Tài liệu Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of Explosives pdf

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CHAPTER FOUR: Patient Distribution 17
Introduction 17
Levels of Patient Distribution 17
Effective and Controlled Distribution 18

CHAPTER FIVE: Surge Capacities and Capabilities for Hospitals 19
Introduction 19
Common Challenges for Hospitals in Terrorist Bombing Aftermath 19
Predicting patient inflow 19
Delays in declaring a mass casualty event 20
Time constraints 20
Limited health care workforce 20
Poor triage
Management of Patient Surge: Over
view 21
Planning 21
Surge capacity and capability map 21
Exercises and drills 22
Redundant systems 22
Triage and level of care 22
Hospital Incident Command System 24
Mass casualty event sites 24
Security 25
Recovery: Ending the emergency status 25
Management of Patient Surge: Resources 25
Staff capacity 25
Medical supplies 26
Blood bank 26
Management of Patient Surge: Mass Casualty Events 26
Receiving casualties 26
Space capacity 26
Victim tracking 27
Hospital decompression 27
Patient identification 28
Public Information 28
Conclusion 29
References 30
Acknowledgements 31
2
Executive Summary
Explosive devices are the most common weapons used by terrorists. The damage inflicted in
recent events in India, Pakistan, Spain, Israel, and the United Kingdom demonstrates the impact
of detonating explosives in densely populated civilian areas.
Explosions can produce instantaneous havoc, resulting in
numerous patients with complex, technically challenging
injuries not commonly seen after natural disasters. Because
many patients self-evacuate after a terrorist attack, prehospital
care may be difficult to coordinate and hospitals near the scene
can expect to receive a large influx, or surge, of patients after a
terrorist strike.
The threat of terrorism exists at a time when hospitals in the
United States are already struggling to care for patients who
present during routine operations each day. Hospitals and
emergency health care systems are stressed and face enormous
challenges. With the occurrence of a mass casualty event (MCE), health systems would be expected
to confront these issues in organization and leadership, personnel, infrastructure and capacity,
communication, triage and transportation, logistics, and legal and ethical challenges.
The purpose of this interim guidance is to provide information and insight to assist public policy and
health system leaders in preparing for and responding to an MCE caused by terrorist use of explosives
(TUE). This document provides practical information to promote comprehensive mass casualty care
in the event of a TUE event and focuses on two areas:
1. leadership in preparing for and responding to a TUE event, and
2. effective care of patients in the prehospital and hospital environments during a TUE event.
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Interim Planning Guidance for Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of Explosives
This guidance recognizes the critical role that strategic leadership can have on the success
or failure of preparing for and responding to a terrorist bombing. It outlines important
leadership strategies for successfully preparing for and managing a TUE mass casualty event,
including the concept of meta-leadership. Effective meta-leaders employ influence over
authority and activate change above and beyond established lines of their decision-making
and control. They are driven by a purpose broader than that prescribed by their formal
roles. Therefore, they are motivated and act in ways that transcend usual organizational
confines, enabling them to successfully confront challenges and barriers in communication,
organization and response, standards of care, and surge capacity.
The successful medical response to an MCE depends on effectively coordinating three
critical areas of patient care: 1) prehospital care, 2) casualty distribution, and 3) hospital care.
Critical steps must be taken throughout the response to ensure rapid and efficient patient
triage, effective and appropriate distribution of patients to available hospitals and health
care facilities, and proper management of the surge of patients at receiving hospitals.
c h a p t e r o n e
Introduction
4
Purpose
The purpose of this interim planning guidance is to provide valuable information and insight to
help public policy and health system leaders at all levels prepare for and respond to a mass casualty
event (MCE) caused by terrorist use of explosives (TUE). Medical preparations for an MCE have
traditionally focused on the scene and prehospital sectors. Comprehensive mass casualty care,
from a health systems perspective, has received far less attention and has evolved separately from
the rest of the emergency response community. This document provides practical information to
promote comprehensive mass casualty care in the event of a TUE. It is not intended to reflect U.S.
Department of Health and Human Services (DHHS) policy but, rather, to provide public policy
and health systems leaders with options to consider when planning their response to an MCE. This
document is a collaboration between the Centers for Disease Control and Prevention (CDC) and the
National Preparedness Leadership Initiative of Harvard University. CDC provides additional specific
mass casualty and blast-injury related material that complements this document. These materials
include “Blast Injuries: Fact Sheets for Professionals,
1
” “In a Moment’s Notice: Surge Capacity for
Terrorist Bombings: Challenges and Proposed Solutions,
2
” and the “Bombings: Injury Patterns and
Care”
3
course.
Primary Objectives
The ultimate aims of this guidance document are to:
1. improve decision making during TUE-MCE events, strengthen system and clinical responses, and
reduce morbidity and mortality;
2. identify leadership strategies that improve preparedness for and response to TUE-MCE events;
3. promote connectivity, coordination, integration, and consistency between the medical response
community and emergency management;
4. encourage health system resilience and maximize the ability to provide adequate medical services
during an MCE;
5. enhance the quality of existing MCE preparedness and response programs used by medical
response entities; and
6. provide a resource tool that could be applied during exercises and lower intensity emergency events.
5
Interim Planning Guidance for Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of Explosives
Background and Structure
Terrorists worldwide have repeatedly shown their willingness and ability to use explosives to inflict
significant death, destruction, and fear. A sudden and unpredictable bombing-related MCE requires
an immediate response; disrupts communication systems; interrupts transportation of casualties,
medical personnel, and supplies; and may overwhelm the capacity of responding agencies.
Even though explosives are the primary weapons used by terrorists, the U.S. health care system
has minimal experience in treating patients with explosion-related injuries. Detonating devices in
crowded public places results in complex, technically challenging injuries not commonly seen after
natural disasters. Deficiencies in response capability could result in increased morbidity and mortality
as well as stress and fear in the community.
Because of the injuries sustained by large numbers of people,
explosions produce unique management challenges for health
providers, beginning with an immediate surge of patients into
surrounding health care facilities. The potential for large numbers of
patients arriving within a few hours may stress and limit the ability of
emergency medical services (EMS) systems, hospitals, and other health
care facilities to care for critically injured victims.
4–6
The ongoing and increasing threat of terrorist activities, combined
with documented evidence of decreasing emergency care capacity
within the U.S. health care system,
7–14
requires proactively preparing
for these situations. Health care and public health systems, individual
hospitals, and health care personnel must collaborate to ensure that
strategies are in place to address these key challenges:
•
receive, evaluate, and treat large numbers of injured patients,
• rapidly identify and stabilize the most critically injured,
• evaluate response efforts, and
• conduct exercises and strategic planning for future events.
6
This document focuses on the main issues and challenges in medical preparedness and response across
the three care settings related to an MCE:
1. field care and patient triage,
2. transportation and distribution, and
3. hospital-based acute care.
The guidance is organized by using terminology and concepts of the U.S. Department of Homeland
Security’s National Planning Scenario #1 (explosives attack) and National Response Framework
and DHHS’ “Medical Surge Capacity and Capability Handbook.” This document is based on
international experience for preparedness and response to mass casualty terrorism events.
Nature of Explosions
An explosion is caused by the sudden chemical conversion of a solid or liquid into a gas with resultant
energy release. Explosive devices are categorized as either high-order explosives (HE, such as C4
and TNT) or low-order explosives (LE, such as pipe bombs, gunpowder, and Molotov cocktails).
HE detonation involves supersonic, instantaneous transformation of the solid or liquid into a gas
occupying the same physical space under extremely high pressure. These high-pressure gases rapidly
expand outward in all directions from their point of formation as an overpressure blast wave. The
extent and pattern of injuries produced by an explosion are determined by several factors:
• amount and composition of the explosive material,
• delivery method,
• distance between the victim and the blast,
• setting (open vs. closed space, structural collapse, intervening barriers), and
• other accompanying environmental hazards.
Nature of Injuries
Blast injuries are categorized as primary, secondary, tertiary, or quaternary. Primary blast injuries result
from HE detonations and the impact of the blast wave on the victim’s body. Damage occurs primarily
in gas-containing organ systems (e.g., lungs, ears, gastrointestinal tract) at the air-fluid interface.
Also, increasing evidence shows primary blast injury to the brain. Secondary blast injuries result from
penetrating and blunt trauma caused by fragments and flying objects striking the victim. Tertiary
blast injuries include blunt and penetrating trauma caused by displacement of the victim (e.g., being
thrown against a wall). Quaternary (formerly miscellaneous) blast injuries are other injuries resulting
from detonation of an explosive device and exacerbation of chronic diseases resulting from the blast.
These injuries include burns caused by the thermal effect of the explosion or consequent fires, crush
injuries caused by structural collapse, and toxic inhalations from a component of the explosive device
or the resultant spillage of hazardous materials.
The location of an HE detonation affects the types of injuries encountered. Explosions in confined
spaces (e.g., bus, subway, building) cause the blast wave to be reflected by the containing surfaces,
resulting in increasing wave pressures affecting casualties. This phenomenon places victims of
7
Interim Planning Guidance for Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of Explosives
enclosed-space detonations at increased risk for primary blast injuries. For more information on
diagnosing, treating, and managing blast injuries, visit http://emergency.cdc.gov/masscasualties/
blastinjuryfacts.asp.
Terrorism Explosions and Health Care Facilities
The chaos generated at the scene of a TUE-MCE is subsequently shifted throughout all phases of
the system response. This chaos often leads to disruption of communication systems and interruption
of transporting patients, medical personnel, and supplies and can overwhelm the capacities of
responding agencies. With prior planning and practice, receiving facilities can minimize the
disarray and confusion associated with receiving large numbers of patients in a short period of time.
Planning for the bombing aftermath requires new thinking in several areas, including leadership,
prehospital and hospital surge capacities and capabilities, distribution of patients, crowd control,
and media relations.
During an MCE, health care systems will be confronted with increased demands and decreased
availability of resources. Regional health care systems best understand their own needs and resources
and must, therefore, develop specific disaster medical surge capacity and capability plans.
The medical response to an MCE consists of two distinct but interrelated spheres of emergency
medical management and care: 1) the explosion scene and 2) the receiving hospitals. These spheres
should be linked by a process of EMS effectively distributing patients.
Expected Health Systems Challenges
Emergency departments (EDs) routinely operate above capacity, with prehospital personnel
occasionally forced to wait for extended periods before transferring patient care to hospital staff.
Patients are frequently evaluated and treated in ED hallways, where they may remain for hours
or days awaiting a hospital bed. The 113.9 million visits to EDs in the United States in 2003
represented a 26% increase from 1993. During this
same period, the number of EDs decreased by 14%
8

and hospitals eliminated more than 10,000 staffed
inpatient medical surgical beds and 7,800 intensive
care unit beds.
9
In addition, although about 75% of
U.S. hospitals’ disaster plans address explosives, only
about 20% of hospitals have conducted at least one
drill or exercise involving use of explosives.
15
The
overburdened health system will be further strained by
a rapid patient surge associated with a TUE-MCE.
Leadership
Effective preparedness and response demand an established, functional leadership structure with
clear organizational responsibilities. In many instances, particularly at a local operational level, such
preparation has not occurred. Confusion over roles and responsibilities may occur and increases the
potential for redundant efforts or gaps in decision-making and response.
Key Health System Challenges
1. Leadership
2. Prehospital care
3. Patient transport and distribution
4. Hospital care
5. Community and media relations
8
Responding to terrorist bombings requires meta-leadership.
Meta-leaders are vital in preparing for and responding to bombings,
and their roles extend far beyond hospitals and emergency services.
Detailed information about meta-leadership and planning needs in
this area is provided in Chapter 2.
Prehospital care
Prehospital care of bombing victims may strain emergency
personnel. Key factors to include in planning, which are covered
in Chapter 3, are minimizing dispatch times for first responder
arrival at the scene; rapidly assessing the situation and appropriate
care needed; protecting on-scene personnel, including awareness of
potential secondary explosive devices; preventing further injuries through prompt removal of victims;
and implementing patient triage, initiating lifesaving interventions, and appropriately transporting
and distributing patients.
Patient transport and distribution
Many planning scenarios adequately address prehospital and hospital clinical care, but few consider
the potential problems of casualty distribution. As in any emergency, distribution involves matching
the medical needs of victims to available transportation and medical facilities. Because of the unusual
nature of injuries found in bombing casualties and the large numbers of simultaneously injured
persons, a coordinated plan for distributing casualties must be a key component of preparedness
plans. Factors to consider when developing plans for patient distribution are discussed in Chapter 4.
Hospital care
In responding to a terrorist bombing, hospitals must prepare to address large numbers of patients
in a short period of time. Such preparedness will affect not only emergency and trauma services but
also other medical, paramedical, administrative, logistical, and security functions. Decisions and
policies developed in advance of a bombing should reflect state and local regulations and guidance.
A full exploration of the many aspects of hospital care relevant in a bombing aftermath is contained
in Chapter 5.
Community and media relations
The community targeted by a bombing suffers the most extensive physical and psychological
effects and should be part of preparedness planning. Involving community organizations, religious
institutions, and local businesses in planning and response efforts can help to calm fears and prepare
people should a bombing occur. Another critical partner in this education effort is the local media.
Guidance for communication and information sharing is included throughout this document.
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Interim Planning Guidance for Preparedness and Response to a Mass Casualty Event Resulting from Terrorist Use of Explosives
c h a p t e r t w o
Principles for Health Systems’
Preparedness in Emergencies
To prepare for a terrorist use of explosives-mass casualty event (MCE), health systems leaders must
focus on 12 principles.
Provide Meta-Leadership
Managing a bombing crisis requires more than good leadership; it requires meta-leadership. The
prefix meta has many meanings, including a more comprehensive form of a process (e.g., meta-
analysis) and the designation of a new but related discipline. Both of these meanings are relevant,
as meta-leadership is a new kind of leadership for new kinds of challenges.
Meta-leadership is defined as overarching leadership that connects purposes and works of different
organizations or organizational units.
16
In many organizations, individuals take on roles and
responsibilities outside of their official position descriptions and use various abilities to augment
the overall operation of the organization. This ability to assume additional responsibilities is typical
of people who are capable of being meta-leaders. In addition, with training and practice, managers
or other team members can become meta-leaders and assume formal roles for making necessary
connections within their own organizations and across organizations.
Principles of Preparedness
1. Provide meta-leadership
2. Decide who is in charge
3. Be proactive and expect the
unexpected
4. Learn from others
5. Exercise MCE response plans
6. Involve the public
7. Work effectively with the media
8. Develop connected emergency plans
9. Communicate during an MCE
10. Be prepared for legal and ethical
issues
11. Alter standards of care
12. Develop resilient medical surge
10
Meta-leaders possess unique mindsets and skills, often going beyond the scope of their experiences.
They are also able to build strong alliances with a diverse array of leaders before an event occurs.
The five dimensions of a meta-leader, which must be used with flexibility and adaptability, are
• The Person of the Meta-Leader: Meta-leaders lead themselves and others out of the
“basement” to higher levels of thinking and functioning.
• Situational Awareness: A problem, change, or crisis compels the meta-leader to respond.
• Leading the Silo: The meta-leader triggers and models confidence, inspiring others to
excellence.
• Leading Up: The meta-leader leads up the chain of command and guides political, business,
and community leaders.
• Leading Cross-System Connectivity: Meta-leaders strategically and intentionally devise
cross-silo linkages that leverage expertise, resources, and information.
Meta-leaders build and maintain
relationships and establish clear
channels of communication.
Effective meta-leaders initiate change outside of their
previously established lines of decision-making and control.
They are driven by a purpose broader than that prescribed by
their formal roles and are motivated and capable of actions
that transcend usual organizational confines. In this way,
meta-leaders successfully confront challenges and barriers in communication, organizational response,
standards of care, and surge capacity.
Meta-leaders build and maintain r
elationships and establish clear channels of communication.
They encourage connectivity, which is built during preparedness and examined during crisis.
This connectivity is important because each emergency response discipline brings unique and
valuable expertise that contributes importantly to MCE readiness in the community. However, the
multitudes of medical and nonmedical responders who have a critical piece of responsibility in saving
lives typically have different plans, emergency terminology, standards, operational methods, and
classifications. Many do not have a good understanding of one another’s roles and responsibilities in
an MCE. Vertical and horizontal integration of existing medical resources in a timely and efficient
manner is a major tool for saving lives during an MCE.
Decide Who is in Charge
Clarifying the response process for leadership, the chain of command, responsibilities, and
coordination is critical—especially during a crisis. The MCE response should be led and coordinated
by two main levels of operation centers: 1) the unified crisis command center for the local area,
which brings together all relevant responding agencies; and 2) the medical command and control
center, which coordinates all medical aspects of the MCE. These operation centers can exchange
information, develop a common picture of the event and available resources, direct capabilities and
resources, coordinate the flow of casualties, maintain mutual communication and understanding,
and lead the public messages.