place in the 2011 Japan earthquake. Man-made events can also occur as monitoring equipment for ventilators, diagnostic equipment, closed
a result of terrorists’ attacks, such as occurred with the Aum Shinrikyo suction devices, or medical gases. Additionally, there could be logistical
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cult’s 1995 release of sarin gas in the Tokyo subway where 12 people were problems regarding the distribution of assets to hospitals once the local
killed and 5000 injured, and in the 2005 London underground station and/or state authorities receive them. Therefore, all hospitals must have
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and bus bombings where 56 people were killed. Although predicted to some internal capacity to augment critical care.
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cause few direct casualties, terrorists could also disperse nuclear material
by placing radioactive materials in a conventional explosive; this “dirty PREPARATION AND PLANNING
bomb” would likely result in more chaos and fear than direct patient
trauma. Of course a “backpack” or improvised nuclear detonation by Every hospital and ICU must undertake catastrophe planning, not only
a suicide bomber would cause catastrophic casualties with significant because disasters may impact any facility, but also because in the United
loss of infrastructure. Finally, the threat of emerging infectious diseases, States, it is an accreditation requirement for hospitals under The Joint
such as the 2003 SARS outbreak or the 2009 nH1N1 pandemic, could Commission (TJC). These standards, started in 2001, require hospitals
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also result in large numbers of medical, critically ill patients. All of these to develop and maintain a written Emergency Operations Plan covering
disasters have the potential for a rapid influx of patients requiring imme- the following areas of emergency management:
diate critical care, and in some cases, long-term critical care. 1. Communication
Lacking specific planning and exercising, critical hospital functions
and the ability to care for patients from a catastrophe may be severely 2. Resources and assets
limited, resulting in further injury or loss of life. For example, as hos- 3. Safety and security
pitals increasingly depend on electronic medical records to provide 4. Staff responsibilities
services, a power system failure or computer virus could halt patient 5. Utilities management
services if back-up systems are not in place. Without an emergency gen-
erator, flooding could result in a power outage throughout the facility 6. Patient and clinical support activities
and intensive care unit (ICU) patients would be left without functioning 7. Regular testing and evaluation of the plan 7
ventilators. Some events may cause hospitals to close when their ser- Semiannual evaluation of the plan is required in the form of opera-
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vices are needed most, either as a result of overextending their capacity
or physical structural damage. Moreover, the medical response would tional exercises. For hospitals that offer emergency services or are
community-designated disaster receiving stations, each exercise shall
be ineffective if the disaster response is not planned prior to a disaster,
causing many victims going without potentially lifesaving medical care use one of the following two scenarios.
as a result of chaos and confusion in the response effort. • An influx of simulated patients
Hospitals possess limited capital and staff time to spend conduct- • An escalating event in which the local community cannot support
ing comprehensive disaster response drills or emergency planning the hospital 8
and preparedness. However, these efforts do afford other benefits to
hospital functionality outside of the ability to effectively respond to an A distinct challenge for hospitals and ICUs is: For what disaster
actual mass casualty event. Such activities support routine patient-care should they prepare? Trying to develop contingencies for all possibilities
activities through improved communications, enhanced use of infec- becomes an overwhelming and expensive enterprise. A hazard vulner-
tion control (IC) precautions, improved interdepartmental coordination ability analysis (HVA) is an effective tool to help hospitals determine
and patient tracking, and optimized working relationships with exter- the likelihood, potential impact, and current vulnerabilities to events.
nal community partners such as Emergency Medical Services, Public TJC defines an HVA as the identification of “potential emergencies that
Health, emergency management agencies, and other hospitals. These could affect demand for the hospital’s services or its ability to provide
enterprises all serve the hospital in both its day-to-day operations as well those services, the likelihood of those events occurring, and the con-
as its integration into the community. sequences of those events.” The HVA tool developed by the American
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All emergencies and catastrophes begin as local events. Some disasters Hospital Association’s American Society for Healthcare Engineering
require a rapid response, such as nerve agent exposure where victims designates emergencies as natural, technological, and human events and
may develop symptoms within minutes before dying of respiratory then rates them in terms of the probability of occurrence, risks posed,
arrest. Other emergencies may impede transportation to and from an and hospital’s level of preparedness. 9
affected area. Patient movement around a city may be prevented because Working through this process with community partners helps hospi-
of the fear of spreading a contagious agent. Finally, although disasters tals and ICUs in their planning. While no plan can truly be “all hazards”
are multidimensional events, hospitals are the lynchpin of the definitive in nature, key processes identified in developing the plan can translate
medical effort because they are always open. Thus hospitals must be across a variety of catastrophes, such as command and control, commu-
prepared to function independently early in a disaster and continue to nications systems, etc. This allows organizations to be flexible enough
support their essential ongoing activities as well as care for the surge of to respond to emergencies of all types and to meet established TJC
patients from the incident. standards for care provision.
Critical care resources may be particularly vulnerable during catas-
trophes. State and federal assets are poised to assist and respond, but HVAs AND ICUs
depending on the extent of the event and other confounding variables
(such as weather), local capabilities must be able to function inde- In working with communities, hospitals must plan their response efforts
pendently for some time. These entities may provide some critical in concert with the HVA of the community and state. Similarly, ICUs
care equipment and supplies, but no specific state or federal teams or should also work with hospital emergency management committees
response systems are ready to provide critical care to large numbers to determine the highly probable events for which they should plan.
of civilian victims of a terrorist attack in the first 24 to 48 hours. The Casualty patterns and victims’ medical needs generally can be predicted
US’ Strategic National Stockpile (SNS) implemented by the Centers for based on the types of hazards identified in the HVA (Table 9-1).
Disease Control and Prevention (CDC) could take up to 12 hours to Reviewing a handful of recent intentional explosions offers a general
reach the hospital—a delay that is likely to be too long in the event of picture of casualty patterns and medical needs of victims in order to
a chemical attack. The SNS cache includes several critical care supplies, demonstrate the type of injuries and care needs following such attacks.

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