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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On notification of a surge
of patients, the admitting department should follow Unidentified Patient
protocols for all disaster patients; this frequently involves assigning
predetermined medical record numbers that are retained throughout
hospitalization. The admitting department should maintain a record of all
elective admissions that have been cancelled.
After notification of
disaster, all anesthesiology staff not immediately involved in a case should
report to the emergency department (ED) to assist in patient management as needed. Operating rooms
should be made ready, and plans should be made to cancel elective cases.
Depending on the level of operating room activity and the volume of patients,
additional anesthesiology personnel may need to be summoned.
The director of the blood
bank will contact the Hospital Command Group (HCG) to determine if any hemorrhaging patients have
arrived or are expected. The blood bank will check inventory of blood to
ensure appropriate amounts are in stock. If sufficient blood is not
immediately available, the blood bank will contact outside suppliers for
additional material. Because blood banks often have limited staffing on
nights and weekends, the director of the blood bank will consult with the HCG
to determine who shall transport blood to the ED.
The laboratory supervisor
will notify chemistry and hematology sections of the lab, as well as the
laboratory director. The lab should follow the Unidentified Patient Policy
protocols using the preassigned medical record number. The disaster patient
retains this number throughout hospitalization.
Department of Medicine
The Department of Medicine
should provide sufficient personnel to assist in the triage, resuscitation,
and management of disaster patients in the ED; manage admitted patients; and
provide administrative and medical support for the discharge of inpatients.
Chief medical residents
should be notified by pager. These individuals, in turn, notify the remainder
of the resident staff. The chief residents designate the staff who will
assist the ED in triage/resuscitation/ED management. The chief residents will
also identify those patients appropriate for immediate discharge. After
details of the bioterror release are known, the chief medical residents will
begin to discharge inpatients. Following discharge, the chief medical
residents will review bed availability with the HCG.
Medical Intensive Care Unit (MICU)
The MICU fellow or senior
resident is dispatched to the ED assess patient needs. The remainder of the
MICU medical staff determines which patients can be discharged from the MICU
in anticipation of disaster admissions. The MICU attending reassigns
residents as needed, determines staffing needs, and calls in additional
personnel to assist in patient management. The MICU charge nurse will
periodically report to the HCG with bed availability.
The nursing administrator
on call will assume responsibility for coordinating nursing activities during
the disaster. Once the hospital transitions to a disaster footing to handle
surges of patients, the nursing administrator will meet with the HCG. The
nursing supervisor will assist with inpatient census management, bed
availability, and nursing availability. The nursing administrator should also
prepare floor nurses for the potential for numbers of patients on medical
floors that greatly exceed normal "maximum" census for that patient
administrator should also be responsible for providing adequate nursing staff
for the ED and disaster discharge areas. If disaster staffing needs exceed
the number of staff available in the hospital, then the nursing administrator
should call in staff to that patient needs can be met.
When the number of
disaster patients exceeds the number of available beds, the nursing staff
should transport patients suitable for early discharge to the designated
discharge holding area. The nursing staff should notify the admissions
department of all early discharges.
The anesthesiologist in
charge should report to the HCG available ORs and staff. The
anesthesiologist in charge should also cancel elective/non-emergent cases. If
patient volume exceeds available staff, then the anesthesiologist in charge
should call in additional personnel.
Day surgical units
should be the location for all disaster patients requiring minor operative
care. In the event of a bioterror release, the number of patients who meet
this category is likely to be small.
Postanesthesia Care Unit (PACU)
The PACU director should
report PACU availability to the HCG. If necessary, additional staff should be
called in. The anesthesiologist staffing the PACU should be responsible for
making decisions regarding PACU matters. If a bioterror attack produces large
numbers of intubated patients that overwhelm MICU capacity, the PACU should
receive MICU overflow.
Pathology should oversee
transport from the ED to the morgue. The route of transport from the ED to
the morgue should be predetermined. If additional morgue/refrigerator space
is needed, the pathology staff should arrange and confirm with local
hospitals and private suppliers additional refrigeration capacity.
Pathology staff should
be responsible for paperwork related to expirations, including
identification, date and time of receipt, and the person receiving the body.
All casualties of the bioterror disaster—either immediate or delayed—should
be referred to the medical examiner. Pathology staff should remember to use
contact precautions consistent with the type of bioterror attack.
The chief radiologist
should be notified of the disaster. A radiology attending should report to
the ED along with a technologist to assist in the prioritization of studies
needed by patients. In the event of airborne pathogen release, all plain
films should be obtained portably in the ED. Although this approach may lead
to suboptimal films, it limits exposure of the hospital and its staff to the
bioterror agent. For other bioterror releases, only those patients requiring
immediate studies or who are unstable for transport should receive portable
All inpatient and
elective studies should be postponed until after the surge is cleared.
This department will
oversee the administration of respiratory treatments. The respiratory
therapist in charge will report to the ED and determine the type and amount
of supplies needed. In the event of an airborne pathogen release, respiratory
therapists will need to have adequate supplies of personal protective
equipment to guard against infection. Furthermore, the number of respiratory
therapists providing care in the ED should be limited, and those individuals
should not return to the main hospital until cleared to do so.
Department of Surgery
All ongoing operations in
the main operating rooms and day surgery units will be ended as expeditiously
as possible. No other procedures should begin until cleared to do so. All
surgical patients will be evaluated for discharge by the nurse in charge of
surgical floors, in consultation with the surgical staff. The department of
surgery should postpone all elective surgeries until the surge is cleared.
Attending staff should remain in the operating rooms in anticipation of
procedures, while chief residents report to the ED to assist in patient
management. The senior surgeon present determines when to call additional
staff from home.
This department is
responsible for the distribution of material to individual departments in the
hospital. On notification of a surge of patients, normal paperwork
requirements should be suspended. The support department should make
available sufficient personnel to distribute supplies as directed by the
The support department
should keep a 48-hour supply of all equipment sufficient for the average
hospital census plus an additional 100 patients.
Child Life Services/Social Work
Child life services should
provide staff support for operations in the disaster discharge area. Child
life activities should collaborate with nursing services in providing these
A labor pool should be
organized from the staff of departments and services not directly involved
with the disaster. The labor pool should be located centrally in a mid-sized
conference room such as the emergency department conference room. The labor pool
should assist in transporting specimens to the laboratories, medical records
pickup, transporting/escorting patients, delivering supplies, and delivering
written messages to patient care areas.
The senior pharmacist on
duty should assume responsibility for transitioning to emergency operations.
The senior pharmacist should notify the Director of Pharmacy, call in
additional staff if needed, and contact the physician in charge to offer
services. The pharmacy department should maintain contact with other
hospitals and local pharmacies for obtaining additional supplies. All
pharmacy staff should remain on duty until the surge is cleared.
The pharmacy should
maintain a 48-hour supply of all pharmaceuticals for the average daily
hospital census plus an additional 100 patients.
One person such as the
director of public affairs should report to the ED; this person should relay
patient information to public affairs staff members at the main reception
area of the hospital. Two public affairs staff persons should staff the main
reception area of the hospital. One should receive patient names and
conditions from the ED while the second should take media calls and respond
to them. One staff member should be available to speak with members of the
media, prepare a news conference, and assist in interviews. Public affairs
staff should escort all members of the media within the hospital.
Psychiatry services should
be available during the disaster. Anticipated services include providing
treatment to patients, families, and staff; advocating for the needs of
patients, families, and staff; providing education to patients, families,
staff, and the media regarding psychosocial effects of terror attacks; and
providing consultation to schools to assist in coping with trauma.
Personnel assigned to the
main reception are should assist parents of victims in locating children; act
as a liaison between Social Service, Public Affairs, and the ED; screen
arriving visitors; and assist Security in managing traffic flow.
A major responsibility of
the security department should be to secure the emergency department against
intrusion by unauthorized persons. Individual health care facilities must
determine the level of personal protective equipment issued to security
officers, as well as the level of force permissible to prevent unauthorized
entry into the hospital. Securing the ED is vitally important to prevent
contamination of the ED and to prevent the disruption of patient services.
should be assigned to the triage area and the ED entrance. These officers
are responsible for ensuring that only casualties, emergencies, and
specifically authorized personnel enter the ED. Personnel assigned to this
area should have a unique identifier such as self-adhesive "disaster dot"
affixed to their hospital identification card.
One security officer
should be assigned outside the main ED entrance; this person will exert
initial control of persons entering the ED, and will distribute disaster dots
to authorized personnel. The following personnel should be authorized to
enter the ED during a disaster surge: medical staff, physicians, critical
care nurses, hospital administration members, members of the ECG, materials
transporters bringing supplies, and specimen transporters.
One security officer
should be assigned to visitor and service elevators to restrict access to the
hospital. An additional security officer should be assigned to ambulance bays
to control access. All other available security officers should manage the
traffic—both private and ambulance—arriving at the hospital.
All other entrances to
the hospital should be secured so that unauthorized entry—and contamination
of the hospital—is impossible. Members of the media should not enter the
hospital unless accompanied by a Public Affairs representative.
Members of the safety
department should make appropriate measurements and observations to ensure
the magnitude of risk of exposure to patients, employees, visitors, local
community, and environment. In the event of an airborne hazard release,
members of the safety department may be needed to assess air sampling and, if
necessary, provide recommendations for temporary airflow barriers to ensure
that the entire facility does not become contaminated.
Once a disaster is
declared, the telecommunications department should page all persons on the
disaster notification list. After all necessary pages have been accomplished,
the page operator notifies the supervisor on call who in turn notifies the
telecommunications manager. The telecommunications department should direct
all inquiries pertaining to the disaster to Public Affairs.
Telecommunications staff should also be prepared to release information
hospital staff who inquire about the level of personal protective equipment
that is needed. No information should be given to the public by the telecommunications