CHAPTER 2

Command Center Support Operations

Introduction

No Command Center can function in total isolation. The role of any Command Center is the management of resources. This is particularly true within a healthcare facility. Just as municipal command centers have resources provided by the emergency services and other public, private, and volunteer services, each with its own specific role to play, the healthcare facility Command Center must rely on specific resources, whether or not they are a part of normal facility operations, in order to successfully achieve its objectives. Such resources tend to be highly task-specific and may be either physical or human resources. While these may vary somewhat from the resources described in a municipal or other Incident Management System model, the variation is the result of meeting specific needs within the facility; needs which often do not exist in municipal and other more generic models. In this chapter, we will explore such resources and their role within the command and control model of a healthcare organization. We will examine both physical locations and human resources and will connect these to the mainstream concepts of IMS and similar command and control models. Finally, we will explore the resource requirements for the creation of such supporting structures in detail.

Learning Objectives

At the conclusion of this chapter, the student will be able to describe the resources required by a Command Center in a healthcare setting in order to support emergency operations, as well as the specific purpose and role of each type of resource. The student will be able to outline the process for the creation of such resources and the resources required. Finally, the student will be able to link these back to the specific types of resources described in most mainstream command and control models.

Role and Purpose

Virtually all Command and Control models employ a variety of task-specific resources in order to assist with resolution of whatever incident is occurring. These may be direct supports to the team in the Command Center (e.g., a Research Unit under Planning), or they may have more specific physical roles to play within the response to the emergency. In a typical command and control model, such as IMS, these may be described as fixed resources, single resources, Strike Teams, or Task Forces. These may be further defined as resources which directly support the Command Center’s operations, and those created by the Command Center in order to support the emergency operation of the facility. Each has its own specific characteristics, uses, and challenges, and each will be examined separately, both in general, and in a healthcare context.

Support Operation Types

Support operations can be usefully defined as being either fixed or mobile. A fixed support operation will occupy one or more predesignated spaces and is unlikely to move from these. Such operations are a part of contingency planning as a part or the larger Emergency Response Plan, and are most usefully preidentified and equipped, with allocated equipment, authority to activate, staffing and activation instructions determined and rehearsed well in advance of any type of real crisis. A mobile support operation usually consists of an individual (single resource¹), a grouping of a single type of resource in order to accomplish a specific objective (Strike Team²) or a multidisciplinary group attempting to accomplish a specific, usually large and complex, task (Task Force). As with fixed support operations, mobile support operations benefit from advance planning, role assignment, training and practice, whenever this is possible. It should, however, be remembered that at issue here is crisis management, and developing resources of many types during any crisis is likely to require some degree of improvisation, although the better the advance planning which occurs, the less the need for large amounts of improvisation. Each of these support types will be examined in detail. A number of examples of each type will also be discussed, although the list is not exhaustive, and the detailed considerations for each example will also be explored.

Observations on Fixed Resources

In a healthcare setting, most resources are, in fact, fixed, and there may be some confusion regarding the categorization of emergency response resources according to the Incident Management System or other command and control models. Indeed, when one examines the model critically, it is entirely possible for a designated work location to be considered a fixed resource, while those staffing that location could, with equal justification, be considered to be a “task force” or even a “strike team.” What actually matters is that the resource, whichever label one decides to place upon it, is positioned within the overall command and control model in a manner which provides useful management and ensures its usefulness. It should also be remembered that not all resources will be required in all incidents. As the simplest illustration of this, an area for triaging incoming patients is entirely unnecessary if the emergency involves the evacuation of the healthcare facility!

Command Center Support Resources

Media Information Center

Most Command Center operations find it useful to maintain and operate a Media Information Center within the facility.³ By keeping the media in one suitable workspace, with access to appropriate resources and information, the commonly occurring problem of the media interfering with emergency operations can be avoided. Such facilities should have workspaces, telephones, Wi-Fi connections for computers, and creature comforts, such as food and coffee. In this location, information can be provided, including background material and media releases. Interviews can be arranged, as can any required media conferences. As long as the required information is provided regularly and consistently, most members of the media will simply use the space, and problems will not occur. Such facilities are normally provided with Security, and members of the media sign in, produce credentials, and are escorted to and from the Media Center by staff. The Media Center is normally the responsibility of the Public Information Officer and subordinate staff.

Family Information Center

In most types of emergencies, concerned family members pose a considerable challenge for those who operate hospitals. When you believe that a loved one has been injured in an emergency incident, or if such an incident has occurred and you cannot contact a loved one, for most people the local hospital is often a point of convergence. This presents challenges for hospitals, attempting to identify victims, locate and reunify with loved ones, sometimes obtain consent for emergency procedures, and to provide relevant and appropriate information to concerned members of the community. It is inappropriate for concerned family members of potential victims to wander through treatment areas searching for loved ones; such processes need to be controlled and supportive and must shield troubled individuals from the view of both the general public and the media. Occasionally, the news will not be good, and this bad news must also be delivered in an appropriate and supportive environment.

In many hospitals, the Command Center will operate a Family Information Center. This is usually a quiet space in a cafeteria, a library, or other similar facilities, where family members can wait for their loved ones to be identified, and also wait for other news regarding the loved ones’ condition. Such facilities are normally staffed by Social Work, Pastoral Care, and/or Hospital Volunteers, and fall under the control of the Planning Chief, whose research staff are the most likely to be able to identify and match up victims with family.

Staff Reporting and Staging

In any crisis, large numbers of staff will end up working somewhere other than their units of origin. This is particularly true when staff are recalled from off-duty status in order to respond to a crisis. This situation puts staff outside of their normal chain of command, and outside of their normal lines of communication. The situation presents other challenges for the facility, particularly with respect to work assignments and timekeeping for recalled staff. It is prudent, in such circumstances, to have a single area where off-duty staff report, have their start and end times registered for compensation, receive briefings on the event and any changes in procedures or policies, and receive work assignments.⁴ This is also useful for those with short-term work assignments; when the assigned task is completed, they simply report back to the same location for reassignment to other needed tasks.

In healthcare, such facilities have typically been described as “staff pools,” however, in keeping with the attempts to standardize terminology and jargon within IMS-related command and control models, it is more appropriate and consistent to call these locations Staff Staging Areas. Such areas are usually populated by either Human Resources or Payroll, or some combination of the two, and in IMS-related command and control models, fall under the control of the Logistics Chief. These arrangements provide for accountability of staff time and expenditures, and can also guarantee a consistent process for ensuring that one resource (staff) is quickly and effectively deployed to where it is required.

Breakout Rooms for the Command Center

Not every member of the Command Team needs to attend every meeting. Indeed, the business process of most Command Centers typically consists of project-related “sidebar” meetings by two or more members of the Team, while other members are working on other projects. The results of the sidebar meetings are then reported to the group at large during the main Business Cycle meetings. In other cases, the Incident Manager may have to provide a progress report to senior management, or individual Team members may need to meet with their subordinates, in order to receive progress reports and assign tasks. Such meetings are highly essential but have the potential to be somewhat disruptive for those attempting to do other work in the Command Center. As a result, one or more “breakout” rooms can provide a useful supportive resource for the actual Command Center. Such facilities should be nearby, but not where they will interfere with Command Center operations and are usually under the control of either the Office Manager, or the Scribe, in most facilities.

Facility Support Resources

Triage Areas

Whenever a major event generating injured victims occurs outside of the healthcare facility, one of the first processes which must be put into place is that of triage.⁵ This sorting of casualties according to severity provides appropriate access to limited treatment resources for those in the greatest need and is the necessary first step in any emergency treatment process. Such processes are usually established at the point of access to the facility (often the entrance to the Emergency Department).

At this point, nurses will initially assess incoming patients, using an algorithm-based approach to triage, and will determine in what order patients will be seen by a physician and/or receive emergency treatment. In some cases, patients are actually physically sorted, with the Emergency Department being reserved for those in the most serious condition, and improvised temporary treatment areas providing care to those with minor injuries and complaints. In the most sophisticated systems, actual channels may be created to direct triaged patients to specific levels of care, often in temporary treatment areas which prevent the overwhelming of the Emergency Department.

Such areas are normally found at the Emergency Entrance to the hospital, and require little in the way of supporting equipment, other than quantities of the approved triage tags, clipboards, pens, and the associated documents for each facility. Also required are traffic cones or plastic security tape to define the area and control the flow of people. Vests or tabards should also be available to identify those staff who are actually a part of the Triage process. Patient care supplies are not a priority, since actual treatment rarely occurs during this process; instead, those who are critically injured pass rapidly through the process to definitive care, and for lesser injuries, any required care can wait until the triage process is completed.

In incidents involving hazardous materials contamination, the triage process, and therefore, the triage area, should be located between the location in which decontamination is occurring and the actual entrance to the hospital. No patient should be triaged until decontamination is completed.

The Triage function usually requires a minimum of one, but it can involve as many as three to four dedicated nurses (in some locations, Nurse Practitioners or Physician’s Assistants are used). In rare cases, the actual triage may be performed by a physician; however, this is not common, since physicians are generally at a premium, and are required for the actual treatment of victims. While the site itself is fixed, and unlikely to be moved for any reason, it is appropriate to view those performing this function as a Strike Team, operating under the IMS banner of Operations.

Decontamination Areas

Although not always required, the nature of some incidents (e.g., hazardous materials release) may require the establishment of areas in which to decontaminate victims prior to their triage and admission to the facility for treatment. No patient involved in such an event should be treated, or even triaged, until such time as decontamination is completed. Doing so potentially places staff and other patients at unnecessary risk of exposure. Nor can one assume, even in the best developed communities, that the Fire Department or other emergency service has decontaminated patients. In large numbers of cases, patients arrive at hospital having received no decontamination whatsoever, often by private vehicle or on foot (see Figure 2.1).

Figure 2.1 External decontamination can be a challenge

In an event involving the deliberate release of Sarin in the Tokyo subway system, thousands of patients were affected, and most arrived at local hospitals with no decontamination whatsoever prior to their arrival. They, in turn, sickened hospital staff and patients, creating chaos.⁶ As a result, hospitals are increasingly under pressure to provide for such eventualities as a part of the hospital accreditation process,⁷ and through national standards.⁸

While staff will require training, the healthcare-based Emergency Manager will also require at least introductory training, in order to properly understand the procedures, issues, and requirements for such an operation. Such training is readily available from a number of excellent public and private sources. The location, resources, and training required for such activities is extensive, but it is also essential. The specifics of such requirements may be found in a number of excellent reference sources provided in the Additional Reading section of this chapter.

Secondary Treatment Facilities

It is easy for a typical Emergency Department to become overwhelmed by the increased demand for services during a mass casualty incident. Such departments are typically designed to meet normal demands for services, with little capacity for surge built into the structure or resources. One strategy for the management of patient flow is the provision of alternate treatment options for those whose injuries or complaints are relatively minor (see Figure 2.2). Some hospitals do this on a daily basis, with triage nurses screening patients arriving at the Emergency Department and also triaging those with minor complaints to Family Practice Units or similar locations. A similar approach can be used during a major incident, with green and some yellow triage tags being directed away from the main Emergency Department, but only if such a treatment resource exists.

Secondary treatment facilities can be created in a variety of locations within a hospital. The most commonly used is the Outpatient Department or Clinic. In many cases, particularly in older hospitals, this space actually was the Emergency Department at some point in the past, and this is a common evolution in space usage in hospitals. Other candidates for usage include lobbies, auditoriums, and similar spaces. Such spaces will require equipment, and the Emergency Manager will need to figure out what specific equipment is required with assistance from those with clinical backgrounds. This will be determined, to some extent, by the level of care which is expected to be provided.⁹ At a minimum, the use of spaces, stretchers, wheelchairs, and basic assessment equipment will need to be sourced, and agreements negotiated for their use during a major incident. Actual patient care equipment and medications will also need to be sourced and made available in kit or cart form, with the provisions for their use clearly identified.

Figure 2.2 An improvised treatment area in a Japanese hospital

Staff to operate temporary treatment areas will also need to be identified, and their use approved. Typical candidates for supervisory roles would include Family Practice or General Practice physicians, Nurse Practitioners and/or Physician’s Assistants. A suitable number of nurses, drawn from units other than the critical care areas, will also be required to provide basic care and ongoing assessments. Such units will also require individuals to register and discharge patients, to perform internal transportation functions, and routine housekeeping of the space. All such individuals normally belong somewhere, and approval for their use, as well as provisions for their activation, will need to be determined in advance. Supply chains for such a facility will also need to be identified in advance.

Once spaces and resources have been identified and secured, the guidelines and specific procedures for their activation, usage, and de-activation will need to be clearly identified and written. They should be incorporated into the Emergency Response Plan, as a case-specific Annex. The Emergency Manager should ensure that the language of such guidelines is clear, concise, unequivocal, and easy to find. In most cases, the best format for such guidance, as with most other guidance provided in the Emergency Response Plan, should be in the form of task-specific checklists. These can be used for both the assembly of the facility, and to orient those in specific roles to their duties.

Once operational, secondary treatment areas can remove a tremendous burden from the Emergency Department by assisting the hospital in addressing the issue of surge without relying on a single point of treatment. This resource permits the triage process to actually create channels of flow for incoming patients, being directed into the Emergency Department, or into one or more secondary minor treatment areas, determined by the initial assessment of the Triage Nurse. In this manner, a patient whose only complaint is a minor laceration may receive timely and effective treatment without ever entering the Emergency Department, with that facility’s limited resources being reserved specifically for those with the greatest need.

Discharge Holding Units

One of the major challenges with meeting a surge in demand for inpatient services, even a disaster, is the fact that all healthcare facilities are essentially boxes of finite size. Most facilities operate at or beyond 90 percent capacity on a daily basis, and in some jurisdictions, well beyond that. In order to provide effective emergency treatment and care for the patients generated by the new emergency, it will almost certainly be necessary to create availability of inpatient bed space.

The normal discharge process for patients often takes as long as 24 hours to complete, from the time that the physician writes the discharge orders until the bed is actually vacated, processed, and ready for a new patient. Even during any type of crisis, the process of care for each patient may be viewed as a continuum; from triage, to initial care, to comprehensive assessment and diagnostics, to comprehensive care (e.g., surgery), and so on. Any delay at any of these steps has the potential to slow or even disrupt the entire process. As with any potential “roadblock,” the ability to take those patients who have already received emergency treatment and put them into the required inpatient beds has a direct bearing on the effectiveness of patient flow throughout the emergency care and treatment system.

One solution, which can assist with the role of the Bed Clearance Task Force in the creation of space for new patients is the creation of Discharge Holding Units, sometimes called Discharge Lounges.¹⁰ Once the discharge of the patient has been ordered, the patient can be moved to a temporary holding area where they will still continue to be supervised while awaiting the completion of final discharge orders, the availability of the required discharge resources (home care, nursing home bed, and so on) transportation, or collection by loved ones. Once this occurs, the bed which the patient was occupying can be processed and made available for the next patient who requires it; often hours earlier than would be the case with normal discharge procedures. This promotes and enhances patient flow from the Emergency Department, through critical care areas, and into the required beds.

Such solutions can be potentially created within a variety of spaces, including lobbies, cafeterias, classrooms and other, similar spaces. Ideally, there should be some proximity to an exit, but not the Emergency entrance. The space will require comfortable seating, as well as clinically designed seating, such as wheelchairs or “geri-chairs,” and also, potentially, a few stretchers. Basic assessment and care equipment should be made available, although in small amounts, since such patients are less likely to require any type of comprehensive care. Washroom facilities will also be required. The space can be staffed primarily by volunteers or non-clinical staff, working under the supervision of a Registered Nurse. The facility can also be supported by Discharge Planning, assisting with the required arrangements, Pastoral Care, and Housekeeping.

Evacuation Holding Areas

During any evacuation of a healthcare facility, predesignated, sheltered areas are required in which to keep patients during the time between removal from the evacuated unit and their transfer to another facility. Unlike the evacuation of conventional buildings, the occupants of a healthcare facility cannot simply exit the building and wait on the street for further direction, unless, of course, there is a pressing issue affecting immediate safety. The required areas are ideally warm and dry, and they continue to meet the immediate needs of the patient until such time as transportation occurs.

Such locations should be located in immediate proximity to an exit door, in order to facilitate removal and transportation, as it becomes available. Such locations should also attempt, as much as is possible, to meet the actual clinical needs of the patients until the point of their transportation. For this reason, it may be prudent to assume that patient needs will fall into one or more of three categories: clinical acuity, mobility, and supervision required. Using this assumption, it becomes reasonable to “triage” patients as they arrive at the exit level, just as incoming patients are triaged during a disaster. By performing this triage, it becomes possible to begin to cohort patients by actual needs, in spaces where those needs can be specifically addressed.

The resource requirements for such spaces will be determined by the patient needs which they are intended to fill. To illustrate, patients requiring simple supervision could potentially sit in a lobby, with several non-clinical staff members accompanying them, under the supervision of a single nurse. Those with mobility challenges would require large amounts of open space for wheelchairs and stretchers to maneuver, as well as accessible washroom facilities. On the other hand, the space may already exist and be fully equipped. To illustrate, it is logical for the Evacuation Holding Area for the critical care units to be the Emergency Department, with its high levels of equipment, emergency power, appropriate skill sets, and access to an appropriate loading point for high-acuity patients. It is necessary for the Emergency Manager, with the assistance of clinical colleagues, to preidentify these spaces and their resource requirements in advance, and to incorporate their usage directly into the Emergency Response Plan.

Mobile Task Forces

Bed Clearance Teams

One of the greatest challenges in addressing surges in demand for service while maintaining the system’s patient flow is the problem of discharging existing clinically appropriate inpatients. Traditional discharge methods involve contacting the patient’s physician, having that physician attend and write appropriate orders for discharge including prescriptions, arranging for follow-up care, either in the home or as office visits, notifying family members, sometimes arranging accommodation (as in long-term care), and arranging transportation. This process can normally take five to six hours, and it has traditionally resulted in the patient being informed immediately, but not actually discharged until the next day. This can result in a delay of up to 24 hours in the vacating of the bed, with additional time required to clean and dress the bed, clean and tidy the patient room, and so on. Such delays can quickly force the flow of patients from an overwhelmed Emergency Department to a complete halt.

Bed Clearance Teams are one option which can be used effectively to address this problem during any major incident. As with all Task Forces, they are interdisciplinary in nature. The team consists of a physician, the Charge Nurse for the Unit, ideally the Discharge Planner, a transportation provider, and housekeeping. The team leader is normally a physician, who may or may not be the patient’s own physician. Their role is to review the available information regarding the patient, as available from the Patient Chart and the Charge Nurse, and determine whether the patient’s treatment is reasonably complete, and whether the patient may be safely and appropriately discharged, either to an alternate venue of care, such as a long-term care facility, or to home.

The Charge Nurse and the Discharge Planner will collaborate to ensure that the patient has a destination, and that the required supports are in place. The patient’s family will be notified, and the personal effects gathered and packaged. Ideally, the patient will then be provided with immediate transportation to a Discharge Lounge or Discharge Holding Unit, to await final discharge. Essential documents, such as prescriptions, will follow the patient to that location. Finally, with the bed freed, it can be cleaned and prepared for the next patient, and the Emergency Department and Admitting made aware of the bed’s availability.

A team such as this, or perhaps several of them, could potentially be an invaluable resource during any type of mass casualty incident. This integrated and systematic approach has the potential to quickly release large numbers of beds which were previously unavailable. The number of beds potentially available employing this approach will vary by jurisdiction, but can be dramatic. A study in one Canadian urban area in 2015 suggested that approximately 12 percent of all acute care beds were “blocked” and could be made available, at least in theory, if required,¹¹ while an earlier study in a U.K. hospital system suggested that the number of “blocked” beds could be as high as 20 percent.¹² These figures do not address the number of patients who are probably being discharged within the next 48 hours, and could probably be sent home safely now, if a crisis were underway.

Specialist Evacuation Teams

One major challenge associated with the evacuation of healthcare facilities is the complex needs of at least some of the patients. Such facilities have historically placed those patients with the least mobility and greatest clinical complexity in some of the most inaccessible parts of the building, making their evacuation a challenge. In a fire scenario, for example, when elevators cannot be used, consider the challenges of evacuating patients from an Intensive Care Unit on the top floor. Such patients are going to need to be carried, often down several flights of stairs, and they are going to require ongoing clinical support while this is occurring. Some ICU patients may require the support of more than one clinician during this movement (e.g., the patient must be manually ventilated and also has several IVs running). Surprisingly, this function of evacuation is only rarely tested, if at all.

It is an erroneous assumption that, during a fire, for example, the hospital will be able to expect that local firefighters will be available to evacuate critical care and low mobility patients, since all are likely to be engaged in the fighting of the fire. This reality has been proven to be true during numerous real-life incidents. Hospitals should prepare and equip specialist teams for this function (see Figure 2.3). Such teams should consist of six to eight strong individuals (everyone needed to carry an ICU patient down several flights of stairs safely) drawn from various departments. Such individuals should be preselected, and they should be provided with periodic training in lifting and carrying techniques, and also regular drills, using a fully weighted mannequin with appropriate equipment attached, to ensure that they can perform their function when needed.

The training should occur in the actual stairwells and evacuation routes which would be used, in order to raise staff familiarity with these locations which they would normally see, at best, only occasionally. Staff from the Unit to be evacuated should also be included in this training, in order to raise their awareness of the evacuation issue and how they would manage the clinical aspects of the patient movement. Clinical staff must also have a clear understanding of the capabilities of the other members of the team; what is possible, and what is not possible. Such a team is interdisciplinary, however, given the fragility of the cargo being carried, the clinicians on the team must be in charge at all times.

Figure 2.3 Specialist evacuation teams

Similar teams with somewhat different skill sets may also be required for the movement of other low mobility patients. While some of these patients are from a critical care setting, this is not true in all cases. Patients with some chronic conditions and the frail elderly are also likely to require similar assistance. Some areas which may require similar teams include the Nursery, the Operating Theatres, Complex Continuing Care, Orthopedics, Coronary Care, and long-term care beds. The preceding list is not exhaustive, and it will vary greatly from facility to facility. Since the patients and their clinical and mobility challenges are different, the training required will be different as well.

Increasingly, the jargon which is being used to describe such teams is the acronym “CASE” (Clinical Acuity Special-Needs Evacuation), and the teams themselves called CASE Teams. The number of CASE Teams required and the time to evacuate a given Unit will be determined by the location, number, acuity, and mobility of the patients. In one published study, it was observed that with critical care patients, the average time required for a team to descend a single floor was 3.75 minutes.¹³ Most hospitals, like other public buildings, have been designed and constructed with an assumption that the average time of descent during evacuation will be approximately one minute per floor, which fails to consider the abilities of the evacuees.

As previously stated, such teams should be preselected and trained. All must be aware of their roles during an evacuation. The composition of such teams, their abilities and procedures, how activation will occur and the authority to activate such resources will need to be determined in advance. All of the above information must be developed, using the advice and assistance of both clinical and nonclinical colleagues, into specific easy to understand and follow procedures, which must then be incorporated into the Emergency Response Plan.

Discharge Holding Units

Discharge Holding Units require an interdisciplinary configuration, and therefore, qualify as a Task Force. Usually under the supervision of a single Registered Nurse, such teams may consist of lesser trained clinical staff (e.g., Healthcare Aides), but may equally consist of nonclinical staff, and even hospital volunteers, in some cases. The Discharge Planner will continue to play a role in completing arrangements for follow-on care, as will Admitting, with the completion of required discharge documentation. Some entity, whether hospital porters or even volunteers, will be required to help facilitate transportation from inpatient beds to the Holding Unit, and clerical support will be required to help to document the disposition of each patient.

Evacuation Holding Units

Evacuation Holding Units tend to be more improvisational, given the circumstances. It is entirely probable that a facility will have more than one such Unit. This is particularly true when exit triage is being performed as a part of the evacuation process. Patients may be “co-horted” into separate Units by means of the triage criteria previously discussed. In such circumstances, the number and types of staff required to form the Task Force for such a location will be determined by the nature of the patients being held there.

In all cases, there will be one individual at a relatively senior level of clinical competency, usually a Registered Nurse, and one individual who is responsible for tracking the arrival and departure of each new patient, as well as the patient’s final destination. Such teams are, by their very nature, improvisational. While the Emergency Manager may not be able to actually create such teams in advance, it is entirely appropriate, with assistance from clinical colleagues, to create formal guidelines for the creation and staffing of such teams, as suggested procedures embedded in the Emergency Response Plan document.

Decontamination Teams

Increasingly, hospitals are correctly concluding that they cannot rely on a planning assumption in which all patients who require decontamination will arrive at the facility with this function already performed. As a result, initiatives by individual hospitals, along with significant changes in the emergency preparedness standards included in many accreditation processes, are resulting in the acquisition of appropriate patient decontamination equipment, as well as selected staff training in decontamination, by most hospitals.¹⁴ Hospital decontamination teams are, by their nature, interdisciplinary affairs (see Figure 2.4).

Figure 2.4 External Decontamination Facilities

The best such teams recognize that the treatment of patients cannot and should not begin until they are fully decontaminated and safe to handle, except in the direst cases of immediate threat to life. Even in such cases, there is a debate as to whether clinical intervention should occur, since the outcome may very well be predetermined, and any staff exposed to the hazard will be lost to further use for an extended period of time, or even entirely. In a well-planned Decontamination Team, the compromise which is struck is the use of clinicians in the role of a Rapid Intervention Team. The majority of team members, and all working in the “Hot Zone,” should be nonclinical personnel with appropriate training. The team should be supervised by someone with subject-matter expertise, with the designated Safety Officer controlling access to the “Hot Zone” and recording exposures, and a Rapid Intervention Team composed of one physician and one or two nurses, all of whom should be specially trained in the donning, doffing, and usage of the appropriate types of personal protective equipment (PPE). Such teams can, and should, be created and staffed in advance by the Emergency Manager, and their use incorporated into the Emergency Response Plan as procedures and guidelines.

Strike Teams

Rapid Intervention Teams

Rapid Intervention Teams are an essential part of any healthcare facility’s decontamination procedure. Outside of the healthcare setting, such teams usually perform a “rescue” function for emergency services while performing decontamination procedures. In healthcare settings, the function is similar, but is somewhat enhanced by the ability to provide at least a potential for definitive medical intervention. In healthcare settings, such teams normally consist of a physician and a nurse, or in some cases, two nurses. Each is specially trained in hazardous materials safety and the use of PPE. The job of such a team is twofold. As a primary responsibility, it is their job to provide rapid medical intervention, should an immediately life-threatening emergency occur during the decontamination process. As a second function, it is the role of this team to retrieve any member of the decontamination team who suffers any type of injury or illness inside the “Hot Zone.”

This team is normally under the supervision of the Safety Officer, who is positioned at the entrance to the “Hot Zone.” The team will usually be present in the “Warm Zone” with PPE partially donned, and they will finish donning equipment and enter the “Hot Zone” only when directed to do so by the Safety Officer. Such teams cannot, or should not, be improvised. The members of such teams require specialized training, and they should be preselected. It should also be noted that any medical equipment assigned for use by the Rapid Intervention Team should be considered disposable. It is highly likely that if any major clinical intervention must occur within the “Hot Zone” it is likely that such equipment will become contaminated, often beyond the point at which decontamination is practical. As a result, equipment such as defibrillator/monitors, equipment kits, and so on, should be second generation, and already removed from first-line service in the facility. The precise equipment required should be the subject of discussion with clinical colleagues.

Conclusion

Within any healthcare setting, crisis management is not “business as usual,” and approaches to problem solving and operational support may be required. While these are not normally found in the day-to-day business operation, they can be, nevertheless, highly successful at providing the ability for the organization to cope with surge, and also to support disaster decision making and operations. Such changes, while they may be assembled and initiated in the middle of whatever crisis is occurring, tend to be far more effective when planned and orchestrated in advance, using staff who have received training and been provided with the time to prepare for such new and different roles. As in most aspects of emergency preparedness, advance work in preparing, planning, sourcing, and training can yield tremendous benefits.

Not all of these ideas will work in every facility; each has its own operating realities, resources, and requirements. The Emergency Manager will have to plan carefully, consulting with clinical colleagues and basing the proposed problem-solving approaches on a clear and comprehensive understanding of the facility and how it operates. Without an understanding of “normal,” it is much more difficult to plan for “abnormal.” Such dramatic changes to response are likely to meet with some resistance, as well. Those in clinical settings typically tend to be somewhat cautious about change, often concerned that what is being proposed is not “ideal medicine.” This may be true, but the reality is that what is being attempted in such circumstances is not best practice, but merely due diligence. If the facility and its staff can simply cope effectively and safely with the current crisis-related surge in demand, there will be no shortage of opportunity to implement “best practice” once the emergency is over. The Emergency Manager working in a healthcare setting will need to be a champion, and a teacher, if such changes to processes are to be effective.

Student Projects

Student Project No.1

Conduct the appropriate research, as well as consultation with clinical colleagues, and create a proposal for a single type of Task Force operation which would support both the Command Center and facility operations. Identify staffing and training requirements, as well as operating space and equipment requirements, and identify sources and costs for all of these items, as well as an implementation plan. Develop a draft operating procedure which provides for activation of the Task Force, normal operating guidelines, reporting structure, and stand down guidelines. Prepare a formal, written proposal document for the facility, ensuring that the proposal document is fully referenced and cited, in order to demonstrate that the appropriate research has occurred.

Student Project No. 2

Conduct the appropriate research, as well as consultation with clinical colleagues, and create a proposal for the addition of multiple secondary treatment areas to the facility’s Emergency Response Plan, in order to prevent the overwhelming of the Emergency Department during a mass casualty incident. Identify and source potential locations, staffing requirements, equipment requirements, potential training and costs. Include draft operating procedures, including activation, normal operating guidelines, reporting structure, and stand down guidelines. Prepare a formal, written proposal document for the facility, ensuring that the proposal document is fully referenced and cited, in order to demonstrate that the appropriate research has occurred.

Test Your Knowledge

Take your time. Read each question carefully and select the MOST CORRECT answer for each. The correct answers appear at the end of the section. If you score less than 80 percent (8 correct answers) you should reread this chapter.

1. The resources which can be provided to support a Command Center or other emergency operations in a healthcare facility may be described as a fixed resource, a single resource, a Task Force, or a:

(a) Improvised Resource

(b) Strike Force

(c) Strike Team

(d) Limited Resource

2. An interdisciplinary group which is brought together in order to complete a single job, or to accomplish a single objective is called a:

(a) Strike Force

(b) Task Force

(c) Strike Team

(d) Specialist Team

3. During any emergency, the healthcare facility’s Media Information Center is usually operated under the direction of the:

(a) Planning Chief

(b) Public Information Officer

(c) Incident Manager

(d) Logistics Chief

4. Areas which are located away from the main Emergency Department, to which lower acuity patients are directed for treatment in order to increase treatment capacity are called:

(a) Staff Staging Areas

(b) First Aid Stations

(c) Family Practice Teams

(d) Secondary Treatment Facilities

5. The Bed Clearance Team is responsible for:

(a) Expediting the availability of inpatient beds

(b) Assisting with the evacuation of low mobility patients

(c) Operating the Discharge Lounge

(d) All of the above

6. When tested, the rate per floor of descent during the evacuation of Intensive Care Unit patients, was found to be about:

(a) 1 minute

(b) 2 minutes

(c) 3.75 minutes

(d) 5 minutes

7. The location in which patients are held while awaiting final discharge from the hospital is called the:

(a) Evacuation Holding Unit

(b) Discharge Holding Unit

(c) Temporary Treatment Area

(d) Waiting Room

8. Specialized support facilities used to support healthcare disaster operations are most effective when they are identified:

(a) By the Incident Manager

(b) By the Logistics Chief

(c) By Clinical Staff

(d) In Advance of the Emergency

9. When providing patient care equipment for any Rapid Intervention Team potentially working in a contaminated ‘Hot Zone’, it is essential that the equipment be:

(a) State of the art

(b) Considered expendable

(c) Rated for outside use

(d) Waterproof

10. The term “CASE Team” is an acronym for Clinical Acuity ____________ Evacuation Team.

(a) Specialist

(b) Safe

(c) Special needs

(d) Staff

Answers

1. (c)  2. (b)  3. (b)  4. (d)  5. (a)
6. (c)  7. (b)  8. (d)  9. (b)  10. (c)

Additional Reading

The author recommends the following exceptionally good titles as supplemental readings, which will help to enhance the student’s knowledge of those topics covered in this chapter:

JCAHO. “Healthcare at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems.” Joint Commission on the Accreditation of Healthcare Organizations webpage, www.jointcommission.org/assets/1/18/emergency_preparedness.pdf (accessed April 16, 2015). Occupational Safety and Health Administration. “OSHA Best Practices for

HOSPITAL-BASED FIRST RECEIVERS OF VICTIMS from Mass Casualty Incidents Involving the Release of Hazardous Substances.” U.S. Department of Labor webpage, www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html (accessed April 16, 2015).