Trauma centers: Prepare for mass casualty incidents by understanding the 10 predictable stages of disruption

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Mass casualty incidents (MCIs) seem to strike at random. That is one reason why these incidents — particularly mass shootings — are so frightening. But while the timing and location of most MCIs are unpredictable, the way these events play out at the scene and the trauma center is not.

Longstanding research shows that no MCI is truly unique — whether it is a natural disaster such as an earthquake, hurricane, flood or tornado, or the result of human violence. At the receiving hospital, an MCI triggers a sequence of disruptions that follow a predictable pattern.

Not every disruption occurs in every event, but all of them are possible. And the larger the MCI, the more likely it is that the trauma center will experience every one of these problems:

1. Communication breakdown creates confusion at trauma center
Early confusion due to poor communication is one of the hallmarks of an MCI. In most communities, police, fire and EMS agencies do not have a common communication frequency for coordinating information. Cell phones have exponentially increased contact with 911 dispatch, but calls from victims and bystanders rapidly overload the system.

As a result, initial reports about the cause of an MCI event, its severity and the conditions at the scene are mostly garbled and inaccurate. All of these factors create confusion at the receiving trauma center.

For trauma center leaders, the takeaway is to keep early reports in perspective. Initial communications serve as notification of an MCI, but not a reliable tool for planning a detailed response. Activate the disaster plan for the highest probable number of casualties, then scale down as the situation evolves.

To increase your readiness for this phase, create a tiered disaster plan based on the likely number of injured patients. For example, plan a “code yellow” response for up to 10 victims, “code orange” for 11 to 25 victims, and a full “code red” for any MCI with more than 25 expected casualties. Your code red plan should include everything from clearing the helipad to requesting blood from nearby hospitals.

2. Minimally injured arrive in first wave of patients
The first survivors of an MCI arrive by privately owned vehicles (pickups, taxis, police cars, etc.) without pre-arrival treatment or notification. These survivors are usually the least injured. But while they may ultimately require minimal attention, they create the risk that the Emergency Department (ED) will be overrun with lower-acuity patients.

This pattern was evident during the Orlando mass shooting of June 2016. Patients with relatively minor injuries began arriving at Orlando Regional Medical Center while the most horrifically injured people were still trapped in the nightclub.

MCI plans should include the creation of a triage area outside of the main ED. The area should include designated sections for separating critical and minor injuries. This will help make sure that seriously injured survivors get the most attention. It will also ensure that any needed decontamination takes place outside the hospital, preventing an unnecessary hospital shutdown.

Your MCI plan should also designate where minimally injured patients will receive care. For many hospitals, triaging these patients to an ambulatory surgery center is an effective solution. The typical ASC has the staff, supplies and space to accommodate many patients with non-life-threatening injuries.

3. “Convergers” descend on hospital
Not far behind the first wave of patients are the many un-injured individuals who converge on the trauma center as the incident unfolds. Convergers include families and friends, media personnel, voyeurs/poseurs and people who just want to help. During a terror incident, this group could also include terrorists seeking a secondary target.

To maintain the ability to treat patients while protecting the facility from unfolding threats, trauma center leaders must:

Lock down immediately. As soon as the trauma center receives notification of an MCI, it must go into immediate lockdown. Develop a plan for securing every door within 5 minutes, with entry restricted to essential persons (physicians, nurses, etc.) and incident survivors. Authority for ordering a lockdown must reside with staff on duty — for instance, the most senior ED physician on site — not with hospital executives who may be unreachable.

While Orlando Regional did go into lockdown during their MCI, my sources report that the lockdown was not ordered until the event had progressed significantly. The danger of poor facility control became evident when rumor suddenly spread that a second shooter was on the hospital campus. The rumor was eventually proven false, but not before it created significant distractions for trauma providers.

The Orange Book notes that “preplanned hospital lockdown procedures” are important for preventing disruptions that can interfere with a trauma center’s ability to provide casualty care. Here’s my suggestion to ACS surveyors: Ask trauma program leaders to explain specifically how they plan to lock down every door and entry way to their facility. If they can’t explain their lockdown process while they are sitting in a conference room, that process won’t happen during an actual MCI.

Establish a perimeter of control. To the extent possible, the trauma center should also be able to establish a secure perimeter extending at least two blocks in every direction. Security staff should use hospital or personal vehicles to block non-essential entryways. (This may require help from personnel in other areas such as engineering, maintenance and housekeeping.) These staff should stand guard at blocked entryways, wearing reflective vests clearly marked “Security”. As with lockdown authority, the ability to order perimeter control should not require bureaucratic approval.

Direct convergers to predetermined sites. Security should direct non-injured individuals to the appropriate pre-determined sites:

  • Family, friends and the “worried well” should be directed to a large space such as an auditorium or conference area.
  • Members of the media should be directed to an area that can accommodate their equipment and space needs. Consider sending the media to the main entrance of the hospital or another area where hospital leaders can make announcements as needed. (In addition, be aware that media helicopters frequently hover over the trauma center following an MCI, creating hazards for incoming and outgoing craft. Hospital leaders may need to work with state government to clear the airspace above the hospital for helicopter evacuations.)
  • Blood donors pose a particular problem because of the vast numbers of responders. Designate a separate clinical building dedicated to blood donation (and away from triage and family areas). That building can be staffed with Red Cross volunteers and other providers.

Leaders should also plan for the possible arrival of special populations such as mentally ill persons and prison inmates. These individuals are usually overlooked in planning efforts, but they pose significant risks. Plan to designate special areas for these populations so they are not mixed with other vulnerable disaster victims.

4. Medical volunteers begin to appear
As a large MCI unfolds, physicians and nurses from other hospitals will arrive at the trauma center to offer their services. The extra help may be a godsend, but it can create confusion and legal risk.

Trauma center leaders should plan for this disruption by establishing mutual aid agreements (MAAs) with other hospitals in the community. MAAs provide emergency credentialing to skilled personnel, allowing them to work under the hospital’s liability coverage where Good Samaritan statutes do not apply. Establish policies that limit the activities of emergency volunteers, provide for supervision and ensure that outside providers have at least basic knowledge of your hospital’s equipment.

5. Demand surges for supplies and equipment
In a mass casualty situation, normal hospital supply management processes are too slow. There is little time to check items out of Central Supply or access supplies and medications from automated dispensing cabinets. This is no time for Pyxis!

To prepare for an MCI, trauma centers need to maintain disaster packs that can be quickly transported to the resuscitation area. Each pack (a duffle bag or bin) should contain adequate supplies for at least 50 patients. Key items include IV start kits and solution, laparotomy packs, suture sets, splints, sterile packs, endotracheal and chest tubes, Foleys, O2 cannulas, etc.

To repeat, do not store your disaster packs in Central Supply. MCIs often take place at night, when CS is minimally staffed. Ideally, the packs should be stored in the ED in cabinets with plastic locks for easy emergency access.

The average trauma center runs on a “just in time” inventory, so an MCI could soon create the need to resupply. Unfortunately, a supply truck is an ideal vehicle for carrying out a secondary terrorist attack. Assign security personnel to identify and divert marked vendor trucks to an alternate entry.

Blood products present a special problem during an MCI, especially when you consider the already difficult logistics of implementing a Massive Transfusion Protocol. This underscores the need for a collaborative MCI planning process that includes hospital-based and regional blood banks.

6. Demand surges for rooms and beds
When a trauma center receives an MCI notification, leaders should immediately enact plans to free up hospital capacity. OR managers should cancel elective surgeries, close those in progress and set up all rooms for trauma surgery. The ICU should transfer marginal patients, even to “hall” beds if needed.
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Nursing unit managers should quickly prepare able patients for discharge to a preplanned area. This area should have gurneys/recliners, water, toileting and handwashing facilities, and medication supplies. Unit caregivers should select dischargeable patients, with orders from residents or advanced practitioners. Cardiac, renal, diabetic and post-op patients can be transferred to a general hospital so their care is not degraded by the unfolding disaster. This is best accomplished when MAAs are in place and patient transport is handled by the receiving facility, enabling the referring trauma center to care for more incoming injured.

7. Recordkeeping systems become overloaded
The arrival of multiple casualties will almost always force staff to abandon the EMR. An effective MCI plan will include alternative recordkeeping systems. The best strategy is to include the following items in the disaster supply packs:

  • Paper forms for creating an initial medical record
  • Paper order slips for labs, radiology and other services
  • Paper supply/billing forms
  • Clipboards and permanent markers
  • Patient arm/leg bands

The arm/leg bands should come in sets of three. The first band is for patient identification, the second is for allergies and the third identifies the patient’s triage level by color or number. In many disasters, staff use a permanent marker to write medications given, triage level, and other key information on the patient’s forehead as well as the chart.

8. The need for compassionate care increases
In an MCI, as in war, the morbidly injured are given palliative care so that many others can survive. MCI plans should include the designation of a supportive care site to which moribund patients can be triaged. For many hospitals, the Physical Therapy department could be a good choice for setting up a compassionate care site. This hospice area can be staffed with nursing assistants and clergy. The goal is to prepare the patient for family viewing and give supportive care to both patients and loved ones.

Disaster plans should also accommodate the deceased. Mortuary and morgue space fills rapidly, so trauma center leaders should consider working with local authorities to secure mobile morgues.

9. Caregiver needs return to the forefront
Physicians, nurses and other caregivers go into “overdrive” at the start of an MCI, but they cannot run on adrenaline forever. Effective MCI plans take into account the human dimension of disaster response.

All caregivers should be encouraged to create a personal disaster pack. When an MCI is called, the individual can grab their disaster pack before they head to the trauma center. The pack should include items such as hygiene products, a change of clothes, water, high-energy protein bars, a three-day supply of medications, a cellphone charger, a flashlight and batteries.

MCI plans should also accommodate the many caregivers who need to bring family members with them to the trauma center during an extended incident. Human Resources should have a Family Care Plan on file for all children, elderly relatives and disabled dependents who will accompany staff during MCIs. The paper plan should include medication/allergy information and name the persons who are authorized to pick up the dependent from the hospital. During an MCI, dependents should be dropped off at a pre-designated area (with their personal disaster pack) and be given an ID band with their name, the staff member’s contact information, and critical medication and allergy information.

10. The trauma center becomes the victim
While mass shootings and terrorist attacks do not usually affect hospitals directly, natural disasters such as earthquakes, tornadoes and flooding can incapacitate a trauma center. Food, sanitary supplies, water and medical equipment may become inaccessible or damaged. Emergency power may be lost, creating blackout conditions.

Evacuating a hospital during an MCI can be harrowing. To mitigate the chaos, trauma centers need to establish MAAs and Memorandums of Understand (MOUs) with nearby hospitals to cover emergency evacuations. Under these agreements, the other hospital agrees to accept evacuated patients and allow trauma center staff to provide care at the receiving facility without having privileges. Obtaining ground transport for these patients could require assistance from outside the disaster area, since local resources may be engaged rescuing and transporting local victims.

Learn more
Preparing for a mass casualty incident requires careful planning and extensive collaboration. To learn more, read U.S. Trauma Center Preparedness for a Terrorist Attack in the Community. This CDC-funded report (R49 CE000792-01) from the Trauma Center Association of America identifies best practices and profiles several hospitals that define excellence in MCI preparedness. In addition, read Critically Conditioned: Trauma Centers Are Crucial Solutions To Mass-Casualty Aftermath And Response in the October 2016 issue of Homeland Security Today.

Connie J. Potter, RN, MBA:HCA is a nationally recognized authority on trauma center and trauma system leadership and management. She is the CEO of TraumaWorks, a trauma management consulting firm.

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