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Hospital Emergency Response Training HERT for Mass Casualty Incidents MCI TraintheTrainer Course

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Title: Hospital Emergency Response Training HERT for Mass Casualty Incidents MCI TraintheTrainer Course


1
Hospital Emergency Response Training (HERT) for
Mass Casualty Incidents (MCI) Train-the-Trainer
Course
  • Course Code B461

2
HERT FOR MCI
  • Hospital Emergency Response Training (HERT) for
    Mass Casualty Incidents (MCI) Train-the-Trainer,
    B461 Course
  • Resident Offering at Noble Training Center,
    Anniston, Alabama
  • 4.0 Days
  • Special offerings for hospital emergency
    departments, administration, and staff personnel
  • Prerequisites
  • IS-195, Basic ICS
  • IS-346, An Orientation to Hazardous Materials for
    Medical Personnel

3
What HERT for MCI is Not?
  • Not a HazMat Course. Need additional training
    under
  • OSHAs Hazardous Waste Operations and Emergency
    Response, 29 CFR 1910.120, par (q), 1990
  • OSHA 3152 Hospital and Community Emergency
    Response What You Need to Know, 1997
  • OSHAs Best Practices for Hospital-Based First
    Receivers of Victims from Mass Casualty Incidents
    Involving Hazardous Substance Releases, 2004
  • Department of Health and Human Services, CDC
    Recommendations for Civilian Communities Near
    Chemical Weapons Depots Guidelines for Medical
    Preparedness, 1995
  • USACHPPM, Technical Guide 275, PPE for Military
    MTF Personnel Handling Casualties from WMD and
    Terrorist Events, 2003

4
What HERT for MCI is Not? (Contd)
  • Not a Hospital Emergency Incident Command System
    (HEICS) Course
  • HERT stresses HEICS as a valuable tool for
    hospitals
  • Recognizes all Hospital Incident Management
    Systems (HIMS)
  • HERT emphasizes a hospital IMS during emergency
    response
  • HERT integrates its HIMS into all aspects of the
    course

5
What HERT for MCI is Not? (Contd)
  • Not a Weapons of Mass Destruction (WMD) Course
  • HERT emphasizes the handling of patients
    contaminated with CBRNE agents
  • Recognizes attendees prior training and skills
    concerning these agents
  • Attendees should receive additional training on
    WMD Events from ODP

6
What HERT for MCI is Not? (Contd)
  • Not a National Incident Management System (NIMS)
    Course
  • HERT emphasizes the use of an incident management
    system to comply with the NIMS
  • Recognizes attendees prior training in the NIMS
  • Has incorporated NIMS where it applies throughout
    the course
  • Participants wanting additional training should
    enroll in FEMAs Online Courses in the NIMS
  • IS 700 NIMS, An Introduction
  • IS 800 NRP, An Introduction

7
Unit One
  • Course Introduction Origin of the Incident
    Command System (ICS)

8
Objectives
  • Review ICS as an incident management tool
  • List uses of ICS in emergency management
  • Describe the history of ICS
  • Discuss the evolution of HEICS
  • Define basic HEICS structure
  • Review ICS organizational chart

9
Objectives (cont'd)
  • Develop an initial organizational structure
  • List minimum staffing requirements
  • Prepare an incident briefing
  • Participate in a planning meeting
  • Develop incident objectives and an Incident
    Action Plan (IAP)
  • Identify appropriate uses of resources

10
What is ICS?
  • The model incident management tool for
  • Command, control, and coordination of an
    emergency response
  • Providing a means to coordinate efforts of
    individual agencies
  • Allowing agencies to work toward a common goal
    for stabilizing an incident
  • Ensuring the protection of life, property, and
    the environment

11
When is ICS Used?
  • Hazardous materials incidents
  • Response to natural disasters
  • Fire and riot control
  • Incidents involving multiple casualties
  • Weapons of Mass Destruction
  • Mass Casualty Events
  • Wide-area search and rescue missions

12
History of ICS
  • Developed in the 1970s in response to major wild
    land fires in Southern California
  • Allowed for collaboration to form the
  • Firefighting Resources of Southern California
    Organized for Potential Emergencies, or FIRESCOPE

13
History of ICS (cont'd)
  • FIRESCOPE identified several recurring problems
    involving multi-agency responses, such as
  • Nonstandard terminology
  • Lack of flexibility to expand or contract
    resources as required
  • Nonstandard and nonintegrated communications
  • Lack of consolidated action plans
  • Lack of designated facilities

14
History of ICS (cont'd)
  • Efforts to address these difficulties resulted in
    the development of an ICS model
  • Success of ICS has resulted directly from
    applying
  • A command organizational structure
  • Key standardized management principles

15
NIIMS versus NIMS
  • NIIMS (existing)
  • Incident Command System (ICS)
  • Training
  • Qualifications Certification
  • Publications Management
  • Supporting Technology
  • NIMS (new)
  • Command Incident Management
  • Preparedness
  • Resource Management
  • Communications Information Intelligence
    Management
  • Science Technology Management

16
Hospital Emergency Incident Command System (HEICS)
  • Modeled after FIRESCOPE
  • Early work by the Northern California Hospital
    Council
  • California authorized a grant to Orange Country
    EMS for HEICS Project 91/92
  • Major rewrite of HEICS documents
  • Now provide the current HEICS Plan
  • HEICS considered a model for hospital incident
    management system

17
HEICS Attributes
  • HEICS attributes
  • Command, control, coordination, and intelligence
  • Functional incident management system
  • A dependable chain-of-command
  • Improved communications through common language
  • Flexibility in section (component) activation
  • Prioritization of duties
  • Adaptable to HazMat, WMD, and MCI

18
HEICS Attributes (cont'd)
  • Organized documentation for improved financial
    recovery
  • Facilitates effective mutual aid with
  • Other hospitals, and
  • Agencies

19
Basic HEICS Structure
  • Basic units of structure
  • Incident Commander
  • Section Chiefs
  • Directors
  • Unit Leaders
  • Officers

20
ICS Organizational Chart
  • Represents lines of authority and communications
  • Command element (IC and staff)
  • Four functional sections
  • Planning
  • Operations
  • Logistics, and
  • Finance/Administration

21
ICS Organization
22
Incident Commander
  • Incident Commander (IC)
  • Defines the mission and ensures its completion
  • Has overall control of incident or emergency
    response
  • Can appoint a deputy commander

23
Command Staff
Public Information Officer
IncidentCommand
Safety Officer
Liaison Officer
24
Command Staff (cont'd)
  • Command Staff is
  • Public Information Officer
  • Liaison Officer
  • Safety Officer
  • Officers can also have Assistants

25
General Staff
26
Planning Section
  • Planning Section
  • Determines and provides for the continuance of
    each response objective
  • Prompts and drives all Officers to develop
  • Short-range action planning
  • Long-range action planning
  • Responsible for preparing the IAP

27
Planning Section (cont'd)
28
Operations Section
  • Operations Section
  • Carries out the objectives to the best of the
    staffs ability
  • Oversees and directs all response operations
  • Determines needs and requests additional resources

29
Operations Section (cont'd)
30
Logistics Section
  • Logistics Section
  • Provides a hospitable environment and materials
    for the overall objectives
  • Ensures service and support for responders

31
Logistics Section (cont'd)
32
Finance/Administration Section
  • Finance/Administration Section
  • Provides funding for present objectives
  • Stresses facility-wide documentation to maximize
  • Financial recovery, and
  • Reduction of future liability

33
Finance/Administration Section (cont'd)
34
Future of the ICS
  • Continues to expand throughout U.S.
  • Law enforcement
  • Government agencies
  • Hospitals and HCF
  • Will be revisited to ensure
  • It remains relevant to response agencies, and
  • Current with standardized ICS models
  • Must be adaptable to include an ICS/UC structure
    for HMI, MCI, and WMD events
  • Should incorporate NIMS as adopted on March 1,
    2004

35
Unit Two
  • Hospital Incident Management System (HIMS)

36
Objectives
  • Describe Hospital Incident Management System for
  • Planned unplanned events
  • Mass casualty incidents
  • HazMat incidents
  • CBRNE events
  • Describe transfer of command

37
HIMS Operations Section Members
  • HIMS Operations Section could consist of
  • Operations Section Chief
  • Group/Division Supervisors
  • CBRNE or HazMat Group
  • SHED or Cafeteria Division, etc.
  • Team Members
  • Triage and Treatment Unit Leaders
  • Triage and Treatment Team Members
  • Hospital Emergency Response Unit (HERU)
  • Team Members

38
HIMS Operations Section Organization
39
Medical Care Group/DivisionMembers
  • Medical Care Group/Division could consist of
  • Medical Group/Division Supervisor
  • Triage Unit Leader
  • Triage personnel
  • Treatment Unit Leader
  • Treatment Dispatcher Manager
  • Treatment Managers
  • Immediate, Delayed and Minor
  • Patient Transport Group Supervisor
  • Medical Communications Coordinator
  • Air/Ground Ambulance Coordinator

40
Medical Care Group/DivisionMembers (Contd)
  • Command from the top down
  • Staff from the bottom up
  • Start with Team or Unit when possible
  • Staff up as span of control is exceeded
  • Maintain unity of command
  • Divisions are geographical
  • North/South East/West 1st floor/2nd floor

41
Medical Care Group/DivisionMembers (Contd)
  • Groups are functional
  • Security, medical care
  • CBRNE or HazMat
  • Groups can have Units
  • Triage
  • Treatment
  • Hospital Emergency Response Unit (HERU)
  • Units may have Teams
  • Decontamination

42
Medical Care Group/Division Organization
43
HazMat/CBRNE Unit Members
  • HazMat/CBRNE Unit Leader
  • Entry Team Leader
  • Hospital Site Access Control Leader
  • Safe Refuge Area Manager
  • Decontamination Team Leader
  • Technical Specialist
  • Assistant Hospital Safety Officer HazMat

44
HazMat/CBRNE Unit Organization
45
Hospital Emergency Response Unit (HERU)
  • HERU Leader
  • Hospital Emergency Response Team (HERT) Leader
  • Initial Assessment Triage
  • Immediate Treatment
  • Delayed Treatment
  • Minor Treatment
  • Unit can be replaced by a Team

46
HERU/HERT Organization
47
Decon Team Members
  • Decontamination Team Leader
  • Initial Contact
  • Decon Triage
  • Decon Site Access Control
  • Decon Set-up and Support
  • Patient/victim is continually triaged

48
Decon Team Organization
49
Scenario Objectives
  • Identify initial incident objectives
  • Incident priorities
  • Life Safety (staff and patients)
  • Incident Stability
  • Property preservation
  • Activate ICS
  • Fill positions as appropriate for the event
  • Key points
  • Span of control (3 7)
  • Unity of command

50
Scenario Planned Event
  • Menu
  • Fried catfish, Cole Slaw, Beans, Hush Puppies,
    Cornbread
  • Ice Cream Cones
  • Beer
  • Soda
  • Entertainment
  • 8 bands, 2 magician shows
  • Vendors
  • 20 Arts Craft booths
  • Childrens Play area
  • Noble Hospital is planning their annual
    fundraiser
  • A two day Fish Fry Festival.
  • Saturday and Sunday,
  • Noon to 10 pm

51
Section Considerations
  • Initial Incident Objectives
  • What are the main functions for
  • (Operations, Logistics, Planning and
    Finance/Admin)?
  • Should the functions be divided?
  • If so, how?

52
Scenario Unplanned Event
  • A complete, community-wide power outage has
    occurred approximately 20 minutes ago. United
    Electric Company has just informed you that there
    is a 50 mile blackout, cause is unknown. Outage
    expected to last 5-7 days.
  • Emergency generators functioning with enough fuel
    for 1.5 days at current emergency load.
    Emergency equipment is working only.
  • The following departments are not on emergency
    power
  • Business office Registration
  • Infection Control Administration
  • Physical Therapy All offices in hospital
  • Pneumatic tube system

53
Scenario Unplanned Event (Contd)
  • Departments on emergency power for critical
    functions
  • Emergency Dept ICU/CCU Medical gases
  • Lab XRay Nursery
  • Surgery Recovery Nursing Units
  • Pharmacy Switchboard
  • Summer weather - 90/58
  • Population 250,000
  • Two hospitals, multiple clinics in area
  • Noble Hospital 250 beds/85 full total
    hospital staff 1800

54
Section Considerations
  • Initial Incident Objectives
  • What are the main functions for
  • (Operations, Logistics, Planning and
    Finance/Admin)?
  • Should the functions be divided?
  • If so, how?

55
Scenario -- Mass Casualty Event
  • There was a stadium collapse at the fairgrounds.
  • Capacity of the stadium is 5000 people. Report
    from
  • EMS indicate over 300 people injured with many
    fleeing
  • the scene in private vehicles. The county Mass
    Casualty
  • Plan has been activated.
  • Summer weather - 90/58
  • Population 250,000
  • Two hospitals, multiple clinics in area
  • Noble Hospital 250 beds/85 full total
    hospital staff 1800
  • ED has 20 beds currently has 16 patients

56
Section Considerations
  • Initial Incident Objectives
  • What are the main functions for
  • (Operations, Logistics, Planning and
    Finance/Admin)?
  • Should the functions be divided?
  • If so, how?

57
Scenario Haz Mat Incident
  • Continuation of stadium collapse
  • There were 20 people that were contaminated
  • With Organophosphate when the holding tank
  • was punctured from a piece of the stadium
  • Some have left the scene en-route to the
  • hospital. EMS will be transporting 6 after
  • gross decontamination (clothing removed
  • and field shower)

58
Section Considerations
  • Initial Incident Objectives
  • What are the main functions for
  • (Operations, Logistics, Planning and
    Finance/Admin)?
  • Should the functions be divided?
  • If so, how?

59
Transfer of Command
  • Transfer command to an equal or more qualified
    person
  • Transfer of command requires
  • Briefing of incident face to face
  • Notification of staff that transfer has occurred
    AND the name of the new person

60
Transfer of Command (Contd)
  • Command transfers to a more qualified IC when
    necessary
  • The new IC will always receive a
    transfer-of-command briefing
  • Hospitals and healthcare facilities must identify
    and train deputy ICs

61
Summary
  • ICS can be used for planned AND unplanned events
    involving the hospital
  • Make the response fit the event only fill the
    positions that are needed
  • Maintain span of control (3 7 people)
  • Use branches and divisions as needed
  • Expand and contract assignments as needed
  • Transfer of Command must be done consistently and
    completely

62
Summary (Contd)
  • Incident priorities
  • Life safety of care providers
  • Patient stability and treatment
  • Property conservation
  • Protect the environment

63
Unit Three
  • Topic 3-1 Chemical and Biological Agents in
    Terrorism

64
Objectives
  • Overview of potential biological agents used in
    terrorism
  • Overview of potential chemical agents used in
    terrorism
  • Overview of common syndromes
  • Define clinical management procedures for
    chemical/biological agents
  • Define guidelines for response plans

65
Routes of Exposurefor Chemical and Biological
Agents
66
Bioterrorism (CDC Definition)
  • Bioterrorism is the intentional or threatened
    use of viruses, bacteria, fungi, toxins from
    living organisms or other chemicals to produce
    death or disease in humans, animals or plants.

67
Potential Bioterrorism Agents
  • Viruses
  • Smallpox
  • Venezuelan Equine Encephalitis
  • Viral Hemorrhagic Fever
  • Biological Toxins
  • Botulinum
  • Staph Entero-B
  • Ricin
  • T-2 Mycotoxins
  • Bacterial Agents
  • Anthrax
  • Brucellosis
  • Cholera
  • Pneumonic plague
  • Tularemia
  • Q Fever

68
Mandatory Reporting Guidelines
  • gt Know your state and local guidelines
  • gt Include them in your plans
  • AND
  • gt Train your staff

69
CDC Category Definitions of Diseases/Agents
  • Category A - Highest priority
  • Can be easily disseminated or transmitted from
    person to person
  • Results in high mortality rates and have the
    potential for major public health impact
  • Might cause public panic and social disruption
  • Require special action for public health
    preparedness
  • Category A Agents
  • Anthrax (Bacillus anthracis) Botulism
    (Clostridium botulinum toxin) Plague (Yersinia
    pestis) Smallpox (variola major) Tularemia
    (Francisella tularensis) and Viral hemorrhagic
    fevers (filoviruses e.g., Ebola, Marburg and
    arenaviruses e.g., Lassa, Machupo)

70
CDC Category Definitions of Diseases/Agents (cont)
  • Category B Second highest priority
  • Moderately easy to disseminate
  • Result in moderate morbidity rates and low
    mortality rates
  • Require special enhancements of CDCs diagnostic
    capacity and enhanced disease surveillance
  • Category B Agents
  • Brucellosis (Brucella species) Epsilon toxin of
    Clostridium perfringens Food safety threats
    (e.g., Salmonella species, Escherichia coli
    O157H7, Shigella) Glanders (Burkholderia
    mallei) Melioidosis (Burkholderia pseudomallei)
    Psittacosis (Chlamydia psittaci) Q fever
    (Coxiella burnetii)

71
CDC Category Definitions of Diseases/Agents (cont)
  • Category B Agents (Cont)
  • Ricin toxin from Ricinus communis (castor beans)
    Staphylococcal enterotoxin BTyphus fever
    (Rickettsia prowazekii) Viral encephalitis
    (alphaviruses e.g., Venezuelan equine
    encephalitis, eastern equine encephalitis,
    western equine encephalitis) and Water safety
    threats (e.g., Vibrio cholerae, Cryptosporidium
    parvum)

72
CDC Category Definitions of Diseases/Agents (cont)
  • Category C Third highest priority
  • Includes emerging pathogens that could be
    engineered for mass dissemination in the future
    because of
  • gt availability
  • gt ease of production and dissemination
  • gt potential for high morbidity/mortality
  • rates and major health impact
  • Category C Agents
  • Nipah virus and hantavirus

73
Most Common Syndromes in Biological Events
  • Flu-like illnesses
  • Acute respiratory symptoms with fever
  • Gastrointestinal symptoms/syndromes
  • Skin lesions (small pox)
  • Acute neuromuscular syndromes

Compliments of CDC/NIP/Barbara Rice
74
Clues to Biological Potential Events
  • Increase in the number of patients with similar
    symptoms
  • Large number of deaths
  • Cluster of an illness from single area
  • Infection that is not endemic to area
  • Common infections in unusual seasons
  • Increase/large number of sick/dead animals
  • Intelligence from law enforcement
  • Stated threat

75
Priorities for Response(All Hazards)
  • Life safety
  • Staff
  • Victims
  • Incident stability
  • Property preservation
  • Protection of the environment

76
Response Considerations for Biological Event
  • Planning
  • Develop policies and procedures for
  • recognition
  • notification
  • isolation/quarantine
  • Pre-exposure
  • Active immunization
  • Prophylaxis
  • Intelligence information

77
Response Considerations for Biological Event
(Contd)
  • Incubation Period
  • Diagnosis
  • Active/passive immunization
  • Antimicrobial treatment
  • Public Health needs (isolation/quarantine)
  • Active Disease Period
  • Diagnosis
  • Treatment (guided by diagnosis symptoms)
  • Public Health needs (isolation/quarantine)

78
Clinical Consideration for Biological Event
  • Basic supplies/address surge capacity
  • Beds/linens
  • Waste management
  • Lab supplies
  • Medical supplies
  • IV solutions and supplies
  • Antibiotics (if needed)
  • Other medications

79
Clinical Consideration for Biological Event
(Contd)
  • Additional needs
  • Extended staffing plan (clinical/non-clinical)
  • Medical staffing plan
  • Mass casualty plan
  • Mass fatality plan
  • Media management plan (Joint Information Center)
  • Mechanism to provide updates/info to staff

80
Clinical Consideration for Biological Event
(Contd)
  • Additional needs
  • Infection Control Practitioner (from hospital)
  • Public Health representative
  • Considering activating the hospital ICS/UCS
  • Family support area
  • Pharmaceutical stockpiles

81
Key Points
  • Some exposures may require decontamination but
    most do not
  • Large events may overwhelm your system
  • Assure that the right people are notified and
    included in the response
  • Implement Incident Command System

82
Reminders
  • Determine alternate care sites in the Planning
    Phase
  • Work with community partners in the Planning Phase

83
Potential Chemical Agents
  • Nerve Agents
  • Blister Agents (vesicants)
  • Pulmonary Agents
  • Blood Agents (cyanides)
  • Toxic Industrial Chemicals
  • Riot Control Agents

View from World Trade Center. Compliment of CDC.
84
Comparative Toxicity of Agents
6000
5000
4000
Ct50 (mg-min/m3)
3000
2000
1000
0
CL
CG
AC
H
GB
VX
AGENT
(L)
(L)
(L)
(L)
(L)
(L)
85
Nerve Agents
  • Actions
  • Interferes with the action of the nervous system
  • Similar to organophosphates
  • Types
  • Sarin (GB)
  • Tabun (GA)
  • Soman (GD)
  • GF
  • VX

Tokyo, Japan Response to Sarin Attack.
86
Blister Agents
  • Actions
  • Cause cellular damage leading to cellular death
    (skin, mucous membranes, eyes, systemic effects)
  • Effects begin immediately, but blisters may be
    delayed (mustard)
  • Types
  • Mustard aka mustard gas (H)
  • Sulfur mustard (HD)
  • Lewisite (L)
  • Mustard and Lewisite (HL)
  • Phosgene Oxime (CX)
  • Pulmonary agent with vesicant effects

Iran Victim of Mustard Agent Attack, CDC
87
Pulmonary Agents
  • Actions
  • Damages the lining in the lung and cause fluid
    leakage
  • Delayed pulmonary edema
  • Types
  • Phosgene (CG)
  • Chlorine (CL)
  • Ricin

88
Blood Agents Cyanides
  • Actions
  • Blocks the use of oxygen in the cells of the body
  • Causing asphyxiation in each cell
  • Least toxic of the lethal chemical agents
  • Types
  • AC and CK
  • Toxic industrial chemicals (TIC)
  • Chlorine, ammonia, arsenic
  • Hydrocarbon (benzene)
  • Highly toxic, corrosive and irritating chemicals
  • Likely terrorists targets of opportunity

89
Riot Agents
  • Actions
  • Causes irritation to eyes, mouth, throat, lungs
    and skin
  • Immediate symptoms are intense and cause people
    to try and stop the effects
  • Types
  • Mace
  • Pepper Spray

90
Clues To Potential Chemical Exposure
  • Shortness of breath/respiratory difficulty
  • Itchy/burning/watery eyes
  • Runny nose
  • Skin irritation
  • SLUDGE
  • Patients reporting odor just prior to symptoms

91
Clues To Potential Chemical Exposure (Cont)
  • Increase number of patients with same symptoms
  • Sick/dead animals and birds
  • Sick/affected first responders
  • Intelligence from law enforcement
  • Stated threat

92
Planning Considerations for Chemical Agents
  • Planning Phase
  • Hazard assessment
  • Designate Triage and Decon areas
  • Develop Respiratory Protection Program
  • Develop Decontamination Program
  • Implement Incident Command System
  • Purchase equipment
  • Develop policies and procedures
  • Train staff
  • Practice and exercise

93
Response Plan Considerations for Chemical Agents
  • Recognition
  • Prevent secondary contamination
  • Escort patient immediately outside/to decon area
  • Initiate hospital HazMat response
  • Notify appropriate staff
  • Don appropriate CPCE

94
Response Plan Considerations for Chemical Agents
(Cont)
  • Determine need for decontamination
  • Decontaminate patients
  • Provide appropriate medical care
  • Decontaminate staff
  • Secure area
  • Decontaminate equipment, as appropriate

95
Antidotes Are Available forSome Chemical Agents
  • Nerve agents/organophosphates
  • Atropine blocks the effects of the chemical
    that causes over stimulation
  • 2PAMCl neutralizes the nerve agent actions
  • CANA Convulsive Antidote, Nerve Agent
  • Diazepam, when required
  • Cyanide
  • Cyanide Kit contains
  • Amyl nitrate (inhalant)
  • Sodium nitrite (injectable)
  • Sodium thiosulfate (injectable)

96
Hospital Partners for Biological Chemical
Response Plans
HazMat Team
97
Community Partners for Biological Chemical
Response Plans
98
Key Points
  • Some exposures may require decontamination but
    you must determine if patient was actually
    contaminated
  • Large events may overwhelm your system quickly
    and without notice
  • Notified and included the right people in the
    response

99
Summary
  • Routes of exposure for chemical and biological
    agents
  • Overview of some potential biological and
    chemical agents used in terrorism
  • Overview of common syndromes
  • Guidelines for response plans
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