- Email: [email protected]
Pediatric Mass Casualty: Are You Ready?
CLINICAL
Pediatric Mass Casualty: Are You Ready?
Authors: Annette Behney, RN, BSN, CEN, Michele Breit, RN, BSN, CEN, and Cheryl Phillips, RN, CEN, Liberty, Mo
Annette Behney, Greater Kansas City Chapter ENA, is Clinical Educator, Liberty Hospital, Liberty, Mo. Michele Breit, Greater Kansas City Chapter ENA, is Clinical Resource Leader, Liberty Hospital, Liberty, Mo. Cheryl Phillips, Greater Kansas City Chapter ENA, is Emergency Department Clinical Director, Liberty Hospital, Liberty, Mo. For correspondence, write: Annette Behney, 20810 NE 176th St, Holt, MO 64048; E-mail: [email protected]. J Emerg Nurs 2006;32:241-5. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.03.005
M
onday, May 9, 2005, 0830: ‘‘This is Liberty Dispatch. Activate your disaster plan. We have multiple injuries; school bus versus cars. . . .’’ This was the phone call that started it all. At 0831, Liberty Dispatch clarified the events unfolding at the scene of the school bus crash in Liberty, Missouri, a suburb of Kansas City (Figure 1). The bus had lost control going through an intersection. Two passenger vehicles also were involved. At least 40 to 50 children on the bus were injured. Ten or eleven children were triaged as critical, and there were 2 adult fatalities at the scene. At 0834, a second phone call from Liberty Dispatch notified the emergency department that Liberty Hospital could expect 2 children who were critically injured; EMS was going to ‘‘scoop and run’’ and arrive at the hospital almost immediately thereafter. A level I trauma team alert was initiated to mobilize the trauma team and trauma surgeon to the emergency department. By 0835, the emergency department was notified that one of the critical patients was now being actively resuscitated. The hospital Disaster Team Alert was initiated. Staff assignments
The ED clinical director assumed the role of incident commander, and the ED clinical resource leader (ie, assistant ED nurse manager) stepped in as treatment areas director. Two ED nurses were assigned to the incoming critical patients, and another was placed at the ambulance entrance to relay room assignments for incoming patients to the EMS crews. (Disaster triage had been done by EMS at the scene.)
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FIGURE 1
Police in Liberty, Missouri, investigate the crash of Bus 80. Between 40 and 50 children were riding the bus when it crashed; 29 passengers were transported to Liberty Hospital.
By 0837, non-ED nursing staff as well as ancillary staff members began to arrive in the emergency department and were assigned to assist specific ED staff members. The emergency department was expecting the 2 critical trauma patients with the possibility of receiving a third. To supplement our one pediatric crash cart, the Special Procedures Department and Pediatrics Unit were notified to send down their pediatric carts. Three critical care rooms were then established with pediatric crash carts, with a pharmacist available for each. In just 10 minutes we were organized and ready to provide life-saving care to multiple victims. At 0840, we received our first 2 patients. Utilizing the Incident Command System,1 each person knew his or her exact job assignment and was ready to
242
perform his or her required duties. At the time of the incident, the emergency department was staffed with 6 registered nurses (RNs), one graduate nurse on orientation, one RN who was new to the department and on orientation, one ED technician, and one secretary. The clinical director, clinical educator, and clinical resource leader were available to assist in the disaster response. One ED physician was on duty that morning, and one more physician was scheduled to arrive at 0900. Once the disaster alert was initiated, 13 staff physicians as well as 4 extra ED physicians responded to the emergency department. Trauma surgeons, pediatricians, and cardiologists were among the specialties responding. Most of the specialty physicians were in the hospital at the time
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FIGURE 2
Liberty Hospital, Liberty, Missouri, a 235-bed regional medical center and level II trauma center with a 28-bed emergency department.
of the disaster and responded to the emergency department according to protocol. Two of the ED physicians were called from our outlying clinics, one called from home after seeing the news, and one called after seeing the crash. One family practice physician took 2 RNs from the hospital education department with him to the school administration building, located between the crash site and the hospital. All patients who were designated as triage ‘‘green,’’ nonurgent, were taken there to be treated or referred as needed.
The emergency department was expecting the 2 critical trauma patients with the possibility of receiving a third. To supplement our one pediatric crash cart, the Special Procedures Department and Pediatrics Unit were notified to send down their pediatric carts. . . . In just 10 minutes we were organized and ready to provide life-saving care to multiple victims. Immediately after the crash, Liberty Public School District administrators assigned district counselors to the June 2006
32:3
emergency department to assist with patient and family support and to provide a primary source of identification for the children. Triage
A total of 29 patients were treated in the emergency department—27 children and 2 adults. Twenty-one of these patients arrived by ambulance within the first hour. Their Emergency Severity Index2 triage levels were as follows: 2 patients were triaged as level 1, 10 patients were triaged as level 2, 16 patients were assigned level 3 status, and one patient was triaged as level 4. There were no level 5 patients. (The patient’s primary nurse assigned the acuity level.) Injuries included spinal cord trauma, open and closed head trauma, and multiple orthopedic injuries. By the end of the day, 18 patients had been treated and released. Six patients were admitted to Liberty Hospital (Figure 2); one of these had to go to the operating room (OR). Five patients were transferred to Children’s Mercy Hospital in Kansas City, a tertiary pediatric hospital. Evaluation and lessons learned
Once everything was done and the debriefings were conducted, we analyzed our performance (Table 1). It seems JOURNAL OF EMERGENCY NURSING
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TABLE 1
Lessons learned and changes in procedure resulting from a pediatric mass casualty incident involving a school bus and two passenger vehicles . .
.
. .
.
Switchboard operators have laminated cards with clearly specified announcement criteria printed on them The treatment area box containing 2-way radios, vests, and other paperwork is kept in the emergency department for quick access Parents of accident victims receive identification bands when they are matched up with their child, which helps to control pedestrian traffic Victims’ clothing may be used to identify them when physical identification is difficult or impossible A social worker is assigned to a room or group of rooms to avoid having to run from one end of the emergency department to the other; a social worker also is assigned to the family area The family area is a short distance away from the emergency department, thus decreasing traffic congestion around the department
that no matter how many drills we hold, communication is the weakest link in the system. This real disaster was no exception. Issues with communication began with the first overhead announcement that was made by the switchboard staff. Because the nature of the emergency was misunderstood, the announcement ‘‘Code Yellow’’ (severe weather alert) was made overhead instead of ‘‘Activate your Disaster Plan,’’ the correct announcement. The incident commander notified the switchboard and the correct announcement was made, but it is easy to imagine the internal confusion this caused initially. To avoid this problem in the future, the operators now have laminated cards with clearly specified announcement criteria printed on them. The hospital’s disaster plan calls for patient care area boxes that contain 2-way radios, vests, and other paperwork to be distributed from Incident Command in administration when a disaster is called. Because of the initial incorrect ‘‘Code Yellow’’ announcement, the emergency department did not receive the radios and vests in a timely manner. We eventually received the equipment at about the time the patients began to arrive. As a result, the plan has been adjusted to keep the treatment area box in the emergency department so staff have quick access to the needed equipment and paperwork.
244
Identifying children and getting their parents to them quickly was another problem area. Parents, hearing about the disaster from radio, television, and the school representatives, began arriving in the waiting room almost as fast as the ambulances were arriving in the garage. Fortunately, the Liberty School District sent several counselors to the hospital to help support both students and parents. Also, they brought with them a list of names of the children who were supposed to be on that bus. As we identified a child, the child’s name was checked off the list. Liberty Hospital’s Social Service Department and Administration staff placed identification bands on parents when they were matched up with their child, which helped to control pedestrian traffic from the waiting room to the main emergency department.
It seems that no matter how many drills we hold, communication is the weakest link in the system. This real disaster was no exception. Identifying most of the children was not difficult because most of them were conscious and could give us their names and the names of their parents. Identification became more problematic in the case of the 2 patients with critical injuries who were unresponsive. One tentative identification came from one of the school counselors who thought she recognized the child. The principal from the school had the foresight to bring his personal digital assistant with him to the hospital; it was loaded with the pictures of all 400 children attending his school. We were able to put a name to the tentatively identified child using this picture identification, an identity that was confirmed when the parents arrived and identified the child’s wristwatch. Even with the personal digital assistant pictures, none of the school staff could recognize the second critically injured child. Unresponsive and intubated, the child had no identifying marks. As ED staff prepared to transfer the child to Children’s Mercy Hospital, we were concerned that the child would be transferred before being identified. Just as the helicopter was landing, the hospital chaplain reported that the child’s father might be in the waiting room. Now the dilemma became how to determine whether this child belonged to this father without bringing the man into the room. Because of the severity of the patient’s
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injuries, we believed that visual identification might be difficult. One nurse in the room had the idea of having the father identify the clothing that was cut off the patient. In this way we were able to identify the child and get the father to the child’s bedside before the transfer took place. As a result of this incident, the staff of our Social Service Department also made some changes to their portion of the disaster plan. Now a social worker is assigned to a room or group of rooms to avoid having to run from one end of the emergency department to the other. A social worker also will be assigned to the family area.
The principal from the school had the foresight to bring his personal digital assistant with him to the hospital; it was loaded with the pictures of all 400 children attending his school. Because of the initial confusion and mass of people, the family area for disasters has been moved from the ED waiting room to another waiting room a short distance away from the emergency department. One social worker will be assigned to oversee communications between the main emergency department and this family area. Hospital response to the disaster call was exceptional. Initially, enough licensed nursing staff were released from other areas of the hospital to allow for 2 nurses per room in the emergent care area (ie, one ED nurse and either an ICU or OR nurse with trauma experience). In the urgent care area, ED nurses acted as team leaders with assistance from pediatric and medical-surgical nurses. Each child had a staff person with him or her at all times. For example, one child had an open fracture of his tibia and fibula and had to go to the operating room. Fortunately, one of the extra nurses assigned to this child was an OR nurse. She was able to reassure the patient and the family that she would be with the child the entire time in the OR, and the family later said that this statement gave them an unbelievable sense of comfort as they waited. Children’s Mercy Hospital was an invaluable resource, putting their transport teams in the air to Liberty Hospital as soon as they heard of the crash. Both critical patients were stabilized and transported within 1 hour. Children’s Mercy Hospital also dispatched one of their
June 2006
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ground units to stay at Liberty Hospital until all the patients from the crash were stabilized and all potential transfers were completed. The teamwork shown by everyone in the hospital and in the community was something that can only be appreciated when looking back on a disaster of this caliber. Nurses, physicians, ancillary staff, EMS, and school district personnel all came together to care for these children and their families. The letters and phone calls of support and praise that we received from the community, other facilities, and the local EMS companies validated our feelings of pride in what we accomplished that day. A medic from one of the mutual aid units that transported children from the crash wrote: ‘‘I would like to commend Liberty Hospital. That was the best mass casualty preparation I have ever seen in my 15 years of EMS.’’ The next time you have a disaster drill and are thinking, ‘‘Why are we doing this again?’’ remember that you do not plan disasters, you can only plan your response to them. Are you ready? REFERENCES 1. San Mateo County Health Services Agency Emergency Medical Services. HEICS: The Hospital Emergency Incident Command System. 3. San Mateo (CA): The Agency; 1998. 2. Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index, version 4: implementation handbook (AHRQ publication No. 05-0046-2). Rockville (MD): Agency for Healthcare Research and Quality; 2005.
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Pediatric Mass Casualty: Are You Ready?
Authors: Annette Behney, RN, BSN, CEN, Michele Breit, RN, BSN, CEN, and Cheryl Phillips, RN, CEN, Liberty, Mo
Annette Behney, Greater Kansas City Chapter ENA, is Clinical Educator, Liberty Hospital, Liberty, Mo. Michele Breit, Greater Kansas City Chapter ENA, is Clinical Resource Leader, Liberty Hospital, Liberty, Mo. Cheryl Phillips, Greater Kansas City Chapter ENA, is Emergency Department Clinical Director, Liberty Hospital, Liberty, Mo. For correspondence, write: Annette Behney, 20810 NE 176th St, Holt, MO 64048; E-mail: [email protected]. J Emerg Nurs 2006;32:241-5. 0099-1767/$32.00 Copyright n 2006 by the Emergency Nurses Association. doi: 10.1016/j.jen.2006.03.005
M
onday, May 9, 2005, 0830: ‘‘This is Liberty Dispatch. Activate your disaster plan. We have multiple injuries; school bus versus cars. . . .’’ This was the phone call that started it all. At 0831, Liberty Dispatch clarified the events unfolding at the scene of the school bus crash in Liberty, Missouri, a suburb of Kansas City (Figure 1). The bus had lost control going through an intersection. Two passenger vehicles also were involved. At least 40 to 50 children on the bus were injured. Ten or eleven children were triaged as critical, and there were 2 adult fatalities at the scene. At 0834, a second phone call from Liberty Dispatch notified the emergency department that Liberty Hospital could expect 2 children who were critically injured; EMS was going to ‘‘scoop and run’’ and arrive at the hospital almost immediately thereafter. A level I trauma team alert was initiated to mobilize the trauma team and trauma surgeon to the emergency department. By 0835, the emergency department was notified that one of the critical patients was now being actively resuscitated. The hospital Disaster Team Alert was initiated. Staff assignments
The ED clinical director assumed the role of incident commander, and the ED clinical resource leader (ie, assistant ED nurse manager) stepped in as treatment areas director. Two ED nurses were assigned to the incoming critical patients, and another was placed at the ambulance entrance to relay room assignments for incoming patients to the EMS crews. (Disaster triage had been done by EMS at the scene.)
June 2006
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CLINICAL/Behney, Breit, and Phillips
FIGURE 1
Police in Liberty, Missouri, investigate the crash of Bus 80. Between 40 and 50 children were riding the bus when it crashed; 29 passengers were transported to Liberty Hospital.
By 0837, non-ED nursing staff as well as ancillary staff members began to arrive in the emergency department and were assigned to assist specific ED staff members. The emergency department was expecting the 2 critical trauma patients with the possibility of receiving a third. To supplement our one pediatric crash cart, the Special Procedures Department and Pediatrics Unit were notified to send down their pediatric carts. Three critical care rooms were then established with pediatric crash carts, with a pharmacist available for each. In just 10 minutes we were organized and ready to provide life-saving care to multiple victims. At 0840, we received our first 2 patients. Utilizing the Incident Command System,1 each person knew his or her exact job assignment and was ready to
242
perform his or her required duties. At the time of the incident, the emergency department was staffed with 6 registered nurses (RNs), one graduate nurse on orientation, one RN who was new to the department and on orientation, one ED technician, and one secretary. The clinical director, clinical educator, and clinical resource leader were available to assist in the disaster response. One ED physician was on duty that morning, and one more physician was scheduled to arrive at 0900. Once the disaster alert was initiated, 13 staff physicians as well as 4 extra ED physicians responded to the emergency department. Trauma surgeons, pediatricians, and cardiologists were among the specialties responding. Most of the specialty physicians were in the hospital at the time
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June 2006
CLINICAL/Behney, Breit, and Phillips
FIGURE 2
Liberty Hospital, Liberty, Missouri, a 235-bed regional medical center and level II trauma center with a 28-bed emergency department.
of the disaster and responded to the emergency department according to protocol. Two of the ED physicians were called from our outlying clinics, one called from home after seeing the news, and one called after seeing the crash. One family practice physician took 2 RNs from the hospital education department with him to the school administration building, located between the crash site and the hospital. All patients who were designated as triage ‘‘green,’’ nonurgent, were taken there to be treated or referred as needed.
The emergency department was expecting the 2 critical trauma patients with the possibility of receiving a third. To supplement our one pediatric crash cart, the Special Procedures Department and Pediatrics Unit were notified to send down their pediatric carts. . . . In just 10 minutes we were organized and ready to provide life-saving care to multiple victims. Immediately after the crash, Liberty Public School District administrators assigned district counselors to the June 2006
32:3
emergency department to assist with patient and family support and to provide a primary source of identification for the children. Triage
A total of 29 patients were treated in the emergency department—27 children and 2 adults. Twenty-one of these patients arrived by ambulance within the first hour. Their Emergency Severity Index2 triage levels were as follows: 2 patients were triaged as level 1, 10 patients were triaged as level 2, 16 patients were assigned level 3 status, and one patient was triaged as level 4. There were no level 5 patients. (The patient’s primary nurse assigned the acuity level.) Injuries included spinal cord trauma, open and closed head trauma, and multiple orthopedic injuries. By the end of the day, 18 patients had been treated and released. Six patients were admitted to Liberty Hospital (Figure 2); one of these had to go to the operating room (OR). Five patients were transferred to Children’s Mercy Hospital in Kansas City, a tertiary pediatric hospital. Evaluation and lessons learned
Once everything was done and the debriefings were conducted, we analyzed our performance (Table 1). It seems JOURNAL OF EMERGENCY NURSING
243
CLINICAL/Behney, Breit, and Phillips
TABLE 1
Lessons learned and changes in procedure resulting from a pediatric mass casualty incident involving a school bus and two passenger vehicles . .
.
. .
.
Switchboard operators have laminated cards with clearly specified announcement criteria printed on them The treatment area box containing 2-way radios, vests, and other paperwork is kept in the emergency department for quick access Parents of accident victims receive identification bands when they are matched up with their child, which helps to control pedestrian traffic Victims’ clothing may be used to identify them when physical identification is difficult or impossible A social worker is assigned to a room or group of rooms to avoid having to run from one end of the emergency department to the other; a social worker also is assigned to the family area The family area is a short distance away from the emergency department, thus decreasing traffic congestion around the department
that no matter how many drills we hold, communication is the weakest link in the system. This real disaster was no exception. Issues with communication began with the first overhead announcement that was made by the switchboard staff. Because the nature of the emergency was misunderstood, the announcement ‘‘Code Yellow’’ (severe weather alert) was made overhead instead of ‘‘Activate your Disaster Plan,’’ the correct announcement. The incident commander notified the switchboard and the correct announcement was made, but it is easy to imagine the internal confusion this caused initially. To avoid this problem in the future, the operators now have laminated cards with clearly specified announcement criteria printed on them. The hospital’s disaster plan calls for patient care area boxes that contain 2-way radios, vests, and other paperwork to be distributed from Incident Command in administration when a disaster is called. Because of the initial incorrect ‘‘Code Yellow’’ announcement, the emergency department did not receive the radios and vests in a timely manner. We eventually received the equipment at about the time the patients began to arrive. As a result, the plan has been adjusted to keep the treatment area box in the emergency department so staff have quick access to the needed equipment and paperwork.
244
Identifying children and getting their parents to them quickly was another problem area. Parents, hearing about the disaster from radio, television, and the school representatives, began arriving in the waiting room almost as fast as the ambulances were arriving in the garage. Fortunately, the Liberty School District sent several counselors to the hospital to help support both students and parents. Also, they brought with them a list of names of the children who were supposed to be on that bus. As we identified a child, the child’s name was checked off the list. Liberty Hospital’s Social Service Department and Administration staff placed identification bands on parents when they were matched up with their child, which helped to control pedestrian traffic from the waiting room to the main emergency department.
It seems that no matter how many drills we hold, communication is the weakest link in the system. This real disaster was no exception. Identifying most of the children was not difficult because most of them were conscious and could give us their names and the names of their parents. Identification became more problematic in the case of the 2 patients with critical injuries who were unresponsive. One tentative identification came from one of the school counselors who thought she recognized the child. The principal from the school had the foresight to bring his personal digital assistant with him to the hospital; it was loaded with the pictures of all 400 children attending his school. We were able to put a name to the tentatively identified child using this picture identification, an identity that was confirmed when the parents arrived and identified the child’s wristwatch. Even with the personal digital assistant pictures, none of the school staff could recognize the second critically injured child. Unresponsive and intubated, the child had no identifying marks. As ED staff prepared to transfer the child to Children’s Mercy Hospital, we were concerned that the child would be transferred before being identified. Just as the helicopter was landing, the hospital chaplain reported that the child’s father might be in the waiting room. Now the dilemma became how to determine whether this child belonged to this father without bringing the man into the room. Because of the severity of the patient’s
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injuries, we believed that visual identification might be difficult. One nurse in the room had the idea of having the father identify the clothing that was cut off the patient. In this way we were able to identify the child and get the father to the child’s bedside before the transfer took place. As a result of this incident, the staff of our Social Service Department also made some changes to their portion of the disaster plan. Now a social worker is assigned to a room or group of rooms to avoid having to run from one end of the emergency department to the other. A social worker also will be assigned to the family area.
The principal from the school had the foresight to bring his personal digital assistant with him to the hospital; it was loaded with the pictures of all 400 children attending his school. Because of the initial confusion and mass of people, the family area for disasters has been moved from the ED waiting room to another waiting room a short distance away from the emergency department. One social worker will be assigned to oversee communications between the main emergency department and this family area. Hospital response to the disaster call was exceptional. Initially, enough licensed nursing staff were released from other areas of the hospital to allow for 2 nurses per room in the emergent care area (ie, one ED nurse and either an ICU or OR nurse with trauma experience). In the urgent care area, ED nurses acted as team leaders with assistance from pediatric and medical-surgical nurses. Each child had a staff person with him or her at all times. For example, one child had an open fracture of his tibia and fibula and had to go to the operating room. Fortunately, one of the extra nurses assigned to this child was an OR nurse. She was able to reassure the patient and the family that she would be with the child the entire time in the OR, and the family later said that this statement gave them an unbelievable sense of comfort as they waited. Children’s Mercy Hospital was an invaluable resource, putting their transport teams in the air to Liberty Hospital as soon as they heard of the crash. Both critical patients were stabilized and transported within 1 hour. Children’s Mercy Hospital also dispatched one of their
June 2006
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ground units to stay at Liberty Hospital until all the patients from the crash were stabilized and all potential transfers were completed. The teamwork shown by everyone in the hospital and in the community was something that can only be appreciated when looking back on a disaster of this caliber. Nurses, physicians, ancillary staff, EMS, and school district personnel all came together to care for these children and their families. The letters and phone calls of support and praise that we received from the community, other facilities, and the local EMS companies validated our feelings of pride in what we accomplished that day. A medic from one of the mutual aid units that transported children from the crash wrote: ‘‘I would like to commend Liberty Hospital. That was the best mass casualty preparation I have ever seen in my 15 years of EMS.’’ The next time you have a disaster drill and are thinking, ‘‘Why are we doing this again?’’ remember that you do not plan disasters, you can only plan your response to them. Are you ready? REFERENCES 1. San Mateo County Health Services Agency Emergency Medical Services. HEICS: The Hospital Emergency Incident Command System. 3. San Mateo (CA): The Agency; 1998. 2. Gilboy N, Tanabe P, Travers DA, Rosenau AM, Eitel DR. Emergency Severity Index, version 4: implementation handbook (AHRQ publication No. 05-0046-2). Rockville (MD): Agency for Healthcare Research and Quality; 2005.
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