What every nurse needs to know about emergencies

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What every nurse needs to know about emergencies

• Kristine M. Gebbie, DrPH, RN
• Columbia University
• September 10, 2004

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Goals

• Describe the role of an incident management
  system at the community and institutional level
• Identify resources for competency development
• Describe functional roles often filled by nurses
• Identify resources for just in time learning

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Standards are increasing

• Possible emergency preparedness questions on
  NCLEX
• Possible licensing requirement similar to
  blood-borne pathogen or abuse-reporting
  requirement
• JACCHO standards require knowledge and drills of
  all hospital personnel
• Public Health Ready includes competency training
  and drills for local health departments

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Coordination in Disasters
FEMA
PRESIDENT
HHS/CDC/VA etc.
STATE DOH
GOVERNORS OFFICE
STATE EMERGENCY MANAGEMENT OFFICE
CITY or COUNTY DOH
CITY OR COUNTY OFFICE OF EMERGENCY MANAGEMENT
MAYORS OFFICE
HOSPITALS OTHER VOLUNTARY HEALTH SECTOR
OTHER
POLICE
FIRE EMS
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Incident Command System
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Uses of ICS

• Jurisdiction-wide interagency coordination
• Agency-specific for internal response
• HEICS
• PhICS

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Basic principles of ICS

• Developed during 1970-80s in So. CA in response
  to wildfires
• Provides a management model for command, control
  and coordination of an organizations emergency
  response activities
• Employs a defined management structure, with
• clear reporting channels
• common nomenclature
• defined responsibilities

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Incident Action Plan

• The mission (example)
• determine if any of these cases are SARS
• implement procedures to prevent transmission to
  others
• The plan
• Perform contact tracing for the nurse
• Perform case investigation for each ED case from
  the surveillance system
• Initiate surveillance for all EDs in the County
• Initiate a fax alert to local physicians to
  increase reporting of cases of symptoms
  consistent with SARS

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Example Section Action Plan

• specific actions needed by each Section or unit
  within the agency to contribute to the
  accomplishment of these objectives?

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Developing your competence

• Almost never begins with a blank slate
• You may already be competent in emergency
  response
• You may not know it
• We have never measured it
• Real training for competence depends on
• knowing the level of competency
• knowing the system or job to be done

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Competency an individual measure

• The individual possesses knowledge and skills and
  is able to perform required task or objective
• Competency statements include
• an action verb, indicating level of performance
  and
• a subject or content area
• and may include a contextual reference

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Competency combinations
Todays focus
Emergency Preparedness competencies
Nursing competencies
Organizational competencies
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Competencies come in different forms

• Workforce competencies
• statements of complex performance within the
  workplace, akin to the KSAs of job
  classifications.
• Can consist of a series of embedded tasks that
  are either sequential or parallel.
• Are demonstrated over long periods of time.
• Require contextual measurement.
• Allow for a range of indicators to measure
  competence.

• Instructional competencies
• building blocks of learning experiences.
• Structure the learning activities.
• Require higher levels of performance to be built
  upon lower level ones.
• Determine the measurement indicators.
• Require measurement in the short term

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• all professional nurse roles and practice
  settings
• acute care facilities,
• clinics,
• schools,
• homes,
• other community venues.

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Example critical thinking

• Use an ethical and nationally approved framework
  to support decision-making and prioritizing
  needed in disaster situations.
• Describe at the pre-disaster, emergency and
  post-disaster phases the essential nursing care
  for
• individuals
• families
• special groups, e.g. children, elderly, pregnant
  women
• communities.

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Example specific assessment

• Perform an age-appropriate health assessment
• airway and respiratory assessment,
• cardiovascular assessment, including vital signs
  and signs of shock,
• integumentary assessment, particularly a wound,
  burn, and rash assessment,
• pain assessment,
• injury assessment from head to toe,
• gastrointestinal assessment, including specimen
  collection,
• basic neurological assessment,
• musculoskeletal assessment, and
• mental status, spiritual, and emotional
  assessment.

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Example technical skills

• Demonstrate knowledge and skill related to
  personal protection and safety, including the use
  of Personal Protective Equipment (PPE) for
• Level B protection,
• Level C protection, and
• Respiratory protection.

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Example core knowledge

• Describe
• the four phases of emergency management
  preparedness, response, recovery and mitigation.
• the local emergency response system for
  disasters.
• the interaction between local, state and federal
  emergency response systems.
• the legal authority of public health agencies to
  take action to protect the community from
  threats, including isolation, quarantine, and
  required reporting and documentation.

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Example professional development

• Recognize the importance of maintaining ones
  expertise and knowledge in this area of practice
  and of participating in regular emergency
  response drills.
• Participate in regular emergency response drills
  in the community or place of employment.

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Bioterrorism Competencies

• More specifics for
• Leaders
• Communicable disease staff
• Clinical staff
• Environmental staff
• Laboratory staff
• Medical examiner/coroner
• Public health information staff
• Other professionals
• Technical and support staff

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Emergency Preparedness and Response Competencies
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Every hospital worker should be able to

• Describe the role of the hospital during response
  to emergencies
• Locate and use the section of the hospital
  emergency response plan that applies to his/her
  department and position.
• Describe his/her emergency response role and
  demonstrate it during drills or actual
  emergencies.

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The clinician competencies

• licensed healthcare providers (e.g., MD, DO, DDS,
  RN, Advanced Practice Nurse, Physician Assistant,
  Clinical Psychologist, Clinical Social Worker,
  Optometrist) who see and triage patients or
  communicate with patients and are in a position
  to recognize initial cases and manage the initial
  care and referral of patients.
• In all cases, the competencies are understood to
  be defined or limited by the legal scope of
  practice of the specific clinician.

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The clinician in an initial assessment and
decision-making role is able to

• describe his/her expected role in emergency
  response in the specific practice setting as a
  part of the institution or community response.
• respond to an emergency event within the
  emergency management system of his/her practice,
  institution and community.
• recognize an illness or injury as potentially
  resulting from exposure to a biologic, chemical
  or radiologic agent possibly associated with a
  terrorist event.

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Competency assessment

• Self assessment, by competency
• E.g., Identify and locate the agency emergency
  response plan or the pertinent portion of the
  plan
• Range of answers from Not Confident to Very
  Confident
• We are each responsible for moving toward a high
  level of confidence

Adapted from University of Illinois-Chicago
School of Public Health Center for Public Health
Preparedness
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Getting ready Family Disaster Plan

Source http//www.fema.gov/pd
f/rrr/fdp-all.pdf
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Personal emergency plan

• Unless you already work a random schedule and
  have full-time backup, such a plan can be
  critical
• Key items include
• Child care
• Elder care
• Pet care
• Transportation

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Saving the Whole Family
www.avma.org/disaster
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Functional Roles in an Emergency or Disaster

• Your role may be the same or similar to what you
  do every day
• or
• Your role may be different from what you usually
  do.

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Job Action Sheet (JAS)

• Describes a specific functional role during
  emergency response
• primary purpose of role during emergency response
  
• what actions need to be taken
• Needed as different people may need to fill each
  role over duration of event, or for different
  events.
• A person may have more than one functional role
• Over the time of one emergency
• Depending on the type of emergency

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ExamplePotential Roles for E.D. Nurses

• Surveillance
• Safety officer
• Patient care
• Triage
• Risk Communication
• Forensics supervisor

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Functional roles and usual rolesone hospital

• Functional role
• Triage Charge Nurse
• Emergent Care Charge Nurse
• Urgent Area Charge Nurse
• Minor Treatment Leader
• Minor Treatment Area Charge Nurse

• Hospital Position
• Triage Charge Nurse
• CN3, CN2, Senior ED RN
• Urgent Area Charge RN
• Nurse Practitioner
• Medical/Surgical Nurse

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Sample JAS Triage nurse

• Reports to Mass Care Operations Coordinator
• Mission Assess individuals presenting for care
  and direct them to the appropriate level of care
  or care site.
• Immediate
• Read entire Job Action Sheet and obtain briefing
  from Operations
• Check equipment and supply expiration dates if
  appropriate
• Conduct triage - emergent, urgent and non-urgent
  care
• Refer to the appropriate level of care, providing
  first aid as needed

• Intermediate
• Maintain patient assessment log
• Prepare patient for transport to appropriate
  level of care
• Report requests to Operations/ Maintain contact
  with Medical Consultant
• Extended
• Monitor supplies
• Prepare end of shift report for Coordinator and
  incoming Triage Nurse
• Plan for the possibility of extended deployment

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Clinical refresher Heat Exhaustion

• Signs and Symptoms
• C/O light-headedness, headache, weakness,
  dizziness, or fatigue
• Observe Temperature normal or moderately
  elevated, excessive sweating, may have irritable
  behavior.
• Those Most at Risk
• Extremes of age
• Exertion in the sun, or confinement in a hot
  environment
• Hx of CV, psychiatric, endocrine, obesity
• Alcohol consumption and psychotropic drugs

• Treatment in Community or Cooling Center
• Move out of sun, into cooler environment
• Decrease activity for remainder of day
• Rehydrate with electrolyte laden fluid 16-32
  ounces per hour.
• Transfer to E.D. for temperature over 103 F. in
  adult, 104 F. in child, any fever for infant lt 6
  months of age.

Source Protocol for NYC-DOH Response to
Heat Waves (DRAFT) 5/13/01
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Clinical refresher Heat Stroke

• Signs and Symptoms
• CNS signs range from confused/combative to
  unconscious
• Tachycardia, hypotension
• Hot or cool, dry skin no perspiration
• Temperature gt than 105 F.
• /- anhydrosis

• Those Most at Risk
• Elderly, alcoholism, psychiatric cardiovascular
  disorders
• Pharmacy psychotropic medications, street
  drugs, alcoholics
• Treatment in Community Setting or Cooling Center
• Life Threatening Emergency ABCs and triage to
  ED

Source Protocol for NYC-DOH Response to Heat
Waves (DRAFT) 5/13/01 Budassi, Sheehy, S.
Emergency Nursing Principals and Practice Mosby,
St. Louis, Mo. 1992.
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Triage Guidelines

• The following should be triaged to the Emergency
  Department
• Temperature
• gt 103 F. for adults
• gt 104 F. for children
• Any elevation in temperature for infants lt 6
  months
• Change in mental status or level of consciousness
• Abnormal vital signs severe tachycardia,
  hypotension

Source
Protocol for NYC-DOH Response to Heat Waves
(DRAFT) 5/13/01
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What are the boundaries?

• Know the limits to your own knowledge/
  skill/authority and
• Know key system resources for referring matters
  that exceed these limits.

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Practice makes better

• Planning for emergencies and training staff are
  only part of the picture
• Regular reviews, exercises and drills are
  essential to maintain awareness, identify areas
  for improvement and develop proficiency in
  response

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Resources

• Emergency Preparedness Response. Acute Mental
  Health Response to Children Affected by
  Terrorism. http//www.bt.cdc.gov/children/PDF/work
  ing/mental.pdf
• Emergency Preparedness and Response. Bioterrorism
  Agents and Diseases.
• http//www.bt.cdc.gov/agent/agentlist.asp
• Emergency Preparedness and Response. Explosions
  and Blast Injuries A Primer for Clinicians.
  http//www.cdc.gov/masstrauma/preparedness/primer.
  htmkey
• Emergency Preparedness and Response. National
  Center for Environmental Health. Emergency Room
  Procedures in Chemical Hazard Emergencies A Job
  Aid. http//www.cdc.gov/nceh/demil/articles/initia
  ltreat.htm
• Emergency Preparedness and Response. Radiation
  Emergencies. Acute Radiation Syndrome A Fact
  Sheet for Physicians. http//www.bt.cdc.gov/radia
  tion/index.asp
• Centers for Disaster Preparedness
• University of South Carolina School of Public
  Health, http//www.sph.sc.edu/acphp/default.htm
• The Mailman School of Public Health, Columbia
  University. http//ncdp.mailman.columbia.edu
• Facing Fear Together Mental Health and Primary
  Care in a Time Of Terrorism. A Toolkit for
  Primary Care Providers Treating a Worried Nation.
  www.facingfeartogether.org , www.integratedprimary
  care.org

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http//www.nursing.hs.columbia.edu or kmg24_at_columb
ia.edu