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Disaster Planning
AORN JOURNAL
OCTOBER 1992. VOL 56. NO 4
Disaster Planning REALISTIC IDEAS FOR THE OPERATING ROOM Robert T. Marousky, RN
D
o you feel that your disaster exercises are merely a waste of valuable OR time? Is your department disaster plan just a paperwork project? This article provides information on how to define the mission of the OR in mass casualty disasters. create basic OR disaster plans, and avoid problems during disaster exercises. T o assist OR managers in designing disaster plans. copies of a generic OR disaster plan, OR managers’ checklist, OR staff member checklist, and an algorithm for decision making are included. These can easily be adapted for use as disaster plans in most OR,.
Operating Room Mission
U
nderstanding the mission of the OR during crises is essential to designing a realistic OR disaster plan. Simply put, the mission of the OR is to provide surgical support for victims of disaster. This is the same support that the OR provides trauma victims on a daily basis. The difference in a disaster situation is that the number of patients needing surgical intervention increases.
Eniergerzcy Recall of Staff
E
very hospital has, or should have, a method of recalling personnel in emergency situations. During large scale disasters, it is not uncommon for staff members to arrive at the hospital before the patients. This is because of the normal lag time at the disaster
site where victims are being extricated, triaged, stabilized, and transported. There are three types of recall systems commonly used-the pyramid, the chain, and the combination pyramid/chain. In the pyramid recall, the first person contacted calls two individuals, these two people each call two others, and so forth down the line. The problem with this method is keeping it updated as staff rosters change. The chain recall method groups individuals by function. For example, all general surgery team nurses are included in one chain. or all nurses who live in the same area are placed together. With this system, when one individual changes, only the recall chain on which he or she is grouped needs to be updated. The chain recall roster normally works better than the pyramid type. The pyramid/chain recall method combines the advantages of both systems. One individual heads the pyramid and calls only two individuals, usually other supervisory personnel. They,
Robert T . Marousky, RN. MS, MS, CNOR. M A J . is a retired US Ail. Force operating room iiiirse. He earned his diploma in nursing at Pottslille (Pa)Hospital School of Nwsiiig, his bachelor of science degree in cldldt education jkotn Southern Illinois University, Carbondale, his master of science degree in safety porn Central Missouri State University, Wai7-enshur.g,and his master of science degree in instructional systems design jifi.omthe Univei.siry of South Alabama, Mobile. 619
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duties to be performed by OR personnel upon their arrival (Table 1). Table I Initially, staff members will need to Generic Disaster Checklist sign in at a designated area in the for Operating Room Staff Members department, Operating room managers c a n use this to m o n i t o r w h o h a s 1. Sign in on sheet in nursing lounge. arrived and their skills and to decide 2. Change into scrub clothes. how many operating rooms can be 3. Report to control desk for duty assignment. If no opened. The sign-in sheet should be one is available to make assignments, complete located in a nonrestricted area of the the next task on the checklist that is not initialed. operating room so personnel can reg4. lnitial each task as it is begun and upon compleister as they arrive. The area, howevtion of task. er, should be out of the normal hospiExamples: tal traffic patterns to prevent congesWipe down and check supplies/equipment in OR tion in the hallways. (list room usually used for trauma first). The sign-in sheet should be simple start /finish and list name, title (eg, RN, licensed Repeat above procedure for all operating rooms practical nurse [LPN], operating room in department. technician [ORT]), and special team start /f ini sh designation (eg, cardiovascular, neuRestock linen throughout department. rology), if applicable. A copy of the start-finish departmental recall roster can serve as Check and restock medication in department. the sign-in sheet if this information is start /finish listed on it. Check and restock sterile supplies in storage area After signing in, OR personnel as necessary. should read the staff checklist. The start-finish staff checklist and the OR manager’s 5. When all tasks are finished, report to control staff checklist (Table 2) can be posted desk and wait in lounge for information update next to the sign-in sheet. Personnel and assignment. can use the staff checklist to find instructions about changing . into scrub clothes and preparing the O R for receiving in turn, call the people who are listed first in emergency cases. The duties listed on the each chain. Personnel in each chain are responchecklist must be specific and include a way to sible for notifying the person below them on verify that tasks are completed. Staff members the recall roster. If someone cannot be reached, or supervisory personnel can initial the checkthe next person down the chain is contacted list as tasks are assigned or completed. until someone is contacted or the end of the Duties should be listed in order of priority. chain is reached. For example, if a room is designated for emergency surgery, that room would most likely be used first. The staff member’s first task is to n disaster situations, everyone wants to wipe down the room, then pick supplies for a help. During the initial stages of a disaster major case. Other duties include preparing all situation, frustration can build because there of the ORs by checking and restocking supply levels in each room, sterile storage, medication may be a period of time when everyone is waiting for something to do. To reduce or avoid cabinets, warmers, and dressing rooms and this. OR staff members need clear guidelines. picking basic supplies for cases. This is best achieved by having a checklist of During this waiting period, it is crucial that
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OR managers know the location of staff members in case they are needed for surgery. Once cases are scheduled, OR personnel are assigned to scrub and circulate as appropriate.
Operating Room Manager-Role
A
ssigning OR staff members to cases and coordinating the scheduling of surgery for disaster victims is a duty that naturally falls to the senior OR manager. The two main functions include coordinating scheduling with surgeons and anesthesia personnel to prioritize patients and assigning OR personnel. These duties can be handled by one person or by individuals assigned to fill each functional role. A reliable disaster communication framework needs to be established between surgeons, anesthesia personnel, and OR managers. The framework must include rationale for prioritizing patients, determining the information needed to schedule cases, and designating the person who will be responsible for scheduling during disaster situations. Operating room managers cannot schedule cases during a disaster without knowledge of anesthesia staffing; therefore, a solid communications link needs to be created. If anesthesia staff members have required duties that would limit their availability during the initial phase of the disaster, OR managers need to know this. For instance, anesthesia staff members might be needed to assist with airway management or to stabilize critical patients in the emergency room or intensive care unit (ICU) before surgery can be performed. Another important communication link involves surgeons. Case coordination and scheduling is best handled by one surgeon (eg, the chief of surgery) who gathers information on all the known surgical patients and works with the OR manager and anesthesia staff members to prioritize patients for surgery. When there is no surgeon available to handle this coordination, the task can be delegated to an anesthesiologist.
Table 2
Generic OR Manager’s Disaster Checklist 1. Call in all staff when disaster plan goes into effect. 2. Post sign-in sheet and copy of checklist at designated location. 3. Require all personnel to sign in, change into scrub clothes, and report to control desk for assignment. 4. Assign staff to scrub and circulate on cases if patients are coming to OR immediately. 5. Appoint tasks according to checklist if patients are not ready for surgery. 6. Require staff members to report back to control desk for reassignment when they have finished preparations. 7. Designate teams to staff each case as cases are scheduled. 8. Ensure personnel have enough help to begin cases. 9. Provide information updates to staff as they become available. 10. Plan for breaks, lunch reliefs, etc. 11. Determine if some staff members can be sent home to rest, and discuss when they will be needed back at the hospital. 12. Cancel elective surgery scheduled for the immediate future if necessary.
If there is no surgeon or anesthesiologist available to coordinate this information, then it is the OR manager’s responsibility. The designated manager will need to obtain information from the surgeons on which patients to schedule first. An algorithm can help simplify that process (Table 3). This person needs to know how many patients require surgery; 0 what preparation is needed before the patient can go to surgery; 0 if the surgery can be safely delayed and for how long; what the intended procedure is, what spe681
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Tablc 3
Algorithm f o r Scheduling Patients During Disasters Patient needs immediate surgery to sustain life (ie, cannot be transferred to another facility).
Patient’s injuries can be handted at this facility.
Schedule in first available OR.
Confer with chief of surgery to determine if patient can be transferred to another facility that can provide definitive care.
cialty items will be needed. and how long the surgery is expected to take: and if the surgeon has arranged for an assistant or if extra OR staff members will be needed. This should sound familiar to anyone who routinely schedules cases. Planning an emergency surgery schedule for disaster victims is an accelerated version of the normal scheduling done on a daily basis. The decisions are much the same. but the pace is quicker. Another key role of OR managers is to keep the staff informed of what is h a p p e n i n g . Factual information regarding the number of casualties in the hospital. news from the disaster site, and what the staff members can expect will help maintain morale. This is especially true during the initial phase of the disaster. The staff should be updated every 30 to 60 minutes. The briefing can be formal or simply update 682
chief of surgery,prioritize patient,
and schedule surgery.
notices posted in the department.
Plurinitig for- Disustera
P
lanning and writing the OR disaster policy and procedure involves analyzing the key steps that need to be taken during an emergency (Table 4). The departmental plan contains four components: defining terms, writing special in5tructions. conducting disaster education. and preparing checklists. Definition of terms. Common terms should be defined to prevent any miscommunication during disaster operations. This is important because it provides everyone involved (eg, OR staff. surgeons. nonsurgical physicians, administrators) with the same understanding of the ternis being used. The term operaring room team is used to identify staff members considered to be part of
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OCTOBER 1992. VOL 56. NO 4
Table 4
Generic Operating Mission statement The mission of OR staff members is to provide surgical support for victims in a disaster situation. Definition of terms Operating i.ooni team. The OR team includes all personnel (eg. RNs, LPNs, ORTs. ancillary personnel) regularly assigned to the OR. Staff members from the PACU are also part of the team. The OR team also may include ICU nurses who have received surgical area orientation and will assist with the stabilization of surgical patients in the holding area. Personnel normally assigned to central supply are included in the central supply team portion of the hospital disaster plan. Surgical ream. The surgical team includes all members listed as the OR team plus surgeons and anesthesia personnel. Operating rooni team location. The OR team will work in the surgical suite. During disaster operations. the normal flow pattern of the d e p a r t m e n t will be changed so that surgical patients are brought to the PACU. if needed. for stabilization before surgery. Postoperative patients will go directly to ICU or a nursing unit if there is no room in the PACU after surgery.
the same group during a disaster. All RNs. LPNs, ORTs, and ancillary personnel who normally work in the OR should be considered members of the operating room team. The team composition inay or may not include personnel working in the central supply department. If it does not. these staff members should be included in a separate section in the overall hospital disaster plan. The same is true for personnel in the postanesthesia care unit (PACU) and anesthesia department. The term siirgical team can
Nondisaster emergency sur'ger:v. This pertains to any patient who is not a disaster victim, but needs emergency surgery. These patients will be triaged and prioritized for surgery along with disaster victims who require surgery. Special instructions I . When called in for a disaster, all personnel will report to the lounge and sign in. 2. Personnel will then change into scrub clothes and report to the control desk. 3. The senior nurse on duty will coordinate the a s s i g n m e n t of personnel using t h e a t t a c h e d c h e c k l i s t s a n d will c o o r d i n a t e scheduling of patients until relieved by the director/supervisor. 4. Master copies of the department's disaster checklists will be kept at the control desk. 5. The OR staff members will initial duties on the checklist when they start and finish tasks. 6. The chief of surgery, chief of anesthesia, and OR director or their representatives will prioritize patients for surgery. 7. Patients who need surgery to save their lives o r limbs will be brought directly to surgery. 8. All other patients will not be taken into surgery until a surgeon is available.
be used if OR staff members, anesthesia per-
sonnel, and surgeons all are considered one team. T h e term ream Iocatiori a l s o should be defined. This may seem obvious, but some administrative disaster planners like to move teams to seemingly better locations without regard to the function of the team. Including blueprints with a diagram of the team's location in the disaster plan is an excellent idea. The flow of patients through the department
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Room Disaster Plan anesthesia personnel are available, OR staff members are available, OR rooms and supplies are available, and necessary diagnostic tests are completed. 9. Critical patients awaiting surgery may be brought to the PACU for stabilization and holding. 10. Nurses from ICU will assist the PACU staff members in the preoperative holding area. 11. Postoperative patients may be taken directly to the ICU or other nursing units if the PACU is still being used for preoperative patients. 12. During the initial portion of a disaster, OR and PACU staff members may be assigned to assist anesthesia personnel with stabilization and triage of patients in other areas of the hospital. 13. During disasters, normal communications may be disrupted, and some personnel may be assigned to act as runners to deliver messages. 0 0
Disaster education Every new employee will attend the hospital-wide disaster education within the first 30 days of employment. This is held in the hospital conference room at noon on the first Monday of every month. As part of their orientation, every new
also must be shown on the diagram. This is important if the personnel transporting patients to the OR are unfamiliar with the area. Operating room managers should define any other terms unique to the hospital or the plan. An example of this may be stating that the PACU becomes the preoperative stabilization and holding area during disaster situations, and patients recover in the ICU. Special instructions. Writing any special instructions that staff members will need
employee will receive specific education about the OR’s role in a disaster including sign-in procedures for department, 0 use of checklists, handling of internal disasters (eg, fires, bomb threats), and special considerations for the handling of patients from external disasters. Every employee will receive annual education during the month of October on fire safety and evacuation procedures. Every employee will receive a one-hour annual refresher course on the OR’s role in a disaster. Specific topics may vary from year to year. Other educational needs will be determined from the findings of the semiannual disaster exercises.
Disaster exercises During disaster exercises, patients will not be brought to the OR. Elective cases will not be cancelled for exercises. Disaster exercises will mainly involve OR management staff members. When on duty, OR staff members will be asked to sign in during disaster exercises and report to the control desk for assignment. Off-duty OR personnel will not be called in for disaster exercises.
should be part of disaster plan development. These instructions might include sign-in policies, checklist guidelines, and patient scheduling procedures. In the sign-in procedures section, explain any special requirements that staff members must follow to enter the hospital during disaster operations. Items such as signing a general hospital roster or having to show a valid hospital identification must be listed. Information arbout checklists should state 685
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where the lists are located. where to post copies, and how to use them. A working copy of the checklist must be located at the OR control desk. The senior OR nurse on duty or the first person to arrive for disaster operations will be in charge of the checklist. Writing a description of how to schedule a patient for surgery during a disaster situation is important. This document can be called "surgical coordination" or "disaster surgical scheduling." and it must include information on the communication and coordination necessary before a patient can be brought to surgery. There a l s o should be a written provision regarding requirements on how to handle lifethreatening cases and nondisaster emergency surgery patients u ho need immediate surgical intervention. Special instructions also should cover the potential assignment of OR personnel outside of the department and the use of other hospital staff who may be assigned to help in the OR. Occasionally. OR nurses may be assigned to help stabilize casualties. assist anesthesia personnel in managing airuay problems. or care for patients with minor lacerations who are being treated in another area of the hospital. Disaster education. Proper staff member education is vital to any disaster plan. While new hospital employees routinely attend a class on the hospital's mission during disisters, the specific role of OR personnel must be included in the department's orientation. Annual education for a11 OR staff members is necessary. October is a good month to devote to disaster education because it blends in very well with National Fire Safety Month. Education programs can focus on how to handle both internal and external disasters, the review of sign-in procedures. and the use of checklists. Staff members from other areas of the hospifa1 who might be working in the OR during a disaster also will need orientation. For example, ICL nurses niay be assigned to help in the preoperative holding area or PACU during a disaster. The disaster plan should describe personnel who could be assigned to the OR during an emergency. For example. "ICU nurse" would
OCTOBER 1'992. VOL 56. NO 1
be listed, but an actual name would not be written on the plan diagram. When new nurses arrive in the ICU, part of their orientation can be a rotation through the OR area where they may be assigned during a disaster.
Problems During Disaster Exercises
P
robletns during disaster exercises occur because of the accelerated pace of the exercise and the compression of many hours of work into a short period of time. Establishing in advance which OR activities will be evaluated during exercises is a good way to avoid problems. This is done by using objective criteria based on the department's disaster plan. Criteria can be written by the hospital disaster planner or by the person who prepares the OR'S portion of the plan. It is important that the disaster planner. exercise evaluator, and OR supervisory staff members (eg, OR managers, surgeons. anesthesia personnel) all understand the criteria. The person who evaluates OR staff members during a disaster exercise should have some surgical knowledge. The actual care of the surgical patient does not need evaluation during exercises. Operating room personnel can handle the surgical needs of disaster victims based on their everyday ability to handle trauma and e m e r g e n c y surgery patients. The areas that do require guidelines for e v a1u a t ion i nc 1u de c om ni un i c a t io n s , patient safety/quality improvement concerns, and disaster simulations. Communication flow can be evaluated by observing how cases are scheduled during the exercise. Criteria for determining this would include ascertaining that the person making the scheduling request is a surgeon or surgical resident, ensuring that the cases are coordinated with key individuals (eg. OR manager, chief of surgery. chief of anesthesia) as listed in the plan, and confirming that the patients are prioritized in relation to all known surgical patients.
OCTOBER 1992. VOL 56. NO 4
Criteria that can be used to evaluate patient safety/quality improvement include 0 ensuring that a surgeon is available; determining that anesthesia personnel can staff the case; verifying that staff members, an OR, necessary supplies, and equipment are available; confirming that necessary diagnostic tests have been completed: and determining that the anticipated surgery can be done safely at the hospital. Because of the time compression factor in disaster exercises, it is not possible to do eveiything that would be done during a real disaster. Many activities, such as taking patients into the OR, are simulated to save time and money. Any simulations used during exercises must be identified in advance so that whoever is evaluating the OR’S portion of the exercise will not misunderstand. To avoid problems during exercises and actual disasters, a critique of the OR disaster exercise is necessary. Immediately after the exercise, the evaluator and key OR staff members need to review the simulation. The evaluator reviews each criterion and the OR score in that category. Surgery representatives can validate the findings or present reasons why exceptions to the findings should be made. Strengths and weaknesses should be identified. Any areas of weak performance become the subject of the next disaster education session. The postexercise critique also may identify problems with the hospital or department’s disaster plan that will require modification. It is important that key individuals not only look at how OR staff members function in a disaster but how they interact with the rest of the hospital personnel during a disaster.
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during disaster exercises. Finally, evaluate the plan during a disaster exercise so that any weaknesses in thie plan can be identified and corrected.
Health Program Targets America’s Youth In an effort to insure the health of America’s children and adokscents, the American Medical Association (AMA) and the American Academy of Pediatrics have launched “Healthy Youth 2000,” according to a July 8, 1992, press release from the AMA. The program is part of “Healthy People 2000,” a broad-based plan designed by the US Public Health Service to increase Americans ’ healthy life span. In the release, the AMA states that there is a need during childhood and adolescence for critical interventions to insure healthy development. Attitudes and behaviors developed during these years toward diet, exercise, sexuality, safety, tobacco, and alcohol have health consequences that continue through adulthood. As part of the program, brochures, books, audio cassettes, and videotapes will be developed for use by children, adolescents, and their care givers. Some 2.5 million brochures about immunization, written in English and SpanishEnglish, now are being distributed to physicians.
Conclusion
U
sing a logical approach. every OR can create a successful disaster plan. The first step is to define the mission of the OR during a crisis situation. Second, devise procedures for staff members. Third, write performance criteria to evaluate OR performance 687
OCTOBER 1992. VOL 56. NO 4
Disaster Planning REALISTIC IDEAS FOR THE OPERATING ROOM Robert T. Marousky, RN
D
o you feel that your disaster exercises are merely a waste of valuable OR time? Is your department disaster plan just a paperwork project? This article provides information on how to define the mission of the OR in mass casualty disasters. create basic OR disaster plans, and avoid problems during disaster exercises. T o assist OR managers in designing disaster plans. copies of a generic OR disaster plan, OR managers’ checklist, OR staff member checklist, and an algorithm for decision making are included. These can easily be adapted for use as disaster plans in most OR,.
Operating Room Mission
U
nderstanding the mission of the OR during crises is essential to designing a realistic OR disaster plan. Simply put, the mission of the OR is to provide surgical support for victims of disaster. This is the same support that the OR provides trauma victims on a daily basis. The difference in a disaster situation is that the number of patients needing surgical intervention increases.
Eniergerzcy Recall of Staff
E
very hospital has, or should have, a method of recalling personnel in emergency situations. During large scale disasters, it is not uncommon for staff members to arrive at the hospital before the patients. This is because of the normal lag time at the disaster
site where victims are being extricated, triaged, stabilized, and transported. There are three types of recall systems commonly used-the pyramid, the chain, and the combination pyramid/chain. In the pyramid recall, the first person contacted calls two individuals, these two people each call two others, and so forth down the line. The problem with this method is keeping it updated as staff rosters change. The chain recall method groups individuals by function. For example, all general surgery team nurses are included in one chain. or all nurses who live in the same area are placed together. With this system, when one individual changes, only the recall chain on which he or she is grouped needs to be updated. The chain recall roster normally works better than the pyramid type. The pyramid/chain recall method combines the advantages of both systems. One individual heads the pyramid and calls only two individuals, usually other supervisory personnel. They,
Robert T . Marousky, RN. MS, MS, CNOR. M A J . is a retired US Ail. Force operating room iiiirse. He earned his diploma in nursing at Pottslille (Pa)Hospital School of Nwsiiig, his bachelor of science degree in cldldt education jkotn Southern Illinois University, Carbondale, his master of science degree in safety porn Central Missouri State University, Wai7-enshur.g,and his master of science degree in instructional systems design jifi.omthe Univei.siry of South Alabama, Mobile. 619
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duties to be performed by OR personnel upon their arrival (Table 1). Table I Initially, staff members will need to Generic Disaster Checklist sign in at a designated area in the for Operating Room Staff Members department, Operating room managers c a n use this to m o n i t o r w h o h a s 1. Sign in on sheet in nursing lounge. arrived and their skills and to decide 2. Change into scrub clothes. how many operating rooms can be 3. Report to control desk for duty assignment. If no opened. The sign-in sheet should be one is available to make assignments, complete located in a nonrestricted area of the the next task on the checklist that is not initialed. operating room so personnel can reg4. lnitial each task as it is begun and upon compleister as they arrive. The area, howevtion of task. er, should be out of the normal hospiExamples: tal traffic patterns to prevent congesWipe down and check supplies/equipment in OR tion in the hallways. (list room usually used for trauma first). The sign-in sheet should be simple start /finish and list name, title (eg, RN, licensed Repeat above procedure for all operating rooms practical nurse [LPN], operating room in department. technician [ORT]), and special team start /f ini sh designation (eg, cardiovascular, neuRestock linen throughout department. rology), if applicable. A copy of the start-finish departmental recall roster can serve as Check and restock medication in department. the sign-in sheet if this information is start /finish listed on it. Check and restock sterile supplies in storage area After signing in, OR personnel as necessary. should read the staff checklist. The start-finish staff checklist and the OR manager’s 5. When all tasks are finished, report to control staff checklist (Table 2) can be posted desk and wait in lounge for information update next to the sign-in sheet. Personnel and assignment. can use the staff checklist to find instructions about changing . into scrub clothes and preparing the O R for receiving in turn, call the people who are listed first in emergency cases. The duties listed on the each chain. Personnel in each chain are responchecklist must be specific and include a way to sible for notifying the person below them on verify that tasks are completed. Staff members the recall roster. If someone cannot be reached, or supervisory personnel can initial the checkthe next person down the chain is contacted list as tasks are assigned or completed. until someone is contacted or the end of the Duties should be listed in order of priority. chain is reached. For example, if a room is designated for emergency surgery, that room would most likely be used first. The staff member’s first task is to n disaster situations, everyone wants to wipe down the room, then pick supplies for a help. During the initial stages of a disaster major case. Other duties include preparing all situation, frustration can build because there of the ORs by checking and restocking supply levels in each room, sterile storage, medication may be a period of time when everyone is waiting for something to do. To reduce or avoid cabinets, warmers, and dressing rooms and this. OR staff members need clear guidelines. picking basic supplies for cases. This is best achieved by having a checklist of During this waiting period, it is crucial that
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OR managers know the location of staff members in case they are needed for surgery. Once cases are scheduled, OR personnel are assigned to scrub and circulate as appropriate.
Operating Room Manager-Role
A
ssigning OR staff members to cases and coordinating the scheduling of surgery for disaster victims is a duty that naturally falls to the senior OR manager. The two main functions include coordinating scheduling with surgeons and anesthesia personnel to prioritize patients and assigning OR personnel. These duties can be handled by one person or by individuals assigned to fill each functional role. A reliable disaster communication framework needs to be established between surgeons, anesthesia personnel, and OR managers. The framework must include rationale for prioritizing patients, determining the information needed to schedule cases, and designating the person who will be responsible for scheduling during disaster situations. Operating room managers cannot schedule cases during a disaster without knowledge of anesthesia staffing; therefore, a solid communications link needs to be created. If anesthesia staff members have required duties that would limit their availability during the initial phase of the disaster, OR managers need to know this. For instance, anesthesia staff members might be needed to assist with airway management or to stabilize critical patients in the emergency room or intensive care unit (ICU) before surgery can be performed. Another important communication link involves surgeons. Case coordination and scheduling is best handled by one surgeon (eg, the chief of surgery) who gathers information on all the known surgical patients and works with the OR manager and anesthesia staff members to prioritize patients for surgery. When there is no surgeon available to handle this coordination, the task can be delegated to an anesthesiologist.
Table 2
Generic OR Manager’s Disaster Checklist 1. Call in all staff when disaster plan goes into effect. 2. Post sign-in sheet and copy of checklist at designated location. 3. Require all personnel to sign in, change into scrub clothes, and report to control desk for assignment. 4. Assign staff to scrub and circulate on cases if patients are coming to OR immediately. 5. Appoint tasks according to checklist if patients are not ready for surgery. 6. Require staff members to report back to control desk for reassignment when they have finished preparations. 7. Designate teams to staff each case as cases are scheduled. 8. Ensure personnel have enough help to begin cases. 9. Provide information updates to staff as they become available. 10. Plan for breaks, lunch reliefs, etc. 11. Determine if some staff members can be sent home to rest, and discuss when they will be needed back at the hospital. 12. Cancel elective surgery scheduled for the immediate future if necessary.
If there is no surgeon or anesthesiologist available to coordinate this information, then it is the OR manager’s responsibility. The designated manager will need to obtain information from the surgeons on which patients to schedule first. An algorithm can help simplify that process (Table 3). This person needs to know how many patients require surgery; 0 what preparation is needed before the patient can go to surgery; 0 if the surgery can be safely delayed and for how long; what the intended procedure is, what spe681
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Tablc 3
Algorithm f o r Scheduling Patients During Disasters Patient needs immediate surgery to sustain life (ie, cannot be transferred to another facility).
Patient’s injuries can be handted at this facility.
Schedule in first available OR.
Confer with chief of surgery to determine if patient can be transferred to another facility that can provide definitive care.
cialty items will be needed. and how long the surgery is expected to take: and if the surgeon has arranged for an assistant or if extra OR staff members will be needed. This should sound familiar to anyone who routinely schedules cases. Planning an emergency surgery schedule for disaster victims is an accelerated version of the normal scheduling done on a daily basis. The decisions are much the same. but the pace is quicker. Another key role of OR managers is to keep the staff informed of what is h a p p e n i n g . Factual information regarding the number of casualties in the hospital. news from the disaster site, and what the staff members can expect will help maintain morale. This is especially true during the initial phase of the disaster. The staff should be updated every 30 to 60 minutes. The briefing can be formal or simply update 682
chief of surgery,prioritize patient,
and schedule surgery.
notices posted in the department.
Plurinitig for- Disustera
P
lanning and writing the OR disaster policy and procedure involves analyzing the key steps that need to be taken during an emergency (Table 4). The departmental plan contains four components: defining terms, writing special in5tructions. conducting disaster education. and preparing checklists. Definition of terms. Common terms should be defined to prevent any miscommunication during disaster operations. This is important because it provides everyone involved (eg, OR staff. surgeons. nonsurgical physicians, administrators) with the same understanding of the ternis being used. The term operaring room team is used to identify staff members considered to be part of
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Table 4
Generic Operating Mission statement The mission of OR staff members is to provide surgical support for victims in a disaster situation. Definition of terms Operating i.ooni team. The OR team includes all personnel (eg. RNs, LPNs, ORTs. ancillary personnel) regularly assigned to the OR. Staff members from the PACU are also part of the team. The OR team also may include ICU nurses who have received surgical area orientation and will assist with the stabilization of surgical patients in the holding area. Personnel normally assigned to central supply are included in the central supply team portion of the hospital disaster plan. Surgical ream. The surgical team includes all members listed as the OR team plus surgeons and anesthesia personnel. Operating rooni team location. The OR team will work in the surgical suite. During disaster operations. the normal flow pattern of the d e p a r t m e n t will be changed so that surgical patients are brought to the PACU. if needed. for stabilization before surgery. Postoperative patients will go directly to ICU or a nursing unit if there is no room in the PACU after surgery.
the same group during a disaster. All RNs. LPNs, ORTs, and ancillary personnel who normally work in the OR should be considered members of the operating room team. The team composition inay or may not include personnel working in the central supply department. If it does not. these staff members should be included in a separate section in the overall hospital disaster plan. The same is true for personnel in the postanesthesia care unit (PACU) and anesthesia department. The term siirgical team can
Nondisaster emergency sur'ger:v. This pertains to any patient who is not a disaster victim, but needs emergency surgery. These patients will be triaged and prioritized for surgery along with disaster victims who require surgery. Special instructions I . When called in for a disaster, all personnel will report to the lounge and sign in. 2. Personnel will then change into scrub clothes and report to the control desk. 3. The senior nurse on duty will coordinate the a s s i g n m e n t of personnel using t h e a t t a c h e d c h e c k l i s t s a n d will c o o r d i n a t e scheduling of patients until relieved by the director/supervisor. 4. Master copies of the department's disaster checklists will be kept at the control desk. 5. The OR staff members will initial duties on the checklist when they start and finish tasks. 6. The chief of surgery, chief of anesthesia, and OR director or their representatives will prioritize patients for surgery. 7. Patients who need surgery to save their lives o r limbs will be brought directly to surgery. 8. All other patients will not be taken into surgery until a surgeon is available.
be used if OR staff members, anesthesia per-
sonnel, and surgeons all are considered one team. T h e term ream Iocatiori a l s o should be defined. This may seem obvious, but some administrative disaster planners like to move teams to seemingly better locations without regard to the function of the team. Including blueprints with a diagram of the team's location in the disaster plan is an excellent idea. The flow of patients through the department
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Room Disaster Plan anesthesia personnel are available, OR staff members are available, OR rooms and supplies are available, and necessary diagnostic tests are completed. 9. Critical patients awaiting surgery may be brought to the PACU for stabilization and holding. 10. Nurses from ICU will assist the PACU staff members in the preoperative holding area. 11. Postoperative patients may be taken directly to the ICU or other nursing units if the PACU is still being used for preoperative patients. 12. During the initial portion of a disaster, OR and PACU staff members may be assigned to assist anesthesia personnel with stabilization and triage of patients in other areas of the hospital. 13. During disasters, normal communications may be disrupted, and some personnel may be assigned to act as runners to deliver messages. 0 0
Disaster education Every new employee will attend the hospital-wide disaster education within the first 30 days of employment. This is held in the hospital conference room at noon on the first Monday of every month. As part of their orientation, every new
also must be shown on the diagram. This is important if the personnel transporting patients to the OR are unfamiliar with the area. Operating room managers should define any other terms unique to the hospital or the plan. An example of this may be stating that the PACU becomes the preoperative stabilization and holding area during disaster situations, and patients recover in the ICU. Special instructions. Writing any special instructions that staff members will need
employee will receive specific education about the OR’s role in a disaster including sign-in procedures for department, 0 use of checklists, handling of internal disasters (eg, fires, bomb threats), and special considerations for the handling of patients from external disasters. Every employee will receive annual education during the month of October on fire safety and evacuation procedures. Every employee will receive a one-hour annual refresher course on the OR’s role in a disaster. Specific topics may vary from year to year. Other educational needs will be determined from the findings of the semiannual disaster exercises.
Disaster exercises During disaster exercises, patients will not be brought to the OR. Elective cases will not be cancelled for exercises. Disaster exercises will mainly involve OR management staff members. When on duty, OR staff members will be asked to sign in during disaster exercises and report to the control desk for assignment. Off-duty OR personnel will not be called in for disaster exercises.
should be part of disaster plan development. These instructions might include sign-in policies, checklist guidelines, and patient scheduling procedures. In the sign-in procedures section, explain any special requirements that staff members must follow to enter the hospital during disaster operations. Items such as signing a general hospital roster or having to show a valid hospital identification must be listed. Information arbout checklists should state 685
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where the lists are located. where to post copies, and how to use them. A working copy of the checklist must be located at the OR control desk. The senior OR nurse on duty or the first person to arrive for disaster operations will be in charge of the checklist. Writing a description of how to schedule a patient for surgery during a disaster situation is important. This document can be called "surgical coordination" or "disaster surgical scheduling." and it must include information on the communication and coordination necessary before a patient can be brought to surgery. There a l s o should be a written provision regarding requirements on how to handle lifethreatening cases and nondisaster emergency surgery patients u ho need immediate surgical intervention. Special instructions also should cover the potential assignment of OR personnel outside of the department and the use of other hospital staff who may be assigned to help in the OR. Occasionally. OR nurses may be assigned to help stabilize casualties. assist anesthesia personnel in managing airuay problems. or care for patients with minor lacerations who are being treated in another area of the hospital. Disaster education. Proper staff member education is vital to any disaster plan. While new hospital employees routinely attend a class on the hospital's mission during disisters, the specific role of OR personnel must be included in the department's orientation. Annual education for a11 OR staff members is necessary. October is a good month to devote to disaster education because it blends in very well with National Fire Safety Month. Education programs can focus on how to handle both internal and external disasters, the review of sign-in procedures. and the use of checklists. Staff members from other areas of the hospifa1 who might be working in the OR during a disaster also will need orientation. For example, ICL nurses niay be assigned to help in the preoperative holding area or PACU during a disaster. The disaster plan should describe personnel who could be assigned to the OR during an emergency. For example. "ICU nurse" would
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be listed, but an actual name would not be written on the plan diagram. When new nurses arrive in the ICU, part of their orientation can be a rotation through the OR area where they may be assigned during a disaster.
Problems During Disaster Exercises
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robletns during disaster exercises occur because of the accelerated pace of the exercise and the compression of many hours of work into a short period of time. Establishing in advance which OR activities will be evaluated during exercises is a good way to avoid problems. This is done by using objective criteria based on the department's disaster plan. Criteria can be written by the hospital disaster planner or by the person who prepares the OR'S portion of the plan. It is important that the disaster planner. exercise evaluator, and OR supervisory staff members (eg, OR managers, surgeons. anesthesia personnel) all understand the criteria. The person who evaluates OR staff members during a disaster exercise should have some surgical knowledge. The actual care of the surgical patient does not need evaluation during exercises. Operating room personnel can handle the surgical needs of disaster victims based on their everyday ability to handle trauma and e m e r g e n c y surgery patients. The areas that do require guidelines for e v a1u a t ion i nc 1u de c om ni un i c a t io n s , patient safety/quality improvement concerns, and disaster simulations. Communication flow can be evaluated by observing how cases are scheduled during the exercise. Criteria for determining this would include ascertaining that the person making the scheduling request is a surgeon or surgical resident, ensuring that the cases are coordinated with key individuals (eg. OR manager, chief of surgery. chief of anesthesia) as listed in the plan, and confirming that the patients are prioritized in relation to all known surgical patients.
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Criteria that can be used to evaluate patient safety/quality improvement include 0 ensuring that a surgeon is available; determining that anesthesia personnel can staff the case; verifying that staff members, an OR, necessary supplies, and equipment are available; confirming that necessary diagnostic tests have been completed: and determining that the anticipated surgery can be done safely at the hospital. Because of the time compression factor in disaster exercises, it is not possible to do eveiything that would be done during a real disaster. Many activities, such as taking patients into the OR, are simulated to save time and money. Any simulations used during exercises must be identified in advance so that whoever is evaluating the OR’S portion of the exercise will not misunderstand. To avoid problems during exercises and actual disasters, a critique of the OR disaster exercise is necessary. Immediately after the exercise, the evaluator and key OR staff members need to review the simulation. The evaluator reviews each criterion and the OR score in that category. Surgery representatives can validate the findings or present reasons why exceptions to the findings should be made. Strengths and weaknesses should be identified. Any areas of weak performance become the subject of the next disaster education session. The postexercise critique also may identify problems with the hospital or department’s disaster plan that will require modification. It is important that key individuals not only look at how OR staff members function in a disaster but how they interact with the rest of the hospital personnel during a disaster.
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during disaster exercises. Finally, evaluate the plan during a disaster exercise so that any weaknesses in thie plan can be identified and corrected.
Health Program Targets America’s Youth In an effort to insure the health of America’s children and adokscents, the American Medical Association (AMA) and the American Academy of Pediatrics have launched “Healthy Youth 2000,” according to a July 8, 1992, press release from the AMA. The program is part of “Healthy People 2000,” a broad-based plan designed by the US Public Health Service to increase Americans ’ healthy life span. In the release, the AMA states that there is a need during childhood and adolescence for critical interventions to insure healthy development. Attitudes and behaviors developed during these years toward diet, exercise, sexuality, safety, tobacco, and alcohol have health consequences that continue through adulthood. As part of the program, brochures, books, audio cassettes, and videotapes will be developed for use by children, adolescents, and their care givers. Some 2.5 million brochures about immunization, written in English and SpanishEnglish, now are being distributed to physicians.
Conclusion
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sing a logical approach. every OR can create a successful disaster plan. The first step is to define the mission of the OR during a crisis situation. Second, devise procedures for staff members. Third, write performance criteria to evaluate OR performance 687