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And ye shall hear of wars and rumours of wars: see that ye be not troubled: for all these things

must come to pass, but the end is not yet. For nation shall rise against nation, and kingdom against kingdom: and there shall be famines, and pestilences, and earthquakes, in divers places. All these are the beginning of sorrows. King James Bible Matthew , 24:6-8

Any man-made or naturally occurring event that results in destruction & devastation and causes suffering, creating human needs, and cant be alleviated w/o support External Disaster: occur outside the health care agency (surrounding community) Internal Disaster: occur inside the health care agency Disaster Preparedness Plan: formal plan of action of coordinating the response of health care agency staff in the event of a disaster TYPES OF DISASTER 1. NATURAL DISASTER 2. MAN-MADE DISASTER

D a te N s g is s r ur in

DISASTER PLAN Goal : To reduce any vulnerability to prevent recurrence Benefits : Decrease in costs of damage control Decreased extent & duration of injury Decreased loss of life Increased ability to response to unforeseen disasters Health-care components early warning signals, with realistic expectations brief assessment of those at risk simple, flexible rescue chains that unfold in organize steps / stages DISASTER MANAGEMENT PHASES 1. preparedness 2. mitigation 3. response 3. recovery 4. evaluation

HUMAN-MADE Radiological accidents Resource shortages (food, water, electricity) Structural collapse, fire or explosions Terrorist attacks (bombing, riots, bioterrorism) Transportation accidents Dam failures (flooding) Hazardous substance accidents (pollution, chemical spills, toxic gas leaks) NATURAL DISASTER NATURAL Floods Forest fires Landslides, mudslides Tidal waves Tornadoes Blizzards, Hailstorms Communicable disease epidemics Cyclones, Hurricanes Droughts Earthquakes, Volcanic eruptions LEVELS OF DISASTER LEVEL 3 Minor, minimal level of damage LEVEL 2 Moderate, with federal assistance LEVEL I Massive, results in presidential disaster declaration, full engagement of federal, regional & national resources

5 PHASES 1. PREPAREDNESS 2. MITIGATION 3.RESPONSE 4. RECOVERY 5. EVALUATION PREPAREDNESS Plans for rescue, evacuation & caring for disaster victims Plans for training disaster personnel, gathering resources Identification of specific responsibilities for disaster personnel Establishment of community disaster plan & public communication system EMS activation, checking proper functioning of emergency equipments Checking of supplies regularly & replenishment of outdated supplies Practice/Mock disaster drills MITIGATION Awareness of available community resources & health personnel to facilitate mobilization of activities & chaos & confusion if a disaster occurs Determination of the resources available for care to infants, older clients, disabled & with chronic health care problems Effective triage officer Clinically experienced Good judgment and leadership

Calm and cool under stress Decisive Knowledgeable of available resources Sense of humor Creative problem solver Available Experienced and knowledgeable regarding anticipated casualties
RESPONSE PUTTING DISASTER PLANNING SERVICES INTO ACTION TO SAVE LIVES & PREVENT FURTHER DAMAGE PRIMARY CONCERNS: SAFETY, PHYSICAL HEALTH, MENTAL HEALTH OF THE VICTIMS & MEMBERS OF THE TEAM RECOVERY ACTIONS TO RETURN TO A NORMAL SITUATION AFTER THE DISASTER PREVENTING DEBILITATING EFFECTS, RESTORING PERSONAL, ECONOMIC & ENVTAL HEALTH & STABILITY TO THE COMMUNITY EVALUATION OFTEN RECEIVES THE LAST ATTENTION IS ESSENTIAL TO DETERMINE THE FF; WHAT WORKED? WHAT DID NOT WORKED? WHAT SPECIFIC PROBLEMS, ISSUES, AND CHALLENGES WERE IDENTIFIED FUTURE DISASTER PLANNING NEEDS TO BE BASED ON EMPIRICAL EVIDENCE DERIVED FROM PREVIOUS DISASTER EMERGENCY PLANS MEETING PLACE FOR FAMILIES (EVACUATION CENTER) HOW TO TURN OFF WATER, GAS & ELECTRICITY AT MAIN SWITCHES REPLACING WATER SUPPLY Q 3MOS. REPLACING FOOD SUPPLIES Q 6MOS. EMERGENCY RESPONSE PLAN KNOW LOCATION OF : A. ESCAPE ROUTES, ESCAPE DOORS. B. KEEP FIRE EXITS CLEAR. C. AVAILABLE EQUIPMENT : - FIRE ALARMS - FIRE SPRINKLER CONTROLS - FIRE EXTINGUISHERS IDENTIFY HAZARDS. A. FAULTY ELECTRICAL EQUIPMENT B. OVERLOADED CIRCUITS C. PLUGS NOT PROPERLY GROUNDED D. SMOKING E. COMBUSTIBLE SUBSTANCES NURSING RESPONSIBILITIES NURSES AT THE SCENE ASSISTING WITH RESCUE, EVACUATION AND FIRST AID NURSES AT THE HOSPITAL TRIAGING VICTIMS AND PROVIDING ACUTE CARE NURSES AT COMMUNITY SHELTERS / HEALTH CLINICS

APIE ON-GOING HEALTH-CARE NEEDS OF VICTIMS PERSONAL & PROFESSIONAL PREPAREDNESS MAKE PERSONAL & FAMILY PREPARATIONS BE AWARE OF THE DISASTER PLAN AT THE WORKPLACE & COMMUNITY MAINTAIN CERTIFICATION IN DISASTER TRAINING & CPR PARTICIPATE IN MOCK DISASTER DRILLS DISASTER RESPONSE IN THE HEALTH CARE AGENCY: FOLLOWING THE DIRECTIONS IDENTIFIED IN THE EMERGENCY RESPONSE PLAN IN THE COMMUNITY: IF ACTING AS THE 1ST RESPONDER, ATTEND 1ST TO VICTIMS WITH LIFE-THREATENING PROBLEMS; ONCE RESCUE WORKERS ARRIVE, IMMEDIATE PLANS FOR TRIAGE SHOULD BEGIN IN EMERGENCIES: GREATEST RISK RECEIVES PRIORITY IN MASS DISASTERS: DOING WHAT CAN BE DONE TO BENEFIT THE LARGEST NUMBER; ATTEND TO THOSE NEEDING MINIMAL CARE TO SAVE THEIR LIVES AND CAN BE AVAILABLE TO HELP OTHERS TRIAGE CLASSIFYING VICTIMS ACCORDING TO THE SEVERITY OF THE INJURY, URGENCY & PLACE OF TREATMENT TRIAGE IS A PROCESS WHICH PLACES THE RIGHT PATIENT IN THE RIGHT PLACE AT THE RIGHT TIME TO RECEIVE THE RIGHT LEVEL OF CARE (RICE & ABEL, 1992) IS THE PROCESS OF PRIORITIZING WHICH PATIENTS ARE TO BE TREATED FIRST AND IS THE CORNERSTONE OF GOOD DISASTER MANAGEMENT IN TERMS OF JUDICIOUS USE OF RESOURCES (AUF DER HEIDE, 2000) DERIVED FROM A FRENCH WORD TRIER WHICH MEANS TO SORT OUT OR CHOOSE ORGANIZED THE 1ST TRIAGE SYSTEM IS BARON DOMINIQUE JEAN LARREY (CHIEF SURGEON OF NAPOLEON) FIVE CONCEPTUAL CATEGORIES 1. DAILY TRIAGE 2. INCIDENT TRIAGE 3. DISASTER TRIAGE 4. TACTICAL- MILITARY TRIAGE 5. SPECIAL CONDITION TRIAGE 1. DAILY TRIAGE DONE EVERYDAY IN THE ED GOAL: IDENTIFY THE SICKEST PATIENTS IN ORDER TO ASSESS AND PROVIDE TREATMENT TO THEM 1ST BEFORE PROVIDING TTT TO OTHERS WHO ARE LESS ILL THE HIGHEST INTENSITY OF CARE IS PROVIDED TO THE MOST

SERIOUSLY ILL PATIENTS EVEN IF THERE IS LOW PROBABILITY OF SURVIVAL 2. INCIDENT TRIAGE ED IS STRESSED BY A LARGE NUMBER OF PATIENTS BUT IS STILL ABLE TO PROVIDE CARE TO ALL VICTIMS UTILIZING EXISTING AGENCY RESOURCES ON-CALL STAFF AS RESOURCES BUT NOT NECESSARILY ACTIVATING DISASTER PLAN HIGHEST INTENSITY: MOST CRITICAL EVERYONE RECEIVES CARE BUT MAYBE LONGER THAN NORMAL 3. DISASTER TRIAGE IS EMPLOYED WHEN LOCAL EMERGENCY SERVICES ARE OVERWHELMED TO THE POINT THAT IMMEDIATE CARE CANNOT BE PROVIDED TO EVERYONE WHO NEEDS IT RAPID, HIGH TECH CARE TO THE MOST UNSTABLE OR ACUTELY ILL (DOING THE GREATEST GOOD FOR THE GREATEST NUMBER) CATEGORIES INCLUDE: CRITICAL LIFE-THREATENING URGENT-SERIOUS MINOR-LOW TECH SETTING CATASTROPHIC- HAVING GRAVE PROGNOSIS 4. TACTICAL- MILITARY TRIAGE SIMILAR TO DISASTER TRIAGE ONLY MILITARY MISSION OBJECTIVES RATHER THAN TRADITIONAL CIVILIAN GUIDELINES DRIVE THE TRIAGE AND TRANSPORT DECISIONS 5. SPECIAL CONDITION TRIAGE IS USED WHEN PATIENTS PRESENTS FROM INCIDENTS INVOLVING WMD, SUCH AS RADIATION, BIOLOGICAL, CHEMICAL CONTAMINANTS THESE MANDATES TO USE PPE MASS CASUALTY INCIDENT (MCI) SIMPLE TRIAGE AND RAPID TREATMENT (START) SECONDARY ASSESSMENT OF VICTIM ENDPOINT (SAVE) SEIRV CLASSIFICATION 1. SUSCEPTIBLE INDIVIDUALS EXPOSED BUT SUSCEPTIBLE 2. EXPOSED SUSCEPTIBLE IND. WHO HAVE BEEN IN CONTACT W/ THE DSE AND MAY BE INFECTED, INCUBATING BUT STILL NONCONTAGIOUS 3. INFECTIOUS SYMPTOMATIC AND CONTAGIOUS 4. REMOVED CAN NO LONGER PASS THE DSE TO OTHERS (SURVIVOR/DEVELOPED IMMUNITY) 5. VACCINATED OR ON PROPHYLACTIC ANTIBIOTICS ARE CRITICAL RESOURCE FOR THE ESSENTIAL WORKFORCE

TRIAGE RATING SYSTEMS WELL=-KNOWN 1. SIMPLE TRIAGE AND RAPID TREATMENT (START) FOR TRIAGING ADULTS 2. JUMPSTART SYSTEM -SECONDARY ASSESSMENT OF VICTIM ENDPOINT (SAVE) FOR TRIAGING PEDIATRIC PATIENTS 3. START/SAVE WHEN THE TRIAGE PROCESS MUST BE OVER AN EXTENDED PERIOD OF TIME SIMPLE TRIAGE AND RAPID TREATMENT (START) WAS DEVELOPED BY NEWPORT BEACH CALIFORNIA, FIRE AND MARINE DEPARTMENT AND HOAG HOSPITAL EASY TO USE PERSONS ABILITY TO RESPOND VERBALLY ANS AMBULATE AND THEIR RESPIRATIONS, PERFUSION AND MENTAL STATUS (RPM) START/SAVE PERMITS THE TRIAGE PROCESS TO EVOLVE OVER HOURS OR EVEN DAYS, THEREBY MAXIMIZING PATIENT SURVIVAL AND RESULTING IN A MORE EFFICIENT USE OF RESOURCES MODIFIED VERSION OF START SUBSTITUTE RADIAL PULSE TO CAPILLARY REFILL COUPLED OF A SYSTEM OF SAVE JUMPSTART SYSTEM -SECONDARY ASSESSMENT OF VICTIM ENDPOINT (SAVE)

CREATED TO MEET THE UNIQUE NEEDS OF ASSESSING CHILDREN LESS THAN 8 YRS OLD OR JUMPSTART= LOOKS LIKE A CHILD START= LOOKS LIKE A YOUNG ADULT OR OLDER DEVELOPED IN 1995 AND MODIFIED BY DR. LOU ROMIG (AN EMERGENCY MEDICINE EXPERT PEDIATRIC AND RESPONSE) 5-TIER (MILITARY TRIAGE) VICTIM IS DEAD OR DYING EMERGENT: LIFE-THREATENING INJURIES READILY CORRECTABLE URGENT: MUST BE TREATED WITHIN 1-2 HRS NON-URGENT (DELAYED): NON-CRITICAL, AMBULATORY NO INJURY: NO TX NEEDED 4-TIER EMERGENT (IMMEDIATE): SERIOUSLY INJURED WITH REASONABLE CHANCE FOR SURVIVAL NON-URGENT (DELAYED): CAN WAIT FOR CARE AFTER SIMPLE 1ST AID EXPECTANT: EXTREMELY CRITICAL & DYING MINIMAL (NON-URGENT): NO IMPAIRMENT OF FUNCTION, CAN TX SELF OR BE TX BY NONPROFESSIONALS 3-TIER (HEALTH CARE AGENCIES) EMERGENT: LIFE-THREATENING INJURIES READILY CORRECTABLE URGENT: MUST BE TREATED WITHIN 1-2 HRS NON-URGENT (DELAYED): NONCRITICAL, AMBULATORY, NO INJURY

TRIAGE CATEGORY CARDIAC CONDITION EMERGENT CHEST PAIN CRUSHING PAIN, FEELING OF PRESSURE, BURNING SENSATION, HEAVINESS OR PAIN RADIATING INTO NECK OR ARMS PAIN ASSOCIATED W/SWEATING, NAUSEA, VOMITING, SOB, DIZZINESS, PALLOR OR CYANOSIS HX OF CARDIAC PROBLEMS OR >40YRS OLD

HEART FEELS AS IF RACING OR POUNDING TRIAGE CATEGORY : RESPIRATION EMERGENT ADULTS (>12YRS OLD) 30 OR MORE 10 OR LESS CHILD (<12YRS OLD) 50 OR MORE 20 OR LESS ACUTE RESPIRATORY DISTRESS RETRACTIONS, CYANOSIS, NASAL FLARING, LABORED BREATHING, WHEEZING, DYSPNEA AT REST URGENT MILD RESPIRATORY DISTRESS PRODUCTIVE COUGH W/ TEMP OVER 102F PRODUCTIVE COUGH W/ STREAKS OF BLOOD ( PINK TINGED) NON-URGENT RESPIRATORY SXS W/NO ACUTE DISTRESS NON-PRODUCTIVE COUGH COLD SXS (SORE THROAT, RUNNY NOSE) TRIAGE CATEGORY : ORTHO / SURGICAL EMERGENT OPEN FRACTURE EXTREMITY INJURY W/ SEVERE DEFORMITY OR NEUROVASCULAR COMPROMISE (DECREASING PULSE, SENSATION OR MOVEMENT) LACERATION W/UNCONTROLLED BLEEDING NECK PAIN 2NDARY TO TRAUMA <48HRS OR ASSOCIATED W/STIFF NECK MAJOR BURNS : >10%TBS, BURNS ON THE FACE, HANDS AND FEET, GENITALIA ---ANY BURN IN A CHILD <1YR OLD PAIN BENEATH A CAST W/A NEUROVASCULAR COMPROMISE URGENT PAIN BENEATH A CAST W/O NEUROVASCULAR COMPROMISE LACERATION W/ CONTROLLED BLEEDING CLOSED FRACTURE SUSPECTED W/O DEFORMITY OR NEUROVASCULAR COMPROMISE BACK PAIN 2NDARY TO TRAUMA IN THE LAST 72HRS MINOR BURNS OTHER THAN MAJOR BURNS NON-URGENT SPRAINS/BRUISES W/O OBVIOUS DEFORMITY EXTREMITY PAIN W/O NEUROVASCULAR COMPROMISE CHRONIC BACK PAIN MINOR INJURY >72HRS WOUND CHECK; SUTURE REMOVAL TRIAGE CATEGORY : OB / GYN EMERGENT PELVIC PAIN & CHANGE IN VS OR SEVERE PELVIC PAIN ALONE >20WKS PREGNANT, PROFUSE BLEEDING PROLAPSED UMBILICAL CORD >20WKS GESTATION W / ABD PAIN / LABOR OR VAGINAL BLEEDING RAPE / SEXUAL ASSAULT HEAVY POST-PARTUM BLEEDING (VS W/IN NORMAL LIMITS) URGENT PELVIC PAIN OVER 48HRS, VS NORMAL BLEEDING(NOT PROFUSE) <20WKS PREGNANT NON-URGENT VAGINAL DISCHARGE. RASH OR ITCH

SUSPECTED PREGNANCY SUSPECTED VENERAL DISEASE BREAST LUMP NON-PROFUSE BLEEDING NOT RELATED TO PREGNANCY CHRONIC PELVIC PAIN MENSTRUAL CRAMPS TRIAGE CATEGORY: GI / GU EMERGENT OBVIOUS BLOOD VOMITUS OR IN STOOL EVIDENCE OF ACTIVE BLEED SEVERE ABDOMINAL PAIN UNCONTROLLED VOMITING URGENT SEVERE RECTAL PAIN UTI W/ SEVERE DISCOMFORT INTERMITTENT RECTAL BLEED (SPOTTING AND ACTIVE BLEED), INCLUDING BLEEDING HEMORRHOIDS NON-URGENT CONSTIPATION PARASITES MILD RECTAL PAIN N&V, DIARRHEA W/ NORMAL VS, NO SIGNS OF DEHYDRATION HEMORRHOIDS NOT BLEEDING SUSPECTED UTI, NO SEVERE DISCOMFORT TRIAGE CATEGORY :NEUR0/ PSYCHIATRIC EMERGENT CLOSED HEAD INJURY W/ABNORMAL VS SEIZURES ACTIVE OR POSTICTAL ALTERED MENTAL STATUS NEW ONSET DRUG OVERDOSE SUICIDE IDEATION EMOTIONAL PROBLEMS (THREATENED TO HURT SELF OR OTHERS) ETOH W/DRAWAL W/ ALTERED MENTAL STATUS OR VS SUSPECTED STROKE (NEW ONSET PARALYSIS ON 1 SIDE OF THE BODY) HEADACHE W/ HX OF HEAD TRAUMA <1WK AGO WITH STIFF NECK/VISUAL PROBLEMS URGENT VERTIGO / DIZZINESS (IF EVENT OCCURRED W/IN THE PAST 12HRS MIGRAINE/HEADACHE NOT ASSOCIATED W/ HEAD TRAUMA CLOSED HEAD INJURY, VS AND LOC NORMAL ACUTE INTOXICATION, VS & LOC NORMAL EMOTIONAL PROBLEMS, PATIENT APPEARS STABLE NON-URGENT HEADACHE, NOT SEVERE, VS NORMAL & NEUROLOGICALLY INTACT REQUEST FOR PSYCHIATRIC REFERRAL; PATIENT APPEARS STABLE W/O SUICIDAL IDEATION TRIAGE CATEGORY : SKIN EMERGENT SEVERE HIVES SEVERE ALLERGIC REACTION URGENT BODY RASH ANIMAL BITES ( NOT SEVERE) NON-URGENT PARASITES (WORMS, CRABS, LICE) INSECT BITES HAS NO HISTORY OF ALLERGIES TRIAGE CATEGORY : TEMPERATURE

EMERGENT

URGENT

>104F FOR >6MOS OLD > 100.5F FOR <3MOS OLD OR CLIENTS WHO ARE IMMUNOCOMPROMISED POSSIBLE HEAT INJURY : CHANGE IN MENTAL STATUS, >101F, (-) PERSPIRING, DIZZINESS, WEAKNESS, NAUSEA POSSIBLE COLD INJURY : W/HX OF COLD EXPOSURE, FROST BITE

101 F-103F IN >6MOS OLD POSSIBLE HEAT INJURY : T-<101F W/O DIZZINESS, WEAKNESS, NAUSEA, ABDOMINAL OR EXTREMITY MUSCLE CRAMPS NON-URGENT * BORDERLINE TEMP >6MOS OLD : >95F & <101F <6MOS OLD : >96F & <100.5F TRIAGE CATEGORY : EENT EMERGENT PENETRATING EYE TRAUMA BLUNT EYE WITH LOSS OF VISION FACIAL SWELLING WITH POTENTIAL AIRWAY COMPROMISE ACTIVE EPISTAXIS INABILITY TO SWALLOW URGENT BLUNT EYE TRAUMA W/O LOSS OF VISION HYPHEMA (BLOOD COLLECTED IN SCLERA) EAR TRAUMA, FOREIGN BODY NON-URGENT SORE THROAT EYE INFLAMMATION (PINK EYE TRIAGE CATEGORY: PEDIATRIC EMERGENT LETHARGY OR DECREASED MENTAL STATUS, ALERTNESS; DIFFICULT TO AROUSE T- >104F (INFANTS & CHILDREN >6MOS OLD) RESPIRATORY DISTRESS ACTIVE BLEEDING (+) TOXIC INGESTION SEVERE PAIN (MOANING) SNAKE BITE ACTIVE SEIZURE DOESNT LOOK RIGHT SUSPECTED CHILD ABUSE URGENT ANIMAL BITE (INJURY NOT SEVERE) ACTIVE VOMITING / DIARRHEA T-101F-103F FOR >6MOS, CHILDREN & ADULTS T-UNDER 101F IN WELL-APPEARING CHILD >6MOS OLD NON-URGENT RASH WITH NORMAL VITAL SIGNS TRIAGE RATING SYSTEMS 2-TIER IMMEDIATE: LIFE-THREATENING INJURIES READILY CORRECTABLE (EMERGENT) & VICTIMS WHO MUST BE TREATED WITHIN 1-2 HRS (URGENT) NON-URGENT (DELAYED): NON-CRITICAL, AMBULATORY, NO INJURY, DYING OR DEAD EMERGENCY DEPARTMENT TRIAGE SYSTEMS EMERGENT (RED): PRIORITY 1

LIFE-THREATENING INJURIES WITH HIGH CHANCE FOR SURVIVAL ONCE STABLE E.G. TRAUMA, CHEST PAIN, SEVERE RR DISTRESS, CPR, LIMB AMPUTATION, ACUTE NEURO DEFICITS, CHEMICAL EYE SPLASHES URGENT (YELLOW): PRIORITY 2 NON LIFE-THREATENING INJURIES IF TX WITHIN 1-2 HRS, REQUIRES EVALUATION Q30-60 MINS. E.G. SIMPLE FRACTURE, ASTHMA, WITHOUT RR DISTRESS, FEVER, HTN, ABDOMINAL PAIN, RENAL STONE NON-URGENT (GREEN): PRIORITY 3 WITH LOCAL INJURIES WITHOUT COMPLICATIONS, WHO CAN WAIT SEVERAL HRS FOR TX, REQUIRES EVALUATION Q1-2H E.G. MINOR LACERATION, SPRAIN, COLDS EMERGENCY DEPARTMENT TRIAGE SYSTEMS WHEN CARING FOR DEAD CLIENTS, RECOGNIZE THE IMPORTANCE OF FAMILY RITUALS & PROVIDE SUPPORT TO THE LOVED ONES ORGAN DONATION PROCEDURES NEED TO BE ADDRESSED IF APPROPRIATE PRIMARY ASSESSMENT * TO IDENTIFY IMMEDIATE OR POTENTIAL THREAT TO LIFE * GATHERS OBJECTIVE DATA, ABCS, TRAUMATIC INJURY FOR HEAD OR CERVICAL SPINE INJURY SECONDARY ASSESSMENT * DONE AFTER TREATMENT * GATHERS SUBJECTIVE & OBJECTIVE DATA, HX, GENERAL OVERVIEW, VS, NEURO, PAIN ASSESSMENT, COMPLETE OR FOCUSED PE