HealthJanuary 30, 2020

Your hospital disaster plan for managing mass casualty incidents

By: Brian Wu, MD, PhD

Earthquakes. Multiple vehicle collisions. Mass shootings. There are any number of reasons your hospital could find itself flooded with patients who need immediate care.

According to the journal Medicine, a mass casualty incident (MCI) can quickly overwhelm an emergency department, sometimes to the detriment of non-MCI patients due to the “crowd-out effect.” However, having a solid hospital disaster plan in place and knowing what to do before, during and after this kind of situation can help you navigate your role in emergency response and give your patients the care they need.


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Planning before the emergency

Fortunately, there are more resources than ever for you and your hospital administrators to draw on to come up with an effective hospital disaster plan. Recently, for example, the Greater New York Hospital Association released a Mass Casualty Incident Response Toolkit. Toolkits like these can help doctors, nurses and hospital staff plan all aspects of an emergency response, including patient care as well as logistical challenges like the registration and tracking of patients, a notification system for alerting and connecting families and issues like cooperating with other local agencies or diverting patients to alternative sites for care. It may be particularly valuable to have a department-specific disaster plan, though these are less common than general institutional plans, according to the authors of a paper published in JBJS Reviews, who were only able to find one orthopedic-specific plan.

At the same time, relatively few physicians have real-world experience with an MCI. This is why drills or simulations are critical for any successful hospital disaster plan. They reinforce exactly what all clinical and nonclinical staff should do in the event of an actual MCI, giving you a much better idea of where you as a physician fit into the overall scheme of the disaster plan. This will lead to greater confidence if it ever has to be put into action. Make sure you understand your role and how it might change across a variety of potential scenarios.

To help map out these scenarios, your hospital administrators may take advantage of recent clinical studies in this area. According to an article in Concepts in Disaster Medicine, researchers used computer-generated hospital simulation models to help test the resources that a hospital has at its disposal to respond to the situation. These resources include staff and space inside the hospital. The simulation software was used to assess all aspects of the hospital’s response, including how to control the flow of patients to different parts of the hospital and the methods used to divert patients to other facilities. The European Journal of Emergency Medicine reported similar benefits from tests of a virtual laboratory and imaging system, including enhancing the realism of MCI simulations.

Acting during the emergency

Dr. Steven J. Davidson of Brooklyn’s Maimonides Medical Center was surprised at how difficult it was for him and his colleagues, despite their preparation, to pivot into action on the morning of September 11, 2001. “Perhaps the most important lesson I can offer from our experience of Sept. 11 is that activating the disaster plan doesn’t truly activate your plan,” he wrote in Emergency Medicine News. “Rather, the experience of caring for your first patient is the true activator.”

During the emergency itself, effective triage is arguably the most important thing to keep in mind. The American Osteopathic Association (AOA) notes that the simple triage and rapid treatment—or START—method is ideal for an MCI. This method divides patients into four categories, from patients whose injuries are “incompatible with life” to category four patients with injuries that are minor.

According to the AOA, it’s best if one physician is assigned solely to triage duty, and a triage should be set up outside of the ER in a place predetermined by your hospital’s emergency preparedness plan. From this location, the flow of patients should be directed depending on their injuries. Patients who are the most severely injured should be transferred to the ER for life-saving interventions, while those with less severe injuries should be transferred to a separate, predetermined area of the hospital for care.

Along with nurses and other critical personnel, you should also expect to report to a secondary area where you can receive assignments so the emergency department isn’t inundated with too many providers at one time.

While these are good general guidelines, it’s important to note that there is more than one way to adequately respond to an MCI and that best way will depend on the type of hospital in which you are employed. In the hospital simulation in Concepts in Disaster Medicine, increasing the number of beds in an internal general ward worked best for level I trauma hospitals, while for level III trauma centers, expanding the capacity of the emergency department was the best way to cope with an MCI.

Coping after the emergency

It is not only patients that are affected by the aftermath of an MCI, Michael Karch, an orthopedic surgeon with emergency experience as a volunteer at ground zero on September 11, told the American Medical Association (AMA). Many physicians and other caregivers will experience some form of emotional trauma or distress after these kinds of emergencies. Karch believes that good preparedness for such an incident can actually help reduce the severity of the emotional aftermath. “Stay within protocol and you will avoid mistakes,” he told the AMA. “Deviate outside of the protocol and you will make mistakes and you’ll lie awake at night.”

Karch also noted that although it can be difficult or impossible to cut out stressors, self-care for physicians and other providers is incredibly important. The stress can be mitigated by healthy lifestyle habits such as a nutritious diet, sleep, taking part in physical activity and mindfulness training. Practice self-compassion, and take as good care of yourself as you would a patient.

Brian Wu, MD, PhD
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