15 Minutes `til 50 Patients
MCI Response
Providence Little Company of Mary Medical Center
Torrance
Torrance, California
Reflection
“Prepare for the unknown by studying
how others in the past have coped with
the unforeseeable and the
unpredictable.”
General George S. Patton
Disaster Response Failures
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Hospital Disaster Plan?
Unknown roles & tasks
Poor communications
Unclear patient pathways
Lack of relevant supplies
“That’s what it says, but that’s not what
we do.”
Successful Solution
• 15 Minutes `til 50 Patients
– Rapid Deployment
– Designated Response
– Tested/Vetted through over 30 Exercises
Actual Events
– Plug and Play Model
– Implemented in 4 So Cal Hospitals
A Few Facts
• Napa Earthquake-August 14, 2014
– M 6.0
– 1 Death
– 200 injuries
• Nisqually Earthquake-February 28, 2001
– M 6.8
– 400 Injuries
• Northridge Earthquake-January 17, 1984
– M 6.7
– 57 Deaths
– 9000 injuries
Event Onset
Code TRIAGE Initiation
ED OFTEN HAS 1st INFO
- EMS radio call
- MAC/ReddiNet notification to ED
- Unusual surge of similar type patients presenting to
Triage
CHARGE RN & MD
- evaluate needs & contact:
- House Supervisor/Admin On Call
House Supervisor/AOC:
- PBX for “Code Triage” overhead page
ED Actions
1st 15 Minutes
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Roles assigned
Triage (Internal)closed
FT emptied into waiting room
Patients processed for discharge or admit
Floor RNs/CNAs come for immediate
admissions
• Consolidate remaining patients
• Count of available beds to Disaster Lead
• ED doors secured
Quick Reference ED
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ED Notified via MAC/Reddi-Net
Notify House Supervisor via Phone/Pager/SpectraLink
House Supervisor MUST Initiate Code TRIAGE with PBX
ED Clinical Supervisor to Assign Staff for Response
ED to Establish External Treatment Area for Incidents involving
Mass Casualties (on Loading Dock)
ED Staff (assigned by ED Clinical Supervisor) to Establish Minor
Treatment Area in CHE
Don Personal Protective Equip
Color Coded Carts contain: Tarps/Canopies/Cots Located in Supply
Shed On Loading Dock (Key to ALL Trailers & Storage in ED)
Additional Cots in Dialysis Room (in CHE*Code=5600)
ED to Clear Out Existing (Rapid Admission to be Completed by Units)
Patients to be Ready to Receive “NEW” Victims
Turn On Hand Held Radio to Communicate Info/Needs to Hospital
Incident Command Center
Update MAC and Incident Command as New Info is Received
Initiation
Roles Assigned
Go-Kits in Radio Room
Loading Dock
0-5 Minutes
5-10 Minutes
Immediate
Delayed
5-10 Minutes
Public Safety
Access Control
Ambulance Drop-Off
Department of Public Safety
• 0-15 Minutes
– Facility Lockdown
– Access Control
• As Patients Arrive
– Traffic Control
– Monitor Egress
• Crowd Control
– Ongoing/PD Assist
DPS
• Deputize Staff/Volunteers
– Post Up at Entry Points
– Observe & Report
• Evidence?
– Cause of Event?
– Maintain Chain of Custody
10-15 Minutes
Assuming Responsibilities
Command Center
Disaster Communications
Set Up
15 Minutes
MCI Treatment Areas
1st 15 Minutes
 10-20 Gurneys to staging
 10-20 Wheelchairs to staging
 Shower trailer moved & set up
 Set up Cots
 Set Up Canopies
 Signs posted
 Supply carts out
 20 IV lines ready
 20 O2 tanks ready
 PPE donned
 Treatment Area teams ready
 Radio checks
Designated Response
Pharmacy
• Pre Stocked Med Carts
• Deploy to
– External Treatment Area
• Loading Dock
• Immediate/Delayed
– Internal Treatment Area
• Minor Treatment
• Center for Health Educ.
• Pharmacy Tech to ED
• Pyxis in Bypass Mode
Radiology
• Deploy to Treatment
Areas
• C-Arm
– Internal Treatment Area
• Portable X-Ray
– External Treatment Area
• PACS Carts
Hospital Actions
1st 15 Minutes
• Command Center Established
– Coordinates resources
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Equipment
Personnel
Patient flow into hospital departments
Ancillary support services
– Communicates with
• ED Disaster Lead directly
• All Departments
ICU/Tele/Med-Surg
1st 15 Minutes
• Safe Patient Hand-Off
• Two RN’s from each unit report to ED
Lead (one to transfer ED patients to
unit-one to assist in patient care in ED
• Facilitate Patient Flow
• Set-Up
Meanwhile…
• MCI Response is not just patient care
centric.
• Labor Pool established.
• Unit Status Reports to HCC.
Facilities/Plant Operations
0-15 Minutes (& Beyond)
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Immediate Facilities Structure Evaluation
Immediate Systems Check
(True Assessment=1.5-2 hrs)
Check Structural Integrity
Report Findings to HCC
• Operations Section Chief
• Deputize On-Site Construction Personnel to
Assist
POM Code TRIAGE
Assessment
POM CODE TRIAGE Building Status Report
AREA
UTILITY / EQUIPMENT
Emergency Generator
ATS
Electricity Fuel Tank
Normal Power Feed
Electric Panel Rooms
Boiler
DA Tank
Heat Exchanger
Steam
Domestic Hot Water
Heating Hot Water
Natural Gas Supply
Chiller
Cooling
Cooling tower
Water Softeners
Domestic Water Supply
Water
Emergency Water Storage Tank
Emergency Water Supply
Air Handler
A/C
Exhaust Fan
Fire Panel
Fire Pump
Fire Life Safety
Sprinkler Water Suppy
Sprinkler Risers
Equipment Room
Elevators
Cab
Data Closet
IS / Phone
Phone Switch
Stairwell
EXIT
Exterior Landings
Department / Floor
Structural Parking Lot
Parking Structure
O2 Bulk Storage
Tank Farm
Manifold Room
Med Gas
Medical Air Compressor
Vacuum Pump
WAG
STATUS
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
STATUS
STATUS
STATUS
STATUS
STATUS
STATUS
2
2
2
3
3
4
4
5
2
2
3
3
4
5
2
2
2
3
3
4
4
5
6
3
3
4
4
5
5
6
7
2
2
2
2
3
3
4
4
5
5
6
6
2
2
2
2
2
3
3
3
3
3
4
5
4
4
2
2
2
2
3
3
3
3
4
4
4
2
2
2
2
2
2
3
3
4
6
7
STATUS
STATUS
STATUS
8
9
10
7
7
8
8
9
10
6
7
8
5
5
6
6
7
7
8
9
10
5
5
5
6
6
7
7
Facilities/POM
Understanding Capabilities
Emergency Resource Inventory
Resource/
Utility
Inventory (On-Site)
20,000 Gal Dom. Hot Water
5,000 Gal within piping system
8,000 Gal in Reverse Osmosis
WATER
33000 Total Gallons on site
Note: 30,000 gallons available in
sprinkler system for extreme
measures
Medical Air
Medical Gases Medical Gas (Vacuum)
(Piped)
Ventilation
Medical Suction
FUEL (Diesel)
FUEL (Gasoline)
Liquid Oxygen
G1
G2
G3
G4
G5
G6
233.6
233.6
233.6
16.8
211.4
211.4
¾
½
317
454
317
454
317
454
23
33
289.9 415
289.9 415
3134 Staff
1000 Volunteers
298 Med Staff
558 (279 beds x2)
4990 Total x 1
gal/day/person
= 6.6 days (158 hrs)
On
On
On
On
10,000 North Tower
1,200 West/Research
30,000 South Tower
=41,200 Gallons Diesel
FULL Load/hrs
Generator
Capabilities
(In Hours)
Capabilities
Emerg
Emerg
Emerg
Emerg
Power
Power
Power
Power
77.86 hrs Full Power
16.8 hrs Full Power
105.7 hrs Full Power
¼
757.6
757.6
757.6
55.6
701
701
Rationing Suggestions
-Limit Patient Bathing
(Sponge bath vs Shower
-Use of Hand Sanitizer for
Hand Washing
-No Flush Order for staff (Bag
Waste w/ scoop of kitty litter
for absorption
See Generator Capabilities
Below
-POM To Ration
-Load Shedding Possible to
Maximize Efficiency/Prolong
Fuel Supply
-Adjust Usage per
Capabilities Chart
NOTE: No Gasoline Storage On
Site!
Must use supply in vehicles
In parking lot
_Gasoline Generators -Utilize Siphon (also located
located in ______
in trailer) to obtain gasoline
from vehicles on site
250 inches (main)
150 inches (reserve)
50 days (1200 hrs)
30 days (720 hrs)
Daily Usage=3-5 Inches
Utilize Liquid O2 to replenish E
and H Cylinders as needed
Facilities/POM
What next?
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Assist with Decontamination
Assist with Infection Control
Assist with Patient Transport
Assist as Runners
Ensure Utilities are Viable
ED Actions
Role Assignments
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Disaster Lead – RN
ED Charge – RN
Set Up & Decon – Techs/CCTs
Triage - RN
Immediate Team
– 2RNs + MD + Reg + RT
• Delayed Team
– 2RNs + MD + Reg + RT
Waiting for Patients
Ground Floor/Set Up Map
Vests
Job Action Cards
Vests
Standing Med Orders
Vests
Floor Units
TRIAGE
As Victims Arrive
• 5-10 second evaluation (START/JumpSTART)
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Respirations
Perfusion
Mental Status
Injury Extent
• Confirm or change EMS triage status
• Put on colored tag/ribbon on patient
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Red = Immediate
Yellow = Delayed
Green = Minor
Black = Expectant/Expired
• Direct to pathway for appropriate care
Triage (External)
Treatment Area Teams
As Victims Arrive
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RNs + MD + Resp + Registration
ABC (CAB) level of care + standing orders
Labs drawn while IV started
Triage tag & Assigned packet = medical
record
• Triage within care areas for victim movement
– Critical care/OR/Tele/x-ray/ED/ etc
– Update lead every 10 minutes
Treatment Area(s)
PLCMMC Torrance
PLCMMC San Pedro
Patient Care
What about the ED…?
Patient Flow…
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Triage all the time everywhere
Immediate first, then Delayed
Common sense!!!
Anticipate needs
– Equipment
– Personnel
– Movement
Critical Elements
• A-B-C (C-A-B) level of care until
hospital can accommodate
• Patient flow does not change even if
location does
• 1st 15 minutes of response sets stage
for entire response
• Roles stay in assigned areas
• Lab/X-ray results stay with patient
Transitioning into Disaster
Mode
• Easy if you are prepared…
• Disaster Planning/Training
• Disaster Exercises
• Hospital Layout
• Common Sense
• Do the best you can under the
circumstances!
Disaster Mode…Simplified
• Comes down to TWO key components:
– Patient CARE
– Patient FLOW
Putting It All Together
• Time Lapse Video from Full Scale
Exercise 4/9/2015
Thank You for the Opportunity
Contact Info
Chris Riccardi, CHSP,CHEP
Emergency Management Officer
Disaster Preparedness and Project Coordinator
Providence Little Company of Mary Medical Center Torrance
o-310-303-5551
e-christopher.riccardi@providence.org