Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Emergency Department Response: Surge of Children With a Communicable Foodborne or Waterborne Illness
Reverse triage would apply to
an outbreak of communicable foodborne or waterborne illness as it would with
communicable respiratory illnesses. In the event of a foodborne or waterborne
pathogen release, a surge of patients may be managed along lines that mimic
standard disaster plans (e.g., victims may be handled in a single geographical
location of the emergency department (ED) if patient volume permits).6
Nonetheless, some variations from standard disaster practice may be required. EDs
often have a limited number of toilets for patient use. If victims suffer
diarrhea, there may not be sufficient capacity to handle patient demands.
Patients that use existing toilets may inadvertently contaminate the facility
and increase the potential for transmission. To forestall this likelihood,
every room in which a patient is assigned should have a dedicated toilet,
either permanent or portable. All clinicians should follow rigorous handwashing
discipline before entering and leaving patient rooms, and use gloves for all
examinations. Gloved hands should not be placed on light switches, elevator
buttons, keyboards, or any other surface that could promote disease spread.
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Response to Patient Surge
A surge of children will
require significant changes in every aspect of hospital operations. Individuals
already within a hospital will need to be relocated to allow efficient
operations during a surge. The actual locations should be defined in each individual
facility's disaster plan, and telephone numbers for each area should be listed.
Table 1 describes potential patient care activities and proposed locations to
which patients or hospital personnel may be transported, if determined to be
medically appropriate by the incident commander.
In addition to the above,
specific elevators should be assigned for the transport of patients. Access to
these dedicated elevators should be limited by security staff; their use should
be restricted to individuals with an appropriate key or identification number.
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Responses During a Surge of Bioterrorism Patients
Each department and division
within a health care facility should develop a personnel disaster tree, which
is an algorithm by which all employees can be contacted in the event of a mass
casualty incident. Once the medical physician in charge has identified a
patient surge, hospital operators will contact department chairs, division
chiefs, and unit directors. These persons will, in turn, contact their
associate directors, nurse managers, or another associate. That person will
contact two to three individuals under their supervision, each of whom will
repeat the practice until all personnel have been notified. An important element
of the disaster notification process is to make staffing requests for:
- Staff who can immediately respond to the disaster.
- Staff who will be responsible for relieving the current staff at the next operational period.
- Staff who are not being requested, but should remain on alert in case they are needed.
To serve as a redundant
system for employee notification, all employees should report to their
immediate supervisor or department manager. If the supervisor or manager is not
in the hospital, that person should be contacted by telephone or hospital
pager. Each department or workgroup should have specific responsibilities
assigned to them; if there are no responsibilities assigned, then members of
that department should report to the labor pool. Employees who are called into
the hospital should have parking available in the most convenient lot. No
employees should make any comment or responses to the media, nor should they
respond to requests for patient information.
It may become necessary to use
outside personnel or volunteers to assist with both clinical and non-clinical
elements of the disaster response. For clinical licensed professionals,
regulatory agencies like the Joint Commission have instituted clear disaster
privileging protocols. Federal programs like Emergency System for Advance
Registration of Volunteer Health Professionals (ESAR-VHP) and local Medical
Reserve Corps programs are an attempt to organize potential health care
responders should the need arise.
Any non-employee volunteers
responding to support the incident by adding the logistic, supply and material
distribution, administrative functions, or other forms of emergency response must
be clearly identified as disaster volunteers and assigned a supervisor who will
oversee their activities. This group of support personnel is typically
protected from civil liability by falling under "Good Samaritan" laws.16 Table
2 describes the proposed responses of individual departments and workgroups
within the hospital during a surge of bioterror patients.
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Surge Stress Management
rescue personnel, and health care workers alike—will demonstrate normal stress
reactions that may persist for several days or weeks after a disaster.17
Approximately one-third of survivors will develop severe stress reactions that
place them at risk for acute anxiety syndromes in the immediate post-event
period and post-traumatic stress disorder (PTSD) in the days to weeks
After a critical incident such as a surge of bioterrorism victims, stress
management in the form of a mandatory meeting decreases negative effects of the
incident on involved staff.18
The debriefing is a confidential, non-judgmental evaluation of the event, the
hospital's response to it, and the staff's feelings about involvement in the
also helps the staff process events related to the surge and returns the
workplace to normal equilibrium. The leadership of the debriefing session
should be drawn from staff trained in critical incident stress management from
psychiatry, social services, and other related fields.18
The debriefing session should ideally occur within 24 hours of the attack, but
it may be delayed by necessity for up to 3 to 4 days afterward.18
Emerging evidence suggests, however, that these meetings may be
counterproductive in some individuals; forcing personnel to "re-witness" the
event may actually increase their despair and promote psychiatric
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