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Show • Methods of crowd and vehicular control outside the facility. • Methods of control of patient, visitor, and staff flow within the facility. • Response to "internal" disasters, e.g. hostage situation in the facility, such as the one at the Alta View, Utah hospital in 1991. • Requests for assistance from state and local public safety members, other emergency responders. the National Disaster Medical System, the Strategic National Stockpile, and other national agencies. • Decision to evacuate the health facility due to damage, threat of mass exposures to a chemical, biological, or nuclear agent, or other reason. • Decisions on release of information to media and family members while maintaining confidentiality requirements of the Health Insurance Portability Account Act of 1996. Having a designated person in charge is particularly important in "Containing the Hazard". The natural tendency of responders is to rush to the scene and help rescue those affected. However, this response may produce additional hazards that seriously compromise response efforts. For example, in the World Trade Center attacks, many of the most experienced disaster managers placed themselves in jeopardy by rushing to the scene of the tragedy (Baker, 2002). Response capabilities could have been seriously compromised if these individuals had been caught in the collapse of the towers. Similarly, providing multiple ambulances with numerous health care providers at other evolving disaster scenes could produce serious loss of capability if secondary explosions occur. Rapidly moving potentially contaminated patients into hospital rooms could place other patients and staff at risk. The person responsible for allocation of health care resources during a disaster must maintain control of the decision-making process to avoid additional risks and to assure the most effective use of limited resources. Unfortunately, as noted by others, the question of authority in many medical organizations is "unresolved" and the chain of command at some hospitals remains unclear. (Bardi, 1999). Confusion regarding who is responsible for making decisions may also exist at other health organizations, including public health agencies. Fortunately, planning for the 2002 Winter Olympics provided valuable insights in helping many Utah hospitals and public health organizations avoid this problem. As is discussed below, realistic practice of disaster plans should be conducted regularly to help assure that all individuals in the organization know the chain of authority. A unique situation exists in hospitals in that there should be a designated hospital administrative authority as well as a medical authority. These two individuals (and their replacements) should have familiarity with each other's roles and responsibilities so when an event occurs, they know their scope of responsibilities. The hospital administrative authority should have responsibility for determining the scope of recall, requests for assistance, patient transfers or diversions, and similar aspects of the facility's overall response. The medical authority must have control over triage, emergency treatment, and other clinical care activities. Having readily-available job descriptions for each member of the incident command team and notebooks with printed roles and responsibilities available in the command center will help to reduce and avoid problems due to "lack of clarity" or "lack of knowing" who has ultimate authority and accountability. COMMUNICATIONS Experience has repeatedly confirmed that difficulties in maintaining effective communications have presented major problems in providing appropriate responses. During the previously referenced tornado, incompatibility of communication equipment between police and other public safety and fire department organizations hindered response activities. Reportedly, some hospitals and other health care organizations had to obtain information from watching local television news broadcasts. Both inter- and intra-hospital communications were affected, with hospitals unable to communicate with each other or within facilities due to downed lines and systems that were overwhelmed. Communication problems at the time of the World Trade Center attacks may have contributed to the loss of lives. Police helicopter personnel recognized the potential for structural collapse, but were reportedly not able to communicate the hazard to fire fighters in the towers (Flynn & Dwyer, 2002). Similar communication problems have been noted in other emergency response situations. Effective communications must be considered in developing recall processes for medical and public health organizations. For example, some organizations have relied on a "one person calls all" system using standard telephone capabilities. If that person is not available, the recall system may not function. Even if the designated person is available, finite time is required for each call. As a result, some people may not be notified until one or more hours have passed, resulting in unacceptable delays. A "pyramid" or "phone tree" system is more efficient, with clear designation of the person responsible for notifying others who, in turn, notify still others in each "branch" or segment. Alternate individuals are clearly identified so that if one person is missing, the notification process will continue without interruption. Such a recall system can be readily adapted to a "modular" recall system so that only a portion of the staff is recalled in case of emergency. A modular capability is particularly important if 24/7 operations are necessary so that some members can be held in "reserve" to provide shift coverage. Senior members of health organizations must have contact numbers and web addresses readily available for the numerous agencies involved in emergency response (CDC, 2000; Gebbie, 2002). The contacts include local, state, and national organizations, including CDC, the Federal Bureau of Investigation (FBI), Federal Emergency Management Administration, and similar groups. Those needing such information include senior administration members, directors of emergency services, and directors of primary services. Each shift should have designated individuals, and alternates, with the capabilities to immediately contact other members of the organization, as well as public health agencies and others needed to respond to the situation. In public health agencies, both the director of the agency and heads of divisions should have similar capabilities on a 24/7 basis. As noted during the TOPOFF plague exercise, exchanging telephone and facsimile transmission numbers during an event is far from optimal (Inglesby, Grossman & O'Toole, 2000). Utah Health Departments have addressed this concern by implementing the Health Alert Network. This system makes it possible to contact all departments instantaneously should a disaster, terrorist attack, or other significant emergency occur. Another necessary aspect of communication is to know the "jargon" of the other, non-health agencies that will be working with the medical groups in responding. The concept of "Incident Command System" underlies disaster responses and delineates responsibilities for involved organizations, but some health members may not be familiar with this aspect. Additionally, as Utah's Health: An Annual Review Volume DC 21 |
