> **Managing Surge Needs for Injuries:**
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Emergency Medical Service Response**
>
> **PURPOSE**
>
> To provide guidance for local emergency medical service (EMS) response
> and to operationalize additional EMS-related resources needed in a
> community within four hours of an explosion. These resources are
> intended to treat 300 injured patients for up to 72
> hours.![](media/image2.jpeg){width="1.29375in"
> height="0.9881944444444445in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> To mobilize the appropriate number and type of EMS resources to
> adequately evaluate injuries, initiate triage, begin transporting 300
> injured patients, and to establish ongoing EMS operations for up to 72
> hours.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **REQUIRED RESOURCES**
>
> 1\. Personnel must be:

-   Appropriately equipped and knowledgeable about chemical, biological,
    radiological, nuclear, and explosives (CBRNE) detection, personal
    protection, and decontamination.

-   Educated in the care of blast-related injuries for adult and
    pediatric patients.

-   Prepared to institute triage.

-   Prepared to institute and participate in unified incident command.

> 2\. A communications system that is interoperable with public safety
> disciplines (fire, law enforcement, EMS, and emergency management) and
> with receiving hospitals and local public health officials.
>
> 3\. Rapid access to sufficient ambulance resources to transport
> critically injured patients.
>
> 4\. Rapid access to sufficient alternative resources (e.g., buses) to
> transport noncritical, injured persons.
>
> 5\. Have the necessary material and the capability to detect CBRNE
> agents to assist with decontamination plans.
>
> 6\. Decontamination equipment for ambulatory and non-ambulatory
> patients; equipment should be rapidly deployable to the explosion
> site, a secondary treatment site, or a hospital.
>
> 7\. Determine/implement secondary triage and treatment sites within
> the community.
>
> **ASSUMPTIONS**
>
> 1\. EMS systems in the United States are highly variable, with a wide
> range of available resources, experience, and financing.
>
> 2\. A functional EMS system is a critical component for planning the
> prehospital management of injured bombing victims.
>
> **ACTION STEPS**
>
> 1\. Education:

-   Train responding EMS personnel about how to treat primary,
    secondary, tertiary, and quaternary blast-related injuries. For
    guidance, go to www.bt.cdc.gov/masstrauma/explosions.asp.

-   Train EMS personnel about National Incident Management System (NIMS)
    compliance; Incident Command System (ICS Homeland Security
    Presidential Directive 5); and the importance of command, staging,
    triage, and treating initial casualties (regardless of rank of the
    provider) should be emphasized.

-   Train EMS personnel about the use of personnel protective equipment
    (PPE) and the risks of transporting potentially contaminated
    patients. The relative importance of gross vs. technical
    decontamination should be reviewed.

-   Train EMS officials in advanced ICS (ICS 700 or equivalent).

> 2\. Local policy and planning:\
> Fire, EMS, law enforcement, emergency management, hospitals, and
> public health should collaborate to develop and complete written plans
> within six months, as listed below. Within one year, other agencies
> listed in these plans (including mutual aid agencies, etc.) must be
> included in ongoing planning and evaluation.

-   Plan for mobilizing 50 ambulances within 10 minutes after the blast.
    At least 75% of these resources should arrive at staging areas in
    the first hour with all arriving in the first 90 minutes. This
    should be accomplished using 9-1-1 EMS resources, mutual aid
    agreements with other EMS providers, or mutual aid agreements with
    nonemergency transport providers.

-   Plan describing each agency's role in the command structure. This
    should include how critical functions of command, staging, triage,
    and treatment will be accomplished in the first 10 minutes of a
    response; how additional ICS elements will be filled over the first
    hour; and how the ICS structure will be formally filled by officials
    trained in advanced ICS (ICS-700 or equivalent) by the end of the
    first hour.

-   Plan describing how alternative transport for 200 ambulatory
    patients will be initiated in the first 10 minutes after an
    explosion.

-   Plan describing the details of interdisciplinary communications
    (primary and alternatives). Representatives from fire prevention,
    EMS, law enforcement, emergency management, hospitals, and public
    health must be included in this plan.

-   Plan for decontaminating and protecting personnel that addresses the
    following:

    -   Agency responsible for scene assessment and determining what (if
        any) decontamination measures are required.

    -   Realistic assessment of the time required to deploy
        decontamination resources for ambulatory and non-ambulatory
        patients.

    -   Deployment of decontamination resources to event site, secondary
        triage sites, or receiving hospitals.

    -   Transport of patients after gross decontamination (technical
        decontamination of patients before transport; appropriate
        personal protective equipment, or PPE; and appropriately
        equipped destination choices).

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-   Plan to establish secondary triage points for ambulatory patients
    (ideally, within the first hour after the explosion). This should
    address the following:

    -   How sites can be activated and staffed with at least one
        transport ambulance, sufficient law enforcement personnel for
        security, and adequate support staff to record arrivals.

    -   How gross and technical decontamination could be accomplished at
        affected site(s).

    -   How medical care at secondary triage sites could be converted to
        treatment areas (e.g., provision of medical supplies, additional
        medical personnel, and other logistical concerns).

-   Plan to establish criteria for determination of death at the scene,
    particularly in a mass casualty situation, and appropriately manage
    the deceased.

> **EVALUATION**
>
> 1\. Plan and conduct a community-wide drill. Afterwards, evaluate it
> by assessing overall operations and EMS resources such as personnel,
> ambulances, and PPE. Evaluate compliance with NIMS.
>
> 2\. Assess and refine plan.
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Emergency Department Response**
>
> **PURPOSE**
>
> To activate additional emergency department resources needed within
> four hours of an explosion. These resources should treat 300 injured
> patients for up to 72
> hours.![](media/image2.jpeg){width="1.1555555555555554in"
> height="0.8902777777777777in"}
>
> **BACKGROUND**
>
> The experiences of the Madrid terrorist bombings were used as a model
> to help develop solutions for managing rapid surge problems during a
> mass casualty event.
>
> **GOAL**
>
> To establish policies, procedures, didactic training, and drills to
> improve institutional preparedness for treating 300 injured patients
> for up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> There should be adequate medical, nursing, and support staff to
> provide initial triage, and to evaluate and stabilize 300 persons.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**
>
> 1\. Developed packets for each patient containing disaster bands
> (those from blood banks
>
> work best), manual charting forms, and manual lab and radiology order
> forms. These
>
> packets should be prepared in advance and stored in the ED.
>
> 2\. Established procedures for obtaining additional personnel,
> equipment, supplies and
>
> beds; establish a mechanism for notifying and activating backup
> personnel.
>
> 3\. Established procedures for triage, patient emergency
> identification of patients
>
> and discharge, and quick documentation.
>
> 4\. Established temporary disaster log to document basic information.
>
> **ACTION STEPS**
>
> 1\. Implement and drill a hospital emergency incident command system
> (such as Hospital Incident Command System or "HICS"); include clinical
> care providers in the training and drill.
>
> If hospital personnel (e.g., practitioners, administrators, nurses)
> have not trained or drilled in a hospital incident command system,
> learned about the National Incident Management System (NIMS), or do
> not understand the function of a Hospital Incident Command Center,
> this information should be included in training sessions.
>
> 2\. Instruct clinical staff, especially surgeons and emergency
> physicians, about the unique aspects of blast-related injuries and
> care following an attack with a radiation dispersal device (RDD).
>
> 3\. Establish an institutional lockdown process and drill on a regular
> basis; include radiation detection and decontamination of arriving
> patients.
>
> 4\. Update the institutional call-down list and perform a functional
> call-down exercise.
>
> 5\. Identify potential institutional surge staffing from employees
> with clinical training, but not currently tasked with clinical jobs.
>
> 6\. Identify patient care supplies for a surge situation, such as
> additional IV equipment, bandages/dressings, gowns, gloves, masks,
> other operating room supplies, etc.
>
> 7\. Develop a regional Unified Command Structure that includes local
> emergency management and area hospitals. This should be achieved under
> the guidance and leadership of the local emergency managers.
>
> 8\. Identify non-patient care areas in the institution that could be
> converted to patient care to expand bed surge capacity.
>
> 9\. Establish and drill a procedure for early patient discharge to
> increase bed capacity. This procedure should include evaluation of ICU
> patients for potential movement to a non-ICU bed and evaluation of all
> patients for potential early discharge or transfer to an alternative
> care site (internal or external to the institution).
>
> **EVALUATION**
>
> When appropriate, evaluation drills have been incorporated into the
> Action Steps listed above. The institutional disaster preparedness
> plan should be updated based on each drill experience.
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Operating Room, Post-Anesthesia Care Unit (PACU), and Intensive Care
> Unit Response**

> **PURPOSE**
>
> To mobilize and assign operating rooms and related assets for life-
> and limb-saving surgical care to the most critically injured of 300
> patients from explosions (care extends to patients from the community
> with acute surgical illness for up to 72 hours after a bombing).
> ![](media/image2.jpeg){width="1.1513888888888888in"
> height="0.8805555555555555in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> Within two hours of a blast event, establish incident command for the
> operating rooms and surgical support areas for up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> Resources needed for communicating within the organization and with
> the community (e.g., satellite phone, walkie-talkie).
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**
>
> 1\. Operating room (OR) assets are a critical component of surge
> capacity after an explosion and must be mobilized quickly.
>
> 2\. The OR capacity of any institution or community (i.e., number of
> operating rooms) is fixed because of structural requirements.
>
> 3\. One or more surgeons, anesthesiologists, and critical care
> specialists will be in the hospital or available immediately after an
> event.
>
> 4\. Other surgeons, anesthesiologists, and critical care specialists
> can be available within two hours of an event to provide direct
> patient care in the ORs and related areas.
>
> 5\. The ORs, post-anesthesia care units (PACU), and intensive care
> units will already be in use.
>
> 6\. Casualties of the blast and patients already in the hospital
> system or in other treatment
>
> centers in the community will occupy one or more of these three areas
> within the next 72

hours.

> 7\. If these areas are not made available in a timely manner, patients
> will suffer greater harm. .
>
> 8\. Some patients could be moved to different care sites.
>
> 9\. Federal resources cannot be expected to arrive sooner than 72
> hours from the time of an explosion.
>
> **ACTION STEPS**
>
> The near-term (six months) solutions listed below include estimated
> hours for each task.
>
> 1\. Identify medical leadership within surgery and anesthesiology for
> disaster planning.

-   Leadership should collaborate in the design, implementation, and
    refinement of an incident command system for an operating room.
    Initially, leadership in surgery and anesthesiology should meet with
    representatives from critical care, emergency medicine,
    administration, and others involved with the institution's disaster
    planning. These discussions will be facilitated by appointing a
    hospital disaster committee.

> 2\. Select individuals for incident command roles.

-   Specify the authority, processes, and responsibilities of the OR
    incident command and a call schedule identifying individuals
    available to fill their roles 24 hours a day, beginning within two
    hours of the event, and extending for 72 hours.

-   Although individuals from several disciplines and departments in the
    operating room and related areas may assist the incident command,
    final decision-making authority should rest with one person---an
    "Operating Room Czar." The OR Czar would have authority to cancel
    scheduled OR cases, rearrange OR schedules, identify patients that
    could be transferred, call in and deploy OR teams, and prioritize
    patients for beds in the OR, PACU, and ICUs. The OR Czar would
    report to hospital incident command.

-   Candidates for this role should be able to assess the medical needs
    of a variety of patients requiring OR services. They must be
    physicians, and would most likely be surgeons. An individual serving
    in this role should not have primary patient care responsibility at
    the same time (i.e., be part of a surgical team).

-   Communication systems linking surgery, nursing, anesthesiology,
    critical care, emergency department, and hospital administration
    should be specified.

-   The OR incident command system must account for personnel
    availability at different times of the day and week and provide for
    transfer of incident command responsibility as the incident evolves
    over 72 hours.

-   The circumstances under which the OR incident command begins and
    ends should be specified.

-   Methods for data collection, testing, monitoring, and improving the
    system should be specified.

> 3\. Assure that individuals who might assume an incident command role
> are knowledgeable about incident command, operations of other hospital
> components, and community disaster response.
>
> This step assures that eligible candidates for OR incident command
> receive appropriate training. Requirements and standards for such
> training should be specified.
>
> 4\. Identify lines of communication and interactions with other
> components of the community-wide disaster plan and regional trauma
> system.

**EVALUATION**

> 1\. Participate in community-wide drills and evaluate performance of
> OR incident command.
>
> Determine when individuals should be present onsite. Review triage
> decisions, quality, quantity, and appropriateness of information
> obtained from and given to others, including hospital incident
> command, emergency medicine, and other community assets.
>
> 2\. Refine and conduct further planning based on drill experience.
>
> **Managing Surge Needs for Injuries:**
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Radiology Response**
>
> **PURPOSE**
>
> Within four hours of an explosion, operationalize radiology support
> for the initial treatment of 300 injured patients and for ongoing care
> up to 72 hours.![](media/image2.jpeg){width="1.05in"
> height="0.8083333333333333in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> To establish policies, procedures, and drills to improve radiological
> preparedness for treating 300 patients injured from an explosion for
> up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> There must be enough radiology personnel (radiologists, technicians,
> and support staff), equipment, and supplies to care for 300 injured
> patients.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**

1.  Radiology services will be a critical component of the hospital
    response to a bombing.

2.  Many patients over a relatively short time period requiring
    radiology may lead to slow-downs and bottle-necks.

> **ACTION STEPS**
>
> The near-term solutions listed below include estimated number of hours
> needed to perform each task.
>
> 1\. Develop a management plan and call list for the radiology
> department to use during a mass casualty event. Drill the plan,
> involving radiologists for immediate ("wet") readings of plain films
> and special studies. This will assist in rapid evaluation and
> treatment of patients. The plan should also optimize and streamline
> radiology study protocols for use during a mass casualty event.
>
> Enhanced radiology patient throughput will be essential in the initial
> evaluation and treatment of blast-injuries. Each radiology department
> must develop a plan to ensure rapid turnaround of patient studies and
> their results.
>
> 2\. When disaster patients arrive, a radiology ultrasound technician
> should be available in the emergency department to support the
> performance of an immediate FAST (Focused Abdominal Sonography for
> Trauma) exam. If this is not possible, the emergency physicians and
> trauma surgeons should be trained to conduct one.
>
> 3\. Conduct an imaging equipment survey; evaluate the status of the
> equipment for multiple traumas, making sure there are adequate amounts
> of portable equipment available and update if needed.
>
> Radiology equipment is expensive and usually requires planning in
> advance for acquisition and installation. However, by evaluating how
> available equipment could be put to maximum use during a mass casualty
> event can improve patient throughput.
>
> 4\. Establish a protocol for augmenting patient movement and
> monitoring in the radiology department. Afterwards, review the
> availability of patient monitoring personnel and equipment to enhance
> departmental throughput, especially for studies such as CT scans.
>
> **EVALUATION**
>
> Where appropriate, evaluation drills have been incorporated into the
> Action Steps listed above. The institutional disaster preparedness
> plan should be updated based on each drill experience.
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Blood Bank Response**
>
> **PURPOSE**
>
> Within four hours of an event, provide blood products for up to 300
> injured patients and sustain support for up to 72 hours.
>
> ![](media/image2.jpeg){width="1.05in" height="0.8083333333333333in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> During the first four hours of a disaster, ensure that that
> appropriate blood products can be located, processed, and quickly
> administered to at least 300 patients requiring transfusions. Identify
> additional needs so that blood products can be collected, processed,
> and administered for up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> **•** AABB documents
>
> • Disaster response plans for hospital and blood collection centers
>
> • Laboratory personnel to collect, process, and distribute products
>
> • Transportation resources, diesel and unleaded fuel, and storage
> equipment (e.g., dry ice)
>
> • Transfusion supplies
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**

-   The most difficult problems involve disruption or interference of
    the blood supply system

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-   Historically, blood supply needs during disaster response have been
    met with the quantity of blood products available at that time.

-   Facilities currently maintain about a three-day supply of blood
    products---which may need to be expanded to a seven-day supply.

-   Typically, fewer casualties require blood products than the total
    number of victims.

-   Local communities have limited sources of blood products.

-   If faced with a surge in demand, blood products will likely be
    transported from blood centers outside the local area.

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-   After a disaster, the public usually responds by volunteering to
    donate larger quantities of blood products than are needed.

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-   An influx of blood donors could tax collecting and processing
    efforts.

-   When resources (personnel, equipment, and supplies) are
    unnecessarily applied to collecting and processing unneeded
    products, these resources cannot process and distributed available
    and urgently needed products to those in urgent need.

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-   The media must continuously provide the community with reliable
    information about the need and supply of blood products.

-   There are limited personnel with the training, education, and skills
    to process and administer blood products within treating facilities.

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-   Additional qualified laboratory personnel may be needed to process
    requests for blood products.

-   Additional nursing personnel may be needed to administer blood
    products.

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-   There may be limited methods of transporting or transferring blood
    products from supplier to destination during a disaster.

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-   Commercial transport (air and ground) may be limited.

-   Blood needs are considered by federal, state, and local governments
    to be a critical element of the public health infrastructure in
    times of emergency.

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-   The AABB Interorganizational Task Force on Domestic Disasters and
    Acts of Terrorism, formed in January 2002, has developed a process
    to educate the community about donations and how to collect,
    process, and move blood products at the time of a disaster.

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-   This multi-organizational task force includes federal and national
    organizations.

-   Published references include a *Disaster Operations Handbook* and a
    hospital supplement that addresses these issues. They include a flow
    chart outlining the process for involving the AABB and appropriate
    national and federal organizations that provide blood products
    during a disaster.

> **ACTION STEPS**

-   Work with AABB to distribute documents to hospitals and blood
    collection organizations/facilities.

-   Identify resources (personnel, equipment, supplies) to meet local
    needs for collection, processing, distribution, and transfusion of
    blood products. This effort must include local media to provide
    consistent messages to the community about blood products, supply,
    and needs. (Note: Individual hospitals and collection organizations
    incorporate the AABB process into their local disaster response
    plans.)

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-   Work with other organizations and government agencies (local,
    regional, state, federal) to make sure blood products are considered
    critical elements of the public health infrastructure in the event
    of a disaster/emergency.

> **EVALUATION**

-   Ensure that survey hospitals and collection organizations
    incorporate AABB processes into local disaster response plans after
    4 to 6 months.

-   Request that hospitals and collection organizations participate in a
    local or regional exercise requiring administration of blood
    products within four hours of an event for up to 72 hours.

    -   Include activation and response of the AABB system, and local,
        regional, and state

> resources in the exercise.
>
> Take this extra page out!
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Hospitalists' Response**
>
> **PURPOSE**
>
> Within four hours, leverage the knowledge and skills of hospitalists
> to treat 300 patients injured from explosions and to sustain care for
> 72 hours.![](media/image2.jpeg){width="1.05in"
> height="0.8083333333333333in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> Within four hours of an explosion, deploy staff and functioning beds
> to treat at least 300 injured patients who require acute inpatient and
> intensive care for 72 hours.
>
> The boldfaced terms have the following meaning:

-   **deploy** -- represents the sum of the following:

    -   redefine (standards of care)

    -   reallocate (on-site staff)

    -   recruit (off-site staff)

-   **functioning** - represents the sum of the following:

    -   supplied (items necessary for care are available)

    -   serviced (patients with assigned caregivers, available clinical
        support services such as laboratory, radiology, and pharmacy)

    -   stepped-down (patients capable of being transferred from ICU but
        in need of close monitoring)

> **RESOURCES REQUIRED**
>
> 1\. The general public's and health care communities' education and
> acceptance of the concept and need for altered standards of care
> during a large-scale disaster response.

2.  Adequate staffing to support response efforts (physicians, nurses,
    technicians, support staff, supplies, and equipment).

> 3\. Mechanism to implement an altered standard of care. This should
> include ways to rapidly "step down" suitable patients (e.g., from ICU
> to floor and from floor to elsewhere)
>
> 4\. Mechanism within hospitals that place hospitalists into
> "real-time" roles that enable them to allocate and ration resources
> and to serve as advisors to and outreach arms of Incident Command.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**

1.  Effective clinical response to a surge of patients from a bombing
    event will require coordination and cooperation among multiple
    medical specialties.

2.  Hospitalists will be an integral component in identifying available
    hospital beds, discharging patients, caring for patients, and
    providing additional support during the response.

> **ACTION STEPS**
>
> 1\. Develop and disseminate an alternate standard-of-care policy for
> use during a disaster situation. Include in-hospital triage for
> alternate levels of care, early transfer to lower levels of care, and
> early discharge. Consider using the Agency for Healthcare Research and
> Quality document as a reference.
>
> Convene ethics panel as necessary. Enlist Society of Hospital Medicine
> (SHM) Ethics Committee as needed.
>
> 2\. Educate appropriate staff about the alternate standard care
> policy.
>
> 3\. Ensure that hospitalists are incorporated into the disaster
> response of each hospital to address issues related to effective
> preparedness and response. the issues already mentioned
>
> **EVALUATION**

1.  Conduct an exercise that implements the alternate standard of care
    policy and uses hospitals as designated in the disaster plan.

2.  Critique the exercise against the response plan; emphasize issues
    about alternate standards of care and performance of hospitalists.

3.  Revise alternate standard of care policy and disaster plan based on
    the outcome of the exercise.

> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Administration Response**
>
> ![](media/image1.jpeg){width="1.125in" height="1.0194444444444444in"}
>
> **PURPOSE** ![](media/image2.jpeg){width="1.05in"
> height="0.8083333333333333in"}
>
> Within four hours, operationalize additional administrative-related
> resources to treat 300 patients injured from an explosion and sustain
> care for 72 hours.
>
> **BACKGROUND**
>
> The experiences of the Madrid terrorist bombings were used as a model
> to help develop solutions for managing rapid surge problems during a
> mass casualty event.
>
> **GOAL**
>
> To organize and support response to influx of 300 patients injured
> from an explosion for a 72-hour period.
>
> **RESOURCES REQUIRED**
>
> The workload associated with an administrative response will require
> access to multiple facilities to support the needs of patients, staff,
> and the general public. Administrators will manage communications,
> acquire political support, work with and respond to media, handle
> public inquiries, manage internal systems and departments.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of the affected communities may vary.*
>
> **ASSUMPTIONS**

-   Health care systems and hospitals should function as an integrated
    system for the best use of resources.

-   A medical response to a mass casualty event must be comprehensive,
    community based, and coordinated.

-   Legal and regulatory issues need to be included in the hospital
    emergency preparedness plan: Emergency Medical Treatment and Active
    Labor Act (EMTALA), Health Insurance Portability and Accountability
    Act (HIPAA), Federal Volunteer Protection Act, Good Samaritan Laws,
    labor laws, OSHA, and facility codes.

-   Activating the community Emergency Operations Center (EOC) and
    hospital's command center are critical to success.

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-   Communication among hospitals, health systems, EMS, EOC, and public
    health cannot be lost or interrupted.

-   Hospitals use the incident command system and have staff who can
    implement it.

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-   Hospitals, long-term care facilities, offices, and clinics have
    Memoranda of Understanding (MOU) to share resources.

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```
-   The EOC includes health care representatives to coordinate medical
    resources.

-   Patients who do not need acute care services should be treated at
    alternate care facilities.

-   The institution must:

    -   Establish a response plan based on the Incident Management
        System (e.g., Hospital Incident Command System (HICS) model).

    -   Include clinics and offices with emergency preparedness plans
        consistent with the hospital.

    -   Include medical, nursing, dental, and pharmacy staff;
        respiratory students; and house staff and fellows, if available.

    -   Determine the location of the command center (not in the ED) and
        backup sites.

    -   Establish written plans to secure the perimeter of the facility
        and access points.

    -   Identify a spokesperson for the hospital (public information
        officer).

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```
-   The preparedness plan should include mechanisms for modifying
    admission, discharge, and procedure schedules.

    -   Defer admissions that are not emergent (develop criteria and put
        into policy).

    -   Notify operating room manager to defer or cancel inpatient and
        outpatient non-emergency surgeries.

        -   Incorporate intensivist, hospitalist, or Chief of Staff's
            designee into plan for discharging patients during emergency
            operations. (See template on Hospitalist Response) Set up
            MOUs with hospitals.

> **Additional staffing issues to consider:**

-   Have available staff address the mental health of victims, families,
    and staff (i.e., psychiatrists, psychologists, licensed mental
    health practitioners, and volunteers).

-   Employ workers trained by the American Red Cross, especially those
    who can provide mental health services.

-   Provide child care services so that staff are free to attend to
    patients.

-   Compile a list of qualified translators for the disaster.

> **ACTION STEPS**
>
> The solutions listed below include estimated hours for each task.
>
> **1. Control of the External Environment**
>
> The external environment will change rapidly during a large-scale,
> mass casualty event. The hospital must be secured and campus traffic
> must be controlled. Such control of the external environment includes
> clearing beds to accommodate incoming casualties, redirecting
> non-emergency patients to other resources, and managing the comings
> and goings of staff. Managing media relations can be challenging when
> trying to provide safe and effective care. The institution's security
> and public affairs offices must work together and be in place before
> the media arrives.
>
> **2. Activation of Hospital Incident Command System (HICS)**
>
> HICS, a widely used emergency management system, is known for
> providing a chain of command with the ability to effectively manage an
> incident, provide accountability of position functions, allow for a
> flexible response to specific emergencies, improve documentation of
> facility actions, provide a common language to facilitate outside
> assistance, and develop prioritized response checklists for senior
> leadership. Identifying the appropriate people to make decisions is
> pivotal in a fast-paced disaster, such as in the Madrid bombings.
> There is little time for meetings and discussion about the appropriate
> use of support functions and personnel. Staff should be trained and
> drilled regularly to ingrain the difference between incident structure
> and normal operations.
>
> **3. Logistics and Supplies**
>
> Coordinating with key suppliers and maintaining current inventories
> throughout the health system will make stocking efforts easier. When
> resources are limited, providers must be prepared to respond to care
> needs with whatever is available.
>
> Logistics include but are not limited to patient transportation. For
> example, housing evacuees and the walking wounded and their families
> is a function of the emergency management program. Knowing the
> locations of designated shelters throughout the vicinity and
> transportation resources for low-acuity patients and their families
> will hasten discharge planning and patient flow in acute care
> facilities.
>
> **4. Alternate Care Sites**
>
> A hospital's ability to mobilize emergency care units and to extend
> care to the city's walking wounded adds to its effectiveness. Triage
> systems are used to prioritize patients so that low-priority patients
> can be directed from the main hospital, allowing ambulances and
> hospital staff to focus on high-priority trauma patients in need of
> medical assistance. Alternate sites, like the ones used during
> Hurricanes Katrina and Rita, allow large health systems to facilitate
> triage and direct patients to appropriate sources of care.
>
> **5. Credentialing**
>
> The Joint Commission on the Accreditation of Healthcare Organizations
> (JCAHO) emergency credentialing system must be tested within an
> organization before it is really needed. State Emergency Systems for
> Advance Registration of Volunteer Health Professionals (ESAR--VHP)
> reflect JCAHO requirements and provide a standardized set of verified
> credentials for volunteers who may be called to assist hospitals
> during emergency situations.
>
> **6. Patient Tracking**
>
> Successful patient tracking begins as soon as they enter the health
> care system. When more time is spent identifying and tracking
> patients, the prospect of reimbursement for related costs is better.
> The ability to track patients, identify their supply consumption, and
> monitor bed use enables senior management to proactively meet the
> needs of health care providers on the frontline. Patient tracking
> systems must be flexible enough to accommodate such needs.
>
> **7. Identify gaps**

-   Ensure coordination between on-scene management and available
    community resources so that specific facilities are not overloaded.

-   Communication among facilities at clinical and administrative levels
    is essential.

> **8. Identify additional sources of community support**
>
> Additional sources of support can include local shelters,
> locally-developed stockpiles,
>
> community pharmacies, drug wholesalers/warehouses, public health
> authorities, etc. Access
>
> to these resources will be important if the event displaces many
> residents due to
>
> contamination, property damage, utility failure, etc.
>
> **9. Establish communication and relationships**

-   Develop communications with local emergency management.

-   Establish communications with local, regional, and state hospitals.

10. **Exercise plans**

-   Establish regular schedules to drill every aspect of a response to
    ensure that all staff understands their roles.

-   Evaluate the drills, and modify plans based on after-action reports.

-   Drill the new plan.

> **EVALUATION**
>
> 1\. Plan, conduct, and evaluate facility-wide drills. The evaluation
> should identify stressors on clinical and administrative activities.
>
> 2\. Plan, conduct, and evaluate community-wide drills. The evaluation
> should identify stressors on clinical and administrative activities.
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Drugs and Pharmaceutical Supplies**
>
> **PURPOSE**
>
> Within four hours of an explosion, acquire the additional drugs and
> pharmaceutical supplies needed to treat 300 injured patients for up to
> 72 hours.![](media/image2.jpeg){width="1.05in"
> height="0.8083333333333333in"}
>
> **BACKGROUND**
>
> The Madrid terrorist bombings were used as a model to help develop
> solutions for managing rapid surge problems during a mass casualty
> event.
>
> **GOAL**
>
> Within four hours of an explosion, acquire appropriate and adequate
> drugs to treat 300 injured patients for up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> The list below includes therapeutic categories, administration route,
> and recommended drug or pharmaceutical supply. For simplicity,
> purchase and stockpile a single or few drugs from each therapeutic
> category. Care providers may have little or no prior experience with a
> drug.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of the affected communities may vary.*

-   Analgesics

> p.o., hydrocodone/acetaminophen (one strength---5/500); IV, morphine

-   Anxiolytics

> p.o. and IV, lorazepam

-   Antipsychotics

> p.o and IV, haloperidol

-   Antibiotics, broad spectrum with low allergy risk

> p.o. and IV, ciprofloxacin

-   Intravenous fluids

> saline and D5W

-   Blood (see Blood Bank Response)

-   Drugs for intubation

> IV etomidate, succinylcholine, and vecuronium

-   Topical burn care agents

> Silver sulfadiazine (Silvadene)
>
> Bacitracin

-   ENT meds for TM perforation

> Cortisporin otic suspension

-   Ocular meds

> Proparacaine
>
> Erythromycin ophthalmic ointment

-   Tetanus toxoid

> **ASSUMPTIONS**
>
> 1\. There may be a demand for certain pharmaceuticals following a
> bombing event with multiple casualties.
>
> **ACTION STEPS**
>
> 1\. Identify community medical leadership and a committee to address
> near-term solutions.
>
> Discussion and decision by EMS, emergency medicine, trauma surgery,
> hospital pharmacy (PharmD), blood bank, hospital leadership, hospital
> nursing, emergency management, public health, and law enforcement
> about transport of pharmaceuticals.
>
> 2\. Inventory drugs and quantities available at points of care
> (prehospital and hospital).
>
> Assuming 4 hospitals and 10 ambulances, committee should delegate a
> point person to contact hospital pharmacists and EMS leadership and
> inquire about inventory.
>
> 3\. Identify gaps between drugs on hand and goal.
>
> 4\. Identify potential sources of drugs in the community besides
> prehospital and hospital supplies (e.g., locally developed stockpiles,
> community pharmacies, drug wholesalers/warehouses, physicians' offices
> via medical society). Identifying additional sources should include
> daily, routine needs of the community.
>
> 5\. Develop relationships with leadership from additional sources; ask
> for "snapshot" inventory of drugs, and establish "mutual aid"
> agreements to rapidly acquire drugs.
>
> 6\. Assess drugs available in the community by adding prehospital +
> hospital + community pharmacies + drug wholesalers/warehouses +
> physicians' offices (through medical society).
>
> 7\. If the drug supply is low, develop a plan for intercommunity
> mutual aid or rationing.
>
> 8\. Develop a plan to rapidly acquire drugs from additional sources
> and deliver products to points of care. This plan should include
> communications between point(s) of care and additional sources, mutual
> aid agreements with additional community sources, transport of drugs,
> and reimbursement.
>
> **EVALUATION**
>
> 1\. Plan, conduct, and evaluate a community-wide drill. The evaluation
> should include measuring quantity and names of drugs and
> pharmaceutical supplies acquired, distributed and administered; times
> when drill started, time drugs were acquired from distribution points,
> duration of transport, time of distribution to points of care, and
> time of administration to patients.
>
> 2\. Refine plan based on drill experience.
>
> ![](media/image1.jpeg){width="1.125in"
> height="1.0194444444444444in"}**Managing Surge Needs for Injuries:**
>
> **Nursing Care Response**
>
> **PURPOSE**
>
> To operationalize additional nursing resources in a community within
> four hours of a terrorist bomb explosion and to treat 300 injured
> patients for up to 72 hours.
> ![](media/image2.jpeg){width="1.051388888888889in"
> height="0.8069444444444445in"}
>
> **BACKGROUND**
>
> The experiences of the Madrid terrorist bombings were used as a model
> to help develop solutions for managing rapid surge problems during a
> mass casualty event.
>
> **GOAL**
>
> Within four hours of an explosion, mobilize the appropriate number of
> facilities and beds, nursing staff, and resources needed to treat 300
> injured patients for up to 72 hours.
>
> **RESOURCES REQUIRED**
>
> The workload will require adequate staffing and backup personnel for
> the initial response, and mechanisms for notification and activation,
> credentialing volunteers, and for ensuring the safety and welfare of
> responders.
>
> *This document is a resource guide. Local needs, preferences, and
> capabilities of affected communities may vary.*
>
> **ASSUMPTIONS**

1.  Nursing personnel are essential for an effective response to a
    bombing, including patient care, patient tracking and information
    management, and logistical support.

> **ACTION STEPS**
>
> The solutions listed below involve providing clinical nursing for 300
> patients over a 72-hour period.

-   Make all physical beds available for care, including those in
    storage and those that can be rented on short notice. Place cots in
    rooms or hallways.

-   Develop criteria and policy to discharge patients who can go home or
    be quickly transferred to long-term care.

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-   Make sure each department has a procedure for mass casualty care.
    These procedures need to be reviewed and be accessible to the
    command center.

-   Departments need to determine procedures for what will be done
    immediately (0--120 minutes), intermediately (2--4 hours) and long
    term (4--24 hours).

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-   Notify all departments of incident and of emergency plan activation.

-   Request that policies be approved by a centralized committee that
    oversees the emergency operations and plan.

-   Update call lists. Every department should have a current list that
    identifies staff by their proximity to the hospital.

-   Make staff aware of where to park, where to report, how to respond,
    etc.

-   Maintain a centralized data base with staff competency skills like
    ACLS (Advanced Cardiac Life Support®), TNCC (Trauma Nurse Core
    Course), ENPC (Emergency Nurse Pediatric Course), and PALS. Identify
    who is competent to care for critically ill patients.

-   Add on-call staff to the disaster call list.

-   Maintain names of retired or unemployed staff in a hospital or
    health system database.

-   Include Medical Reserve Corp information/lists in the emergency
    response plan.

-   Prepare badges in advance for credentialed professional staff.

-   Credential volunteers in advance. Community agencies typically
    manage volunteers.

-   Set up a system so that the hospital can verify credentials (i.e.,
    State ESAR--VHP).

-   Ensure that staff is assigned to tasks with which they are most
    familiar and perform daily; do not change routine procedures.

> **EVALUATION**
>
> Hospitals/health systems should plan and execute a drill with EMS at
> least once a year. The drill should include objectives to accommodate
> 300 patients with beds, staffing, and resources.
>
> Critique the completed drill, write a report, and share the findings
> with participants. Hospital administrators should analyze the report
> and make recommendations to the disaster plan. Any deficiencies should
> be tested in the next drill.
>
> Planning a drill is expensive. Exercises must be done in conjunction
> with state or county/city emergency management agency staff with the
> resources to conduct them.

**Conclusion**

Worldwide bombings occur almost daily and are escalating in complexity
and sophistication. As noted throughout this report, we know the U.S.
health care system will be overwhelmed by a terrorist bombing. The
proposed solutions outlined in this report, provide strategies that can
be put in place *now*---before a crisis strikes---to address the system
wide and discipline-specific surge capacity challenges to providing an
effective response.

**Acknowledgments**

CDC's Injury Center would like to thank the many medical care and
administrative experts who contributed to the conceptualization and
content of this report by participating on the Surge Capacity Expert
Panel, writing sections of this document, reviewing text and providing
valuable comments.

Bob Bailey, MA

Senior Advisor to the Director

Division of Injury Response

National Center for Injury Prevention and

> Control

Center for Disease Control and Prevention

Atlanta, GA

Palmer Bessey, MD, FACS

Professor

Department of Surgery

Cornell University

Associate Director

William Randolph Hearst Burn Center

New York, NY

Steve Cantrill, MD

Associate Director

Denver Health Medical Center

Denver, CO

Alexander Duncan, MD

Assistant Professor

Emory University Hospital

Atlanta, GA

Kevin Gerold, DO, JD, MA(Ed)

Director

Critical Care Medicine

Department of Anesthesiology

Johns Hopkins Medicine

Baltimore, MD

Joe Henderson, MPA

Associate Director

Office of Terrorism Preparedness and

Emergency Response

Centers for Disease Control and Prevention

Atlanta, GA

Richard C. Hunt, MD, FACEP

Director

Division of Injury Response

National Center for Injury Prevention and Control

Center for Disease Control and Prevention

Atlanta, GA

Mark Johnson, MPA

Retired Chief, Community Health and

Emergency Medical Services

Alaska Department of Health & Social Services

Juneau, AK

Arthur Kellerman, MD, MPH

Professor and Chair

Department of Emergency Medicine

Emory University School of Medicine

Atlanta, GA

Robert M. Kellman, MD

Professor and Chair

State University of New York

Upstate Medical University

Syracuse, NY

Jon Krohmer, MD, FACEP

Medical Director

Kent County EMS

Grand Rapids, MI

David Lehmann, MD, PhD

Professor of Medicine and Pharmacology

State University of New York, Upstate Medical University

Syracuse, NY

Patricia Lenaghan, RN, MS, CEN, FAAN

Director, Biocontainment Unit & Magnet Program

The Nebraska Medical Center

Nebraska Medical Center

Omaha, NE

LTC John McManus, MD, MCR, FACEP

Research Physician, US Army Research Program for Combat Casualty Care US
Army Institute of Surgical Research Transitional Program Director, San
Antonio Uniformed Services Health Education Consortium Medical Director
Fort Sam Houston and Camp Bullis Fire Adjunct Assistant Professor
Emergency Medicine OHSU and USUHS

Norman McSwain, MD, FACS

Trauma Director, Charity Hospital

Tulane University School of Medicine

New Orleans, LA

Wayne Meredith, MD

Professor and Chairman,

Department of General Surgeons

Wake Forest University

Winston-Salem, NC

Stuart Mirvis, MD

Professor

University of Maryland, Radiology & Shock Treatment

Baltimore, MD

LCDR J. Morris, MPH

US Public Health Service

National Bioterrorism Hospital Preparedness Program

Health Resources and Services Administration

Rockville, MD

Brent Myers, MD

Wake County EMS Medical Director

Raleigh, NC

Robert Novelline, MD

Professor of Radiology

Harvard Medical School

Boston, MA

Richard Orr, MD

Physician

Children\'s Hospital of Pittsburgh

Pittsburgh, PA

Thomas A. Peters, MBA, MHA

Vice President

University Health System

San Antonio, TX

Sally Phillips, RN, PhD

Director, Bioterrorism Preparedness Research

Agency for Healthcare Research and Quality

Rockville, MD

Edward Racht, MD,

Medical Director, Clinical Associate Professor of Emergency Medicine

City of Austin/Travis County Emergency Medical Services System

University of Texas-Southwest Medical Center

Austin, TX

Scott Sasser, MD

Senior Advisor to the Director

Division of Injury Response

Centers for Disease Control and Prevention

Atlanta, GA

Richard Sattin, MD

Associate Director for Science, Acting Team Lead (Research)

Centers for Disease Control and Prevention

Atlanta, GA

Paul Schmidt, MD

Professor

Department of Pathology and Cell Biology

Tampa, FL

Richard Serino

Chief

Boston Emergency Medical Services

Boston, MA

Jason Stein, MD

Director, Quality Improvement

Emory Hospital Medicine

Emory University Hospital

Atlanta, GA

Gam Wijetunge

Highway Safety Specialist

National Highway Traffic Safety Administration

Washington, DC

Janet Williams, MD, FACEP

Director

Center for Disaster Medicine and Emergency Preparedness

University of Rochester

Pittsford, NY

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