Jane’s Mass Casualty Handbook:
Hospital Emergency Preparedness and Response
First Edition

By using Jane’s Mass Casualty Handbook: Hospital Emergency Preparedness and Response healthcare facilities and hospital personnel can prepare for, respond to and recover from mass casualty incidents.

This handbook is available for single copy purchases in our online store. For quantity discounts, please fill out the form at the right.

Topics covered include the role of a hospital in large-scale emergency operations, the Hospital Emergency Management Program (EMP), the Hospital Emergency Operations Plan (EOP) System Description, the Hospital Emergency Operations Plan, explosive and incendiary casualties, chemical and radiation preparedness, biological events, emergency preparedness training as well as simulation exercises and organizational learning. Other subjects discussed are emergency operations, emergency operations terminology, the primary obligations of the healthcare facility, obtaining federal and state assistance, the Department of Homeland Security, the Department of Health and Human Services, the Department of Defense and the Department of Defense Reserves, the Department of Veteran’s Affairs, the Environmental Protection Agency, the Department of Energy, the Emergency Management Program, specific EMP tasks, hospital EOP goals during emergencies, hospital EOP objectives, hospital EOP mass casualty assumptions, hospital EOP critical considerations, hospital EOP system descriptions, management in an emergency, operations, support functional areas, response, planning, logistics, finance and administration, demobilization, recovery after an emergency, EOP special cases, characteristics of blasts and the philosophy of response, human effects of explosives and incendiaries, complications impacting medical management of blast victims, nuclear explosives in addition to integration with other response organizations. Characteristics and philosophy of response for chemical, radiation, biological emergencies are also included. The particular needs of mass gatherings and high security/high risk events and VIPs and high-level protectees are covered. Specific steps are provided for training exercises in addition to example briefing letters and a hospital emergency operations exercise evaluation checklist, and a list of acronyms is given for clarity at the back of the handbook. Please note that this guide should be used to augment an organization’s existing policies and procedures as well as advice from emergency services and other appropriate literature.

TABLE OF CONTENTS

FOREWORD: Emergency Management – day to day management systems are not suited to large-scale emergencies.

PREFACE: Systematic Approach to Preparedness, Management and Response -- provides the management and response architecture for agencies responding to emergency incidents and is defined as the combination of facilities, equipment, personnel, procedures and communications operating within a common organizational structure with responsibility for the management of resources.

1.0 CHAPTER 1: Hospital Role in Large-Scale Operations

1.1 Introduction -- an all hazards approach will assist healthcare facilities in preparing for any type of crisis.
1.2 Emergency operations — the big picture – hospitals primarily integrate within the Incident Command System within a mass casualty incident under Operations.
1.2.1 Hospital coordination and integration with community response – hospitals should coordinate as a single unit with local government during both planning and response.
1.2.2 Information management – is a complex issue, therefore, hospital managers must understand both the local and state levels of emergency management.
1.3 Terminology -- incident management terms vary across the US as well as by incident circumstances, however, this handbook uses terms appropriate to a hospital-centric crisis.
1.4 Primary obligations of the healthcare facility -- are the safety of staff and existing patients, the capacity to care for regular patients and an ongoing commitment for medical care to the community.
1.4.1 Hospital Emergency Management Program (EMP) – is a formal effort to oversee the development, implementation and maintenance of policies and procedures for emergency response.
1.4.2 Hospital Emergency Operations Plan (EOP) -- an EOP document describes the goals, objectives, methods and processes for response to and recovery from an emergency for the institution, and contains certain elements such as management structure and function during a hospital emergency, the delineation of emergency functions, the required activities during all emergency response phases, the methods for adequate information processing, the processes for continuity of operations if hazards impact the hospital itself, guidelines for the development and release of public information messages.
1.4.3 Mutual aid -- pre-established agreements between healthcare facilities to provide personnel, equipment, facilities and other assistance to each other during times of crisis.
1.4.4 Response integration -- hospitals must be flexible enough to integrate with other community emergency response resources during a crisis.
1.5 Federal assistance – is not directly requested by an individual hospital.
1.5.1 Department of Homeland Security (DHS) – the Federal Emergency Management Agency (FEMA), the American Red Cross as well as the national Urban Search and Rescue (US&R) Response System now fall under the direction of DHS.
1.5.2 Department of Health and Human Services (DHHS) -- retains many public health assets that may be deployed to assist state and local authorities in managing a health emergency such as the Centers for Disease Control and Prevention (CDC), the Commissioned Corps Readiness Force (CCRF) and the Medical Reserve Corps.
1.5.3 Department of Defense (DoD)/Reserves -- may support local jurisdictions with various assets but is not in charge of the incident.
1.5.4 Department of Veteran’s Affairs -- may be used in support of a local jurisdiction through NDMS, FRP or other organizations.
1.5.5 Environmental Protection Agency (EPA) – has resources for use in support of local efforts in environmental monitoring and cleanup.
1.5.6 Department of Energy (DoE) – also has assets to assist a local response to a radiological emergency.
1.6 State assistance – if an incident extends beyond a single jurisdiction, the state may coordinate the overall response, including using the National Guard, the National Guard Civil Support Teams, State Emergency Management Agencies and state public health and medical response teams.

2.0 CHAPTER 2: Hospital Emergency Management Program (EMP)

2.1 Emergency Management Program (EMP) -- organizes and addresses all activities related to emergency preparedness and encompasses the tasks required before as well as after the response to a crisis, and the part that addresses response and recovery is referred to as the Emergency Operations Plan (EOP).
2.1.1 Requirements of the EMP manager -- requires the highest level of support from senior hospital management.
2.1.2 EMP meetings – should be held quarterly, must be well organized, with a well defined agenda, should address issues involving significant conflict or requiring in depth investigation and committee member attendance should be mandatory.
2.1.3 EMP committee -- should have wide, senior-level hospital representation.
2.2 EMP tasks – tasks are reviewed.
2.2.1 Components -- grouped into the four components mitigation, preparedness, response and recovery.
2.2.2 Hazard and vulnerability assessment -- risk is the potential hazards a facility faces as well as the vulnerability of the facility to the identified hazards.
2.2.3 Mitigation -- pre-event planning and implementation actions that prevent the occurrence of an emergency/disaster.
2.2.4 Preparedness -- activities that build capability and capacity to address potential care needs identified.
2.2.5 Response -- activities in response to an incident or potential incident.
2.2.6 Recovery -- activities designed to return responders and the facility to normal operational status as well as restore the hospital’s capability to respond to future crisis situations.

3.0 CHAPTER 3: Hospital Emergency Operations Plan (EOP) System Description

3.1 Introduction -- details hospital response to events that may occur away from the hospital or within the hospital campus which can cause an unusual impact on normal hospital operations or services.
3.2 Hospital EOP goal during emergencies -- to provide the best possible care while assuring the safety of hospital staff and patients.
3.3 Hospital EOP objectives – to protect the hospital staff, current patients and the hospital’s obligation to the community, provide the best possible medical service and lastly, address environmental and regulatory requirements.
3.4 Hospital EOP mass casualty assumptions –planning assumptions and response assumptions should be addressed.
3.4.1 Planning and response assumptions: event characteristics – event characteristics many include few details initially available about the incident, many casualties may rapidly arrive, little or no warning may be given, patients will arrive without having been processed by EMS, the hospital is outside the HAZMAT contaminated area, time is critical and specific agent identification will be unknown.
3.4.2 Planning and response assumptions: victim characteristics – most will be self-referrals, they will be unprotected, untrained and undisciplined, all ages may be encountered, pre-existing medical problems could be common among victims, perpetrators may be among the victims and the victims will recognize that time is critical.
3.5 Hospital EOP critical considerations – that response be cost-effective, simple, easy to use, that they have the ability to train staff on EOP, the ability to make revisions, minimize manpower, provide immediate availability, provide maximum possible surge capacity, that the response be consistent with hospital’s priorities, to protect patient privacy and other patient protections, provide rapid patient processing and preserve evidence.
3.6 Hospital EOP system description -- described functionally rather than by organization.
3.7 Management – management issues are discussed.
3.7.1 Management responsibilities -- responsible for hospital response to event.
3.7.2 Management functions -- the Hospital Incident Manager oversees the management function and other responsibilities of management include safety and security, public information/media relations and liaison with external response organizations.
3.8 Operations – operations concerns are discussed.
3.8.1 Operations objectives -- to directly achieve the objectives set by management.
3.8.2 Operations functions – include patient reception and emergency care, emergency medical or surgical interventions, inpatient services, surgical interventions, critical care, general care, outpatient services, patient diagnostics, patient tracking and patient family assistance.
3.9 Support functional areas -- assists management and operations in accomplishing hospital response goals and objectives.
3.9.1 Logistics support -- all support functions such as personnel, equipment, supplies and the response facilities.
3.9.2 Planning/information -- support hospital response through information processing and plan development.
3.9.3 Administration and finance -- supports hospital response by dealing with finance, business continuity and regulatory compliance issues.
3.9.4 Position descriptions -- develop position descriptions and operational checklists for the response system for your individual hospital.

4.0 CHAPTER 4: Hospital Emergency Operations Plan — Concept of Operations

4.1 Hospital EOP concept of operations -- covers all phases of a response and describes interaction between various hospital functions.
4.1.1 Information function (plans): concept of operations -- is responsible for Information collection and dissemination.
4.2 Incident identification -- the obvious incident and the surreptitious incident should both be considered.
4.3 EOP activation decision -- mobilizes the hospital and sets up the Hospital Incident Management Post (HIMP).
4.3.1 EOP advisory – provides information about an unusual occurrence or risk of an occurrence but does not order mobilization.
4.3.2 EOP alert -- provides notification of an unusual occurrence, with an alert that EOP activation is possible or anticipated, and provides guidance on the degree of mobilization activities to undertake.
4.3.3 Intermediate EOP activation -- provides guidance to hospital staff on the EOP components being activated.
4.3.4 Full EOP activation -- mobilized according to EOP procedures, with procedures designed for demobilization of components as further incident information is received and processed.
4.4 Notification -- the information function is responsible for notification messages.
4.4.1 Notification internal to facility – include notification to all wards/departments and to key hospital and medical personnel, overhead public announcements, other means of notification, and methods for recipients to confirm they received notification.
4.4.2 Notification external to facility -- accomplished using pagers and phone trees, but is logistically difficult.
4.4.3 Notification actions -- confirm receipt of notification to the information officer, including a brief report on current operational status of the notified element.
4.5 Mobilization -- prepares the hospital to execute EOP.
4.5.1 Organization of on-duty personnel -- recruitment of adequate personnel.
4.5.2 Organization of off-duty personnel – those assigned to work from home may be assigned phone trees, mobilizing resources and monitoring media reports tasks.
4.6 Response – response issues are discussed.
4.6.1 Management -- HIMP should be established at a pre-designated location in addition to a back-up location should the facility be compromised.
4.6.2 Public information: receiving and managing the media – the media area should be established away from the main hospital building.
4.6.3 Operations – the mass casualty care surge capacity approach.
4.6.4 Patient reception – covers decontamination, and triage using categories based upon urgency and consumption of complex and scarce medical resources.
4.6.5 Patient registration surge process -- must provide enough initial information to maintain patient accountability and allow systems for ordering patient laboratory studies and X-rays and patient medical data tracking.
4.6.6 Patient treatment -- surge capacity and surge capability should both be considered.
4.6.7 Patient mental health -- the mental health of patients may be the most important intervention in certain events.
4.6.8 Discharges -- only discharge patients if their injuries or illnesses are obviously uncomplicated.
4.7 Planning -- provides critical support to management by assisting in the development of the hospital action plan.
4.8 Logistics – logistic issues are discussed.
4.8.1 Facility: plant and engineering – to ensure facility integrity a rapid, pre- developed facility assessment should be completed as well as the ability to address critical facility problems.
4.8.2 Facility: security and perimeter management -- is critical both for personnel safety and effective emergency operations management.
4.8.3 Patient treatment support – sufficient supplies of pharmaceuticals and blood products are of concern.
4.8.4 Volunteer processing -- volunteer reception, registration and credentialing should be located near staff reception.
4.8.5 Personnel support -- food, hydration, including stations, showers, breaks, television for updates, telephones to speak with families, living quarters in extreme events, medical evaluation and care area for hospital staff and psychological services, including pastoral services should all be available for staff.
4.9 Finance/administration – financial concerns are discussed.
4.9.1 Finance support -- tracks financial costs of hospital participation in an emergency response.
4.9.2 Emergency contracting -- must be capable of rapidly developing and executing emergency contracts for necessary support services.
4.9.3 Business continuity – the financial and administrative Continuity of Operations Plan (COOP) must cover demobilization and recovery as well as organizational learning.
4.10 Demobilization – steps for demobilization are outlined.
4.11 Recovery and organizational learning -- is the period when the focus of incident activity is on returning the organization to its pre-event state and is managed by the IMS until normal processes can take over.
4.12 EOP special cases: hospital (‘internal’) hazard impact threats -- EOP must address the management of threats that directly impact the healthcare facility such as power failures, water failures, medical gas failures, environmental control failures, hazardous materials release, fire, facility structural compromise, hostage incidents and bomb threats.
4.13 Completion of the hospital EOP – should include the development of position descriptions, operational checklists and equipment and supplies lists.

5.0 CHAPTER 5: Explosive and Incendiary Casualties

5.1 Characteristics of blasts and philosophy of response – a blast is a high-speed chemical decomposition of explosive materials, often arranged so that shrapnel and incendiary materials increase the impact also fragments from other objects around the explosive device may be dispersed by the explosive force and cause additional harm.
5.1.1 Explosive force impact on inanimate objects and structures -- a blast wave causes the distortion of structural materials, resulting in fracture and/or failure in addition to causing structural materials to be loosened from their fixings and can affect interior structural supports.
5.1.2 Explosive forces and human impact -- high explosives cause injury to humans through the primary blast effect, ballistics blast effects, bulk flow of gasses and air away from the explosion site, then back into the vacuum, structural collapse and falling debris, smoke and fire, toxic gases and hazardous materials and dust.
5.2 Human effects of explosives and incendiaries – the human effect of explosives are discussed.
5.2.1 Primary blast effects -- primary human impact from the pressure wave will cause differential distortion of tissue, particularly around air-containing structures within the body.
5.2.2 Ballistic effects (shrapnel) -- cause penetrating trauma in exposed parts of the human body.
5.2.3 Human displacement -- whole-body human displacement with instantaneous acceleration as well as deceleration in an equally sudden fashion as walls and large objects are encountered.
5.2.4 Structural collapse and falling debris – blasts which cause the progressive collapse of structures containing humans are associated with high mortality rates.
5.2.5 Smoke and fire -- smoke and heat may cause injury in an unexpected group of victims, for example those trapped in elevators and rooms far above the actual fire.
5.2.6 Toxic gases and hazardous materials -- toxic substances may also be released and cause injury.
5.2.7 Incident evaluation -- death and severe injury is most likely when the blast occurs inside the structure where victims are located, when structural collapse occurs and when blast and victims are in water or enclosures and in front of ‘reflecting’ surfaces.
5.3 Complications impacting medical management of blast victims – specific concerns are addressed.
5.3.1 General considerations – such as sudden, severe onset, victims will move toward care before the organized response is initiated, possible utility compromise, no initial perimeter control at the scene which can result in injuries among volunteers.
5.3.2 Specialty mass medical care considerations – such as primary, secondary and tertiary blast injuries in patients, rapidly evolving airway injuries, lacerations, concussive injuries, penetrating injuries, smoke inhalation and burns, major traumas, the difficulty in differentiating minor traumas form major traumas, blast, burn and penetrating and blunt trauma.
5.3.3 Mass burn care -- thermal burns are graded according to the depth of skin injury and the size/body location.
5.3.4 Hospital triage -- START and other basic triage systems used by EMS may be insensitive to critical but initially subtle injuries.
5.4 Nuclear explosives -- although the threat of a nuclear explosion directed against a civilian population is low, such an explosion would have a severe, widespread impact on the nearby population and will result in mass fatalities.
5.5 Integration with other response assets -- the hospital could be required to interface with local or state law enforcement groups or federal entities such as the FBI or ATF.

6.0 CHAPTER 6: Chemical and Radiation Preparedness

6.1 Characteristics and philosophy of response – emergencies involving chemical or radiological agents pose specific and difficult challenges.
6.2 Agents – specific agents are discussed.
6.2.1 Chemical -- any chemical capable of causing harm to humans and which can be delivered effectively could become a chemical weapon.
6.2.2 Radiation -- radiation-emitting substances can be classified with chemical agents, since many of the protective actions and medical considerations are similar.
6.3 Specialty response requirements – are discussed in detail.
6.3.1 Decision to decontaminate a patient -- err on the conservative side, providing the greatest degree of safety for healthcare personnel.
6.3.2 Contamination of the hospital – will result in at least a temporary impact on operations.
6.3.3 Decontamination procedures and facilities – must be designed with responder safety as the primary goal as well as the protection of the facility and patients.
6.4 Personal Protective Equipment (PPE) -- is designed to shield or isolate individuals from chemical, physical and biological hazards and various types are discussed.
6.4.1 Training -- regularly scheduled training should be held for personnel expected to respond in PPE and training should include fit-testing for devices using a facemask as well as include activities that personnel might perform during an incident.
6.4.2 Safety – a staff member should be designated to monitor the safety of personnel wearing PPE during any exercise or actual response.
6.4.3 Maintenance – gear should be inspected regularly for degradation of materials, with particular attention to seams, check expiration dates and replace when needed, and equipment should be secured, but readily available to appropriate staff.
6.5 Decontamination facilities -- have specific requirements such as rapid set- up, should be external to hospital yet close to resuscitation areas, have privacy from on-lookers and media, segregation of the sexes and separate areas for stretcher-bound patients.
6.6 Decontamination procedures -- should be established and rehearsed.
6.6.1 Patient reception -- decontamination areas should be clearly marked to present visual direction to patients.
6.6.2 Staffing -- staff required will vary depending on the decontamination facility.
6.6.3 Crowd control -- may become necessary with large numbers of potentially contaminated victims.
6.6.4 Decontamination procedures -- initial triage of victims should take place rapidly by a senior level nurse, physician assistant or physician wearing PPE.
6.6.5 Decontaminants -- the physical removal of the agent from the victim is required.
6.6.6 Special decontamination situations – establish the isolation and removal of patients who become disruptive or deteriorate.
6.6.7 Post-decontamination – once patients have undergone the decontamination process they should undergo a secondary, more thorough triage and registration.
6.6.8 Staff decontamination -- thoroughly wash-off while wearing PPE upon completion of all patient decontamination and follow the listed procedures.
6.7 Specialty mass care considerations -- events with large numbers ofpatients can present a wide range of injuries.
6.7.1 Chemical burns -- base burns are typically worse than acid burns.
6.7.2 Nerve agent syndrome -- organophosphate ‘nerve’ agents causing acetyl cholinesterase inhibition may produce specific signs and symptoms such as salivation, lacrimation, urination, defecation, gastric upset and emesis.
6.7.3 Chemical conjunctivitis -- many chemicals can cause minor to major irritation and injury to the conjunctiva.
6.7.4 Inhalational injury -- injuries included in this category might be asphyxiation, damage to the upper or lower airways, systemic absorption of some toxins and bronchoconstriction.
6.7.5 Radiation sickness -- exposure to some radiation sources can cause DNA mutagenesis and destruction of rapidly replicating tissue.
6.7.6 Patient mental health -- exposure or potential exposure to a chemical agent may produce patient symptoms even when there is no evidence of it.
6.8 Integration with other response assets – integration with other agencies may be required such as local Hazardous Materials teams and law enforcement.

7.0 CHAPTER 7: Biological Events

7.1 Characteristics and philosophy of response -- four types of biological terrorist event should be considered for example a biological toxin dispersal causing the known or suspected contamination, a biological agent release that is announced or immediately recognizable, a biological agent released and detected after its incubation period and lastly, a biological hoax.
7.2 Agents -- any biological agent that has human effects and can be suitably disseminated could be used.
7.3 Specialty response requirements -- large numbers of rapidly deteriorating patients after a large-scale, undetected agent release may be the most difficult scenario.
7.3.1 Event recognition -- a biological attack may not be immediately recognized.
7.3.2 Initial response – concerns such as infection control, delayed recognition, and hospital notification are discussed.
7.3.3 Response -- response coordination is required between hospital staff and public health authorities.
7.3.4 Surge capacity – has specific requirements such as supportive care and disease containment.
7.3.5 Logistics – specific requirements are discussed such as caring for staff.
7.3.6 Individual patient interactions -- one of the most challenging actions may be managing individual patient interactions during the response.
7.3.7 Patient follow-up -- patients should be entered into a registry with a uniform database.
7.4 Integration with other response assets -- integration with other response organizations could be required.

8.0 CHAPTER 8: Special Situations

8.1 Mass gatherings and high security/high risk events -- if some events occur in proximity to a hospital extra preparation may be required.
8.1.1 Planning for patient load/patient types – it is difficult to predict patient loads and types with many planned events.
8.1.2 Security – an event may involve the closure or rerouting of streets or mass transit routes.
8.1.3 Logistics – if entrance is to be hindered explanations should be provided to patients, decisions may need to be made about the delivery of replacement supplies and other preparations to consider include extended personnel shifts during extreme circumstances.
8.1.4 Riot control agents -- patients exposed to riot-control agents may be treated as detailed.
8.2 VIPs and high-level protectees – specifics are discussed.
8.2.1 Characteristics and philosophy of response – do not allow the individual’s status to interfere with good, regular medical care.
8.2.2 Hospital security procedures – specific topics discussed are internal and external threats and personal belongings and bio-waste.

9.0 CHAPTER 9: Training, Exercises and Organizational Learning

9.1 Training -- healthcare facilities must meet the training requirements of applicable city, state, federal and nongovernmental regulatory agencies.
9.2 Exercises – JCAHO drills should be conducted regularly to test emergency management.
9.2.1 Exercise planning -- exercises should be viewed primarily as a tool to evaluate the EOP system and procedures, the training quality and adequacy for staff, the equipment, and as an opportunity to impart understanding to outside agencies that interface with the hospital during EOP operations.
9.2.2 Scenario – the scenario should be realistic and of moderate severity and should be constructed so all objectives are addressed.
9.2.3 Exercise evaluation -- evaluate both the exercise and the performance of the EOP.
9.2.4 Victims -- the ‘victims’ should simulate the affect and behavior of real victims impacted by the specified hazard.
9.2.5 Safety plan – a safety plan should be developed for the exercise, addressing any safety concerns that could arise during the exercise.
9.2.6 Patient reassurance – staff should reassure patients and their families as well as provide placards placed in public areas of the hospital and handouts provided explaining that the exercise is happening and that no compromise in the quality-of-care is expected.
9.2.7 Critique and debriefing – schedule a ‘hot-wash’ critique by key personnel immediately following the exercise.
9.2.8 Planning steps – include the mission, objectives of the exercise, develop the scenario, plan for evaluation, designate personnel ahead of time and schedule an after-action exercise evaluation.
9.2.9 Community-wide training and exercises -- be active in development and implementation of community-wide training and exercises.
9.3 Example briefing letter for exercise ‘victims’ – an example letter is provided.
9.4 Evaluation of the EOP response or exercise -- information must be captured in a usable format that promotes efficient processing of the information and incorporation of EOP changes.
9.5 Hospital emergency operations exercise evaluation checklist – a checklist is provided.

Acronyms -- a list of acronyms used in the document are listed for clarity.