Chapter 15: Emergency Preparedness in Healthcare

Safe, Effective Care Environment

• The Joint Commission established emergency preparedness management standards for healthcare facilities, which mandate the development of an institutional emergency preparedness plan.
• The plan must include institution-specific procedures for:
  • Notifying and assigning personnel
  • Notifying external authorities of emergencies
  • Managing space and supplies, and providing security
  • Isolating and decontaminating radioactive or chemical agents
  • Evacuating and setting up an alternative care site when the environment cannot support adequate client care and treatment
• Disasters can be internal (e.g. loss of electric power, communication ability, or severe damage within the facility) or external (e.g. hurricanes, floods, disease epidemics)

Security and Disaster Plans

• A healthcare facility's emergency preparedness plan must include:
  • Evacuation and relocation plans
  • Procedures to notify extra personnel
  • Safety and hazardous materials protocols
  • Infection control policies and practices
• The plan must also include a process for conducting two emergency preparedness drills per year, which should include an influx of clients beyond those being treated by the facility
• Participating in one community-wide practice drill per year is also required

Nursing Role in Disaster Planning and Emergency Response Plans

• Nurses are involved in the development of a disaster plan for healthcare facilities
• The plan must take into consideration the potential for various types of natural and man-made emergencies, and resources necessary to meet the potential emergency
• Nurses are expected to set up an emergency action plan for personal family needs
• Communication, using common terminology, is important within any emergency management plan

Triage

• Triage principles are followed in healthcare facilities involved in a mass casualty event
• Casualties are separated based on their potential for survival, and treatment is allocated accordingly
• The categories of triage are:
  • Emergent or Immediate Category (Class I): highest priority, life-threatening injuries with high possibility of survival
  • Urgent or Delayed Category (Class II): second-highest priority, major injuries that are not yet life-threatening
  • Nonurgent or Minimal Category (Class III): next highest priority, minor injuries that are not life-threatening
  • Expectant Category (Class IV): lowest priority, clients who are not expected to live and are allowed to die naturally

Fire

• If evacuation of the unit is necessary, horizontal (lateral) evacuation is done first, followed by vertical evacuation to other floors if client safety cannot be maintained
• The RACE (Rescue, Alarm, Contain, and Extinguish) mnemonic is used to guide the order of actions in case of a fire

Severe Thunderstorm/Tornado

• In the event of a severe thunderstorm or tornado, shades and drapes are drawn to protect against shattering glass
• Beds are lowered to the lowest position and moved away from windows
• Ambulatory clients are relocated to hallways or other secure locations

Biological Pathogens

• Bioterrorism is the intentional release of pathogens that can harm people, livestock, or crops
• Early detection and management is key, as manifestations are often similar to other illnesses
• Recognition of a possible bioterrorism attack includes:
  • Unusual disease occurrence at a specific time or place
  • Atypical manifestations
  • Disease occurrence in a specific community or people group
• Management of a biological incident includes recognition of the occurrence, directing personnel in the proper use of personal protective equipment, and decontamination and isolation in some situations### Biological Pathogen Manifestations, Prevention, and Treatment

Inhalational Anthrax

• Manifestations: fever, cough, shortness of breath, muscle aches
• Prevention: anthrax vaccine for high-risk individuals, antibiotics (ciprofloxacin and doxycycline)
• Treatment: antibiotics (ciprofloxacin, doxycycline, vancomycin, penicillin, and anthrax antitoxin), plus supportive care

Viral Hemorrhagic Fevers (Ebola, Yellow Fever)

• Manifestations: high fever, chills, fatigue, internal and external bleeding, shock, jaundice
• Prevention: vaccination available for yellow fever, barrier protection from infected person, insect repellent use
• Treatment: supportive care (prevent dehydration, provide skin care, medications for pain and fever), antibiotics for secondary infections

Smallpox

• Manifestations: high fever, chills, vomiting, delirium, rash
• Prevention: vaccine, contact and airborne precautions
• Treatment: supportive care (prevent dehydration, provide skin care, medications for pain and fever)

Cutaneous Anthrax

• Manifestations: starts as a lesion that becomes vesicular and necrotic with black eschar, fever, chills
• Prevention: anthrax vaccine for high-risk individuals
• Treatment: antibiotics (ciprofloxacin, doxycycline)

Plague

• Manifestations: sudden fever, headache, weakness, pneumonia with shortness of breath, chest pain, cough, and bloody or watery sputum
• Prevention: vaccine under review by the Food and Drug Administration, insect repellent use
• Treatment: streptomycin or gentamicin, doxycycline or ciprofloxacin in mass casualty situations

Botulism

• Manifestations: double vision, slurred speech, descending progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing
• Prevention: airway management, antitoxin
• Treatment: supportive care, elimination of toxin

Fundamentals for Nursing: Security and Disaster Plans

Hazardous Material Incidents

• Identify the hazardous material with available resources
• Contain the material in one place prior to the arrival of the hazardous materials team
• Decontaminate individuals as much as possible at the scene or as close as possible to the scene
• Follow the facility's emergency response plans

Nuclear Incidents

• Decontamination is necessary
• Irrigate skin with running water, except in the case of dry chemicals (lye or white phosphorus)

Explosive Incidents

• Gather a specific history of the injury, if possible
• Follow the facility's emergency response plans

Bomb Threat

• Listen for distinguishing background noises and voice characteristics
• Ask where and when the bomb is set to explode
• Clear the area and isolate the device as much as possible
• Cooperate with police and others

Active Shooter Situation

• Run and evacuate if there is a clear path of exit
• Hide and silence phone if unable to evacuate
• Fight and throw items to stop the shooter if unable to run or hide

Security Plan

• Nurses should be aware of security measures, including identification systems, electronic security systems, and key code access

• Prepare to take immediate action when security breaches occur

• Time is of the essence in preventing or stopping a breach in security### Mass Casualty Event and Client Discharge

• In a mass casualty event, stable clients need to be discharged to make beds available for injury victims.

• A client who is dehydrated and receiving IV fluid and electrolytes should not be recommended for discharge.

• A client with a nasogastric tube to treat a small bowel obstruction should not be recommended for discharge.

• A client scheduled for elective surgery can be recommended for discharge.

• A client with chronic hypertension and a blood pressure of 135/85 mm Hg can be recommended for discharge.

• A client with acute appendicitis and scheduled for an appendectomy should not be recommended for discharge.

Clients in Emergency Situations

• Unstable clients or those requiring nursing care are not discharged or relocated unless they are in imminent danger.

Disaster Plan

• The disaster plan is developed by nurses and other healthcare team members.
• Criteria for activating the disaster plan must be clear.
• Each employee has a role outlined in the plan, and administrative control is determined.
• A designated area for the command center is identified, along with an incident control manager.

Emergency Communication

• Communication is key in emergency management, using common terminology.

Fire Safety

• If a nurse discovers a fire, they use the RACE (Rescue, Alarm, Contain, and Extinguish) mnemonic to guide actions.
• Nurses turn off supplemental oxygen for clients who can safely tolerate room air.
• Ambulatory clients are asked to assist in removing clients from wheelchairs.

Triage

• Triage principles are followed in health care facilities during mass casualty events.
• The principles differ from those used in day-to-day services or urgent care settings.
• Casualties are separated into categories according to their potential for survival and treatment is allocated accordingly.

Triage Categories

• Emergent or Immediate Category (Class I): Highest priority for clients with life-threatening injuries and high possibility of survival.
• Urgent or Delayed Category (Class II): Second-highest priority for clients with major injuries that are not yet life-threatening.
• Nonurgent or Minimal Category (Class III): Next highest priority for clients with minor injuries that are not life-threatening.
• Expectant Category (Class IV): Lowest priority for clients who are not expected to live and are allowed to die naturally.

Severe Thunderstorm/Tornado

• Draw shades and close drapes to protect against shattering glass.
• Lower beds to the lowest position and move away from windows.
• Place blankets over clients who are confined to beds.
• Close all doors.
• Relocate ambulatory clients to hallways or other secure locations.
• Monitor for severe weather warnings using television, radio, or Internet.
• Do not use elevators.

Biological Pathogens

• Use recommended isolation measures as indicated.

Emergency Response Guidebook

• If a bomb-like device is located, do not touch it and try to contain it in one place while closing doors to isolate the area.
• Know the location of the safety data sheets manual and notify the appropriate authorities and personnel (police, administrator, director of nursing).
• If individuals are contaminated, decontaminate them as much as possible at the scene or as close as possible to the scene.

Safety Precautions

• Wear gloves, gown, mask, and shoe covers to protect yourself from contamination.
• Keep elevators available for authorities and watch for suspicious objects (packages and boxes).
• Remain calm and alert, and try not to alarm clients.

Active Shooter Situation

• Evacuate if there is a clear path of exit, leaving belongings behind.
• Transport or move clients only if needed for treatment and care.
• Take measures to protect yourself and others, and recognize indications of infection/poisoning and recommended treatment.

Radiologic Incidents

• Bioterrorism is the intentional release of pathogens that can harm people, livestock, or crops.
• Be alert to indications of a possible bioterrorism attack, and recognize early signs of infection/poisoning.
• Management of the incident includes recognition of the occurrence, directing personnel in the proper use of personal protective equipment, and decontamination and isolation.

Chemical Incidents

• Take measures to protect yourself and avoid contact with the chemical.
• Assess and intervene to maintain the client’s airway, breathing, and circulation, and administer first aid as needed.
• Decontamination is necessary, except in cases of dry chemicals (lye or white phosphorus).

Explosive Incidents

• Can result in burn injuries, wounds from airborne fragments, force due to altered air pressure, and temperature changes.
• Gather a specific history of the injury, if possible (name and concentration of the chemical, duration of exposure).

Bomb Threat

• When a phone call is received, extend the conversation as long as possible and listen for distinguishing background noises.
• Note distinguishing voice characteristics of the caller and ask where and when the bomb is set to explode.
• Approach the scene with caution and note whether the caller is familiar with the physical arrangement of the facility.