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Show Planning for Health Care Responses to Natural Disasters, Terrorism, and Other Mass Casualty Situations Royce Moser, Jr., M.D., MPH; George L. White, Ph.D., MSPH; Colleen Connelly, BSN, R.N.; Linda K. Amos, Ed.D., R.N. Natural disasters, terrorism, and other incidents may produce a large number of casualties over a short period of time. Providing effective treatment and public health response requires appropriate planning. In addition to addressing provision of care or other health activities, planners should focus on the need for efficient Command and Control, Communications, and Coordination. Experience has demonstrated that failure to address these "4 Cs " can seriously compromise responses during actual events. This discussion considers aspects of the "4 Cs " that have been found useful in developing and practicing plans that permit coordinated, effective responses in emergency situations likely to produce mass casualties. The tornado that touched down in Salt Lake City in 1999 demonstrated that health care organizations may have little or no warning of an event that could produce mass casualties. Fortunately, the number injured by the tornado was relatively small, but the rapidity with which the situation evolved illustrates the need for health care organizations and other emergency programs to plan to respond and to coordinate before such an event occurs. The Joint Commission for Accreditation of Healthcare Organizations emergency management standards has long required accredited facilities to plan for emergency situations, but the potential for terrorism has made planning even more complex (CDC, 2000). Additionally, plans are often oriented toward relatively limited number of patients rather than the large number of people who would seek treatment after a major emergency incident. Other health organizations, such as public health departments, and emergency medical services (EMS) have requirements separate from the care of the ill or injured in hospitals, but will be called upon to provide immediate responses to health threats created by the event. The potential for large numbers of casualties may produce a sense that "nothing can be done" so there is little use in planning. A comment sometimes heard during planning sessions that reflects this attitude is "No disaster will ever follow a plan, so why plan?" Obviously, each disaster situation will pose unique challenges, but health personnel who have planned will be able to make effective, coordinated responses to the changing situations. Conversely, members of those facilities who have not developed and practiced plans often make disorganized, ineffective responses that may even produce additional casualties among the responders (Moser, White, Lewis-Younger & Garrett. 2001). Experience by the authors and others in actual and simulated mass casualty situations has repeatedly demonstrated that planning must not focus solely on provision of care for ill or injured (Moser, White, Lewis-Younger & Garrett. 2001; Macin-tyre, Christopher & Eitzen, 2000, higlesby, Grossman & O'Toole, 2000). hi order for plans to be effective, attention must also be directed to the "4 Cs" of Command and Control, Communications, and Coordination. This discussion will focus on the u4Cs", and will assume that plans have been made for other aspects of emergency response activities. COMMAND AND CONTROL hi a disaster situation, it is absolutely essential that all individuals in a health organization clearly understand the chain of authority. This ensures that order can be maintained if the person in charge is unable or unavailable to perform his or her duties. (Gebbie, 2002). Failure to identify the person(s) responsible for making decisions during an emergency situation can produce significant confusion and a disorganized response (Baker, 2002; Flynn & Dwyer, 2002). During a recent simulated bioterrorism incident involving plague, designated TOPOFF because "top" government officials at the national and state level were involved, up to 100 individuals participated in conference calls and attempted to make response decisions during the event (higlesby, Grossman & O'Toole, 2000). Not surprisingly, decisions were made one hour, reversed shortly thereafter, and new decisions were made that were subsequently overturned. During the World Trade Center attacks, a serious problem was that the Office of Emergency Management "...had failed to fully establish the most basic aspect of emergency response: determining who is in charge..." (Baker, 2002). "Table top" exercises have identified conflicts between local, state, and federal agencies regarding who was in charge or who had authority to make response decisions. Confusion also occurred between provision of care and the need to protect criminal evidence (Moser, et al., 2001). It is essential that the persons) in a health organization responsible for making decisions have that authority clearly defined when such conflicts arise. As discussed subsequently, the responsible individuals must coordinate with police, EMS, and all other public safety, law, and emergency response teams. Those in charge must decide to implement, or modify, capabilities delineated in the response plan. Such decisions, include, but are not limited to, the following: • Scope of recall (as discussed in the following Communications section). • Shift assignments for staff, recognizing the potential need for 24-hour, 7-days a week (24-7) operations. • Designation of patient triage, treatment, "overflow"areas. • Discharge or transfer of patients to accommodate those seriously ill or injured as a result of the event. • Assurance of documentation of all patients seen and treatment provided. 20 Utah's Health: An Annual Review Volume DC |