Medical center emergency/mass casualty response
Initiation of response
- Mass Casualty response is typically initiated by the Emergency Unit/Department who will hear via HEAR or EMSystem of an event.
- Internal emergency response is typically initiated by Administration/Administrative Supervisor/Nursing Supervisor.
- Initiated per emergency preparedness plans.
Communication for both types of events will be overhead paged through the fire alarm system and also sent on a L3 group page. Additionally, the hospitals have a system for notification of staff via home, cell, desk phones, pager, and email. This notification process is coordinated through TFC.
Redundant communications processes (cell phones, radios, runners, etc) will be utilized in the event primary communications are non-functional.
Initial communication will typically initiate setup of a command center. Additional communications will address that the command center is open, phone number to call, and any additional information (regarding labor pool, etc) known at the beginning of an event.
Command Center information
|Command Center||Location||Primary Phone Number||Secondary Phone Number|
|BJC||4444 Forest Park, Boardroom||286-2978||533-2017|
|SLCH – Primary||SLCH 3rd floor Boardroom||454-4575||454-0517|
|SLCH – Backup||SLCH Conf. Rm. 11E34||454-4575||454-0517|
|BJH – Primary||BJH South, East Pavilion, Conf. Rm. A||747-3290||454-6850|
|BJH – Backup||BJH North, Steinberg, Brown Rm.||454-8555||454-0492|
If these areas are not available, the Farrell Conference Room (2nd floor) in the Center for Advanced Medicine may be used.
Key people, who have been identified in advance, will report to the command center to facilitate setup and initial evaluation of the event.
On-site response expectations
- Staff should not leave their areas of responsibility until told to do so (even if their shift has ended).
- Once the labor pool is activated, extra on site staff should report to the labor pool to be utilized as needed throughout the hospital
- One resident is expected to stay on the unit with their initial responsibility to be evaluation of patients for early discharge (for mass casualty event). They should work closely with the Charge Nurse for that area.
The hospitals utilize a Hospital Incident Command System (HICS) structure for communication in an event. This may mean you are reporting to someone different than you would on a daily basis. In most cases, the physician group will report to the Medical Care Branch Director under the Operations Section.
Washington University GMEC Disaster Plan
The hospital and medical school are in the process of updating and refining emergency/disaster response plans. Last year’s ice storms and recent table top exercises revealed that many graduate clinical training programs did not have disaster response plans or a mechanism for checking on trainees in the immediate aftermath of a disaster. They have asked the GMEC to ensure that each training program develops and disseminate a written response plan as well as identify ways that they will contact their clinical staff. The Washington University GME Disaster Committee was created to help move this initiative forward. Realizing that training programs vary in size and complexity, no single plan will meet everyone’s needs. All programs will need to address certain common needs but the specifics of how they achieve those benchmarks will be left to individual program to create. This document strives to provide general background information about the medical center’s existing disaster plans and outline general principles regarding trainee and program response during an emergency. The other portion of the document is a list of questions that experts have identified as critical to responding effectively during a disaster.
Disasters likely to impact the medical center can be divided into 3 categories;
- Isolated INTERNAL emergencies which stress the hospital/medical school’s infrastructure (internal fires, floods, power outages) without affecting outside community resources
- EXTERNAL disasters (commercial building fire/explosion, plane crash, snow storm) where the medical center infrastructure is intact and operational
- REGIONAL disasters (earthquake, tornado, pandemic) where both the community and medical center itself are impacted/damaged. The portions of the medical center may or may not be operational
Different types of disasters will require varying levels of response from the hospitals/medical school and training programs. Individual training program response plans must be simple, flexible, well communicated to ensure that programs can respond effectively during disasters.
- If the hospital/medical school declares a disaster it implies that local (division/department/hospital) resources have been exceeded and additional help is needed. This response may be limited to a single clinical area (emergency department, operating rooms, ICUs ) or activated hospital-wide
- In the event of a disaster the hospitals and school will open their Disaster/Incident Command Centers
- Notification will occur in a tiered manner (refer to BJH and SLCH disaster plans) with chief residents or pre-identified clinical program liaisons being alerted via the paging system. These individuals will be responsible to notifying individual program trainees and staff.
- House staff and clinicians on duty will be notified of an INTERNAL disaster per the hospital’s communication system (overhead paging, fire alarm).
- On duty clinical staff will be expected to remain at their assigned clinical station
- The hospital/medical school command centers will be responsible for notifying chief residents/clinical program liaisons of the need additional staff
- Training programs must have a means of contacting their clinical staff to assess availability and also direct staff as needed (text and alphanumeric group and individual paging capability). [BE SURE THIS DOES NOT RELY ON HOSPITAL OPERATORS TO MAKE THIS HAPPEN, BUT IS AN INTERNAL PROCEDURE]
- House staff, fellows and clinical staff are discouraged from reporting to the medical center unless instructed to do so to reduce confusion and exposure to potentially dangerous conditions
- Programs have a minimum of 5-points of contact for individual trainees and a plan that allows them to check on trainees during a disaster. This information must be provided to the consortium GME office and updated every six months.
- Monthly clinical on-call lists for each program must be provided to the GME office so that a detailed list of individuals working on any given day can be assembled if needed (allows command center to assess staffing and accountability of trainees)
- Programs will designate, authorize and train a chief resident or clinical liaison to be the primary contact to the hospital command center/administration during a disaster
- The hospitals/school have pre-identified out of hospital staging areas where trainees will be directed to gather (Eric Newman Education Center or Steinberg building)
If conditions warrant a Level III page will be initiated by hospital administrators. This alphanumeric or text page will go out to all program directors and critical GME personnel (Chief residents, clinical program liaisons, hospital GME staff) in addition to other hospital and medical school personnel. This notification may be limited to information only or may direct key individuals to take action (notify house staff/fellows of the situation and assess availability, instruct chief residents/clinical program liaisons to report to the Command Center, request programs activate / call in clinicians to a staging area). [This level of detail is not currently included in pages but work is ongoing to allow this as part of the hospital’s plan]
In the event of a hospital wide disaster, the hospital and/or medical school command center will be opened. Chief residents/program liaisons will be directed to report to the hospital command center to provide information and act as a conduit to their program trainees/staff. They will report to the Incident Commander or designated Chief Medical Officer.
House staff/fellows on duty in the hospital will be informed of a disaster declaration by the nursing supervisor in their clinical area or via overhead hospital-wide announcements. They are to remain on duty in their assigned area and continue to provide primary clinical care. Residents/fellows working at SLCH – one individual is to remain on the floor and other trainees are to report to the internal labor poor as per overhead announcements. They are not to leave the area until told to do so by hospital incident command center staff or their chief resident/program liaison.
Off duty house staff/fellows will be notified of the situation by their individual program/clinical department. The specifics of how this is to occur will be left to the programs. Information sent to trainees will likely instruct them to do one of the following;
- Notify of event and provide availability or standby
- Notify of event and instruct on specific staffing needs (report to ED, OR, ICU, etc)
- Notify of event and direct them to a staging area
Staging of clinical providers
If additional clinical staff is required, house staff/fellows will be directed to gather in a pre-designated staffing area (Eric Newman Education Center/Steinberg Building). The decision to call in and stage clinicians will be made by the hospital command centers. Chief residents or program liaisons will activate their program’s call down list and direct trainees to the appropriate location.
Arriving providers should park in SLCH/BJH/WU parking facilities (NOT in on campus parking facilities ie. SLCH visitor garage) check in with GME and program staff at the staging area (accountability of clinical staff is paramount for security and manpower assessment). When possible the check –in area will be manned by members of the GME office who have access to lists of residents/fellows. Large training programs (Medicine, Pediatrics, Surgery, and Radiology) are encouraged to assign a non clinical staff member to the staging area to help GME staff with registration of arriving house staff/fellows. The hospital command centers will appoint a staging area director. Arriving residents/fellows will be grouped according to level of training and clinical ability (senior surgery resident vs pathology intern).
Once clinical needs are identified, the hospital command centers will contact the staging area director to request providers. Some individuals will be directed to assume specific tasks –ie., senior surgeons sent to assist in the operating suites, emergency medicine trainees to triage or the emergency department. Others will be placed in a general labor pool that can be drawn upon for basic, less specialized clinical duties. In the event the hospital establishes an off-site clinical area residents/fellows may be assigned to this area.
This is a partial list and should be considered in the context of the event
|Senior Internal Medicine||Medicine||Medical ICU and floors|
|Senior General Surgery||Trauma surgery||Operating suites, SICU|
|Orthopedic Surgery||Trauma surgery||Operating suites|
|Neurosurgery||Trauma surgery||Operating suites, NNICU|
|Emergency Medicine||Triage and Emergency Medicine||Emergency Department|
|Anesthesia||Anesthesia||Operating suites, PACU|
|Senior Laboratory Medicine||Laboratory||Laboratory and blood bank|
|Senior OB/GYN||OB/GYN and general surgery||L&D, Operating suites|
|Senior Pediatric||Pediatrics||PICU, Emerg Dept, Floors|
|Critical Care Fellows||Critical Care (medical /surgical)||MICU, SICU, PICU, NNICU, NICU|
|Surgical fellows||Surgical||Operating suites and ICUs|
|Senior Psychiatric||Mental health||Mental health crisis stations|
|General Labor Pool|
|Junior Internal Medicine||Medicine||Medical floors, float pool|
|Junior General Surgery||Surgery||Surgical floors, float pool|
|Junior OB/GYN||OB/GYN and Surgery||Surgical floors, float pool|
|Junior Pediatrics||Pediatrics||Pediatric floors, float pool|
|Junior Psychiatric||Mental health||Psychiatric wards, float pool|
|Junior Laboratory Medicine||Float pool|
|Junior Surgical Subspecialty||Surgery||Float pool|
|Fellows (non critical care)||Medical/Surgical||Float pool|
|Others not assigned||Float pool|
Critical Questions and Issues
It is expected that each program will review the questions below and decide how best to answer them. Responses will be based on training program size and degree of specialization (residency vs subspecialty fellowship). If the program documents written answers for each of these questions and communicates effectively with program personnel responsible for responding in the event of a disaster they will have by default created a basic disaster response plan.
1. Do you have appropriate and up to date contact information on trainees (5-points of contact)?
A. Who maintains and updates this list?
B. Where is this list kept (paper, electronic – probably should have both available) is it shared with GME?
C. Is the resident/fellow list integrated with a faculty/staff list?
2. How will you contact them – group page, email, phone tree?
A. Is there system redundancy?
B. Are you able to place group pages (single number vs sets of numbers)?
C. Who is responsible to placing the actual calls/emails/pages?
D. What will you do if you can’t contact or account for an individual trainee?
E. Have you tested your plan?
3. Who is responsible to reporting to the hospital command center (chief resident, program liaison) to provide information to the incident commander and staff managing the disaster?
A. Are they part of the hospital’s Level 3 paging/notification system?
B. Does this person have access to your departments on call schedule and how will they account for on duty trainees?
C. Are they knowledgeable about what resources your clinical department has available to respond to a disaster?
D. Do they have Incident Command System (ICS) training?
4. Do residents /fellows know how they will be contacted in the event of a disaster and where to report to?
A. How will on duty residents/fellows be able to check on their families and homes?
B. If the hospital is non operational where will you establish a department/division command center?
5. Do residents/fellows know who to contact during a disaster to report their condition (injured, safe and able to work, out of town, etc) – is there a central phone number, email or physical address they are to access?
A. Who is responsible for staffing this phone/computer and keeping track of reporting trainees?
B. Employee Disaster Hotline Number (once activated) is 314-362-5056.
6. Who in your group (Program Director, Chief resident, Chair or Chief) has the authority to active your department’s call-down list?
A. During off work hours who has the authority to activate the disaster plan?
B. How will the department disaster manager end or deactivate the disaster plan once the command center has terminated the disaster
7. How will you utilize your residents/fellows to provide clinical care during a disaster?
A. What special or unique skills sets do your trainees possess?
B. What minimal level of training is required to provide specialized services?
C. How will you relieve/spell trainees from clinical duty if the disaster continues for greater than 24 hours?
8. In a disaster would you alter your standard of care and allow trainees to perform clinical activities with less supervision than usual?
A. Have you defined those clinical privileges and identified which trainees can/will do various tasks ( ie., PGY4 and 5 residents may start surgical cases without attending present but not PGY 1-3)
B. If you have non clinical trainees (on research year) how will you utilize these individuals?
THESE ARE THINGS THEY SHOULD CONSIDER THEY WILL HAVE TO DO, BUT SHOULD BE A LARGER DISCUSSION THAN JUST THE INDIVIDUAL DEPARTMENT LEVEL. WITH REGARD TO THE STAFFING ISSUE, IT IS PROBABLY OK TO DETERMINE AT DEPT. LEVEL, BUT IF POSSIBLE THESE DISCUSSIONS SHOULD BE HELD AT A HIGH LEVEL TO TRY TO MAINTAIN CONSISTENCY WITHIN THE HOSPITAL, ON THE CAMPUS, AND IDEALLY ACROSS BJC……WE SHOULD PROBABLY DISCUSS THIS FURTHER. DEB MAY BE ABLE TO PROVIDE SOME INSIGHT INTO THIS ALSO]
9. How will faculty maintain supervision of trainees (program responsibility)?
A. If trainees are assigned to an off campus or alternative treatment site (established by the hospital) how will faculty provide supervision?
B. How will clinical duty hours as defined by ACGME be tracked and modified to meet requirements?
10. What circumstances would force you to move to an altered standard of care?
A. If the disaster lasts longer than 24 hours how will it affect your clinical services ability to provide care?
11. Do you have means of intra-departmental communication (radios) should cell and landline phone service be compromised?
12. Have you designated a department/division level disaster management team?
A. Have you identified clinical issues they are likely to face?
B. Have you identified administrative issues they are likely to face?
13. What hospital/medical center resources are available to you and your trainees and has this information been shared with residents/fellows/staff? [Material to be shared by the hospitals and medical school]
A. Child care while residents/fellows are working in the hospital TRY TO MAKE OWN ARRANGEMENTS, BUT IF NOT WE CAN PROBABLY PROVIDE
B. Pet care while residents/fellows are working in the hospital SEE ABOVE COMMENT
C. Access to the hospital and parking during a disaster NEED TO HAVE/WEAR BADGE
D. Access to food while on duty during a prolonged event
E. Access to sleeping quarters during a prolonged event FOR STAFF ONLY, DO NOT HAVE FAMILY ARRANGEMENTS AT THIS TIME
F. Medical care for injured providers (residents/fellows/staff and their immediate families)
G. Distribution of mass prophylactics in the event of a biological incident
H. Pay may not be on normal cycle/in normal manner during certain types of emergencies how might this impact trainees
Washington University/Barnes-Jewish Hospital Graduate Medical Education Consortium Disaster Policy
To establish the procedures to be followed to provide administrative support for the WUSM/BJH/SLCH GME Consortium and its house staff subsequent to an event or series of events that cause significant interruption in the provision of patient care, as mandated by ACGME’s Policies and Procedures.
This policy applies to all ACGME-accredited residency programs, associated faculty, residents, and staff.
An event or set of events causing significant alteration to the residency/fellowship training experience at one or more residency/fellowship programs. Hurricane Katrina is an example of a disaster.
Extreme emergent situation:
A local event (such as a hospital-declared disaster for an epidemic) that affects resident education or the work environment but does not rise to the level of an ACGME-declared disaster as defined in the ACGME Policies and Procedures.
POLICIES APPLICABLE TO A DISASTER
ACGME declaration of a disaster
When warranted, the ACGME Chief Executive Officer, with consultation of the ACGME
Executive Committee and the Chair of the Institutional Review Committee will make a declaration of a disaster. A notice of such will be posted on the ACGME website with information relating to ACGME response to the disaster.
After declaration of a disaster, triggering implementation of the GME Consortium Disaster Policy:
- The DIO or designee will meet with each Program Director and appropriate university and/or hospital officials to determine the ability of the programs to continue to provide adequate educational experiences for residents and fellows.
Insofar as a program/institution cannot provide at least an adequate educational experience for each of its residents/fellows because of a disaster, the DIO and Program Director(s) will proceed to:
- arrange temporary transfers to other programs/institutions until such time as the residency/fellowship program can provide an adequate educational experience for each of its residents/fellows, or
- assists the residents in permanent transfers to other programs/institutions, i.e., enrolling in other ACGME-accredited programs in which they can continue their education.
If more than one program/institution is available for temporary or permanent transfer of a particular resident, the preferences of each resident must be considered. Programs will make every effort to expedite the temporary or permanent transfer decision to maximize the likelihood that each resident/fellow will complete the year in a timely fashion. All transfer decisions must be in writing and signed by the Program directors of the transferring and accepting programs, as well as the DIO of the GME Consortium. As soon as arrangements for temporary or permanent transfers have been confirmed, the Program Director or their designee will notify each resident.
- After a period of 6 months, if the institution or program is unable to reconstitute, the program director and DIO must discuss the possibility of permanently transferring training to the accepting program. Program directors must review the program specific requirements with residents to determine whether their specialty requires a minimum number of years of training in the same institution.
- The DIO or designee will contact the ACGME Institutional Review Committee Executive Director within ten days after declaration of the disaster to discuss the due date for submission of plans for program reconfigurations and resident transfers to the ACGME. The DIO will then provide initial and ongoing communication to university/hospital officials and all affected Program Directors.
- The Program Director must discuss the potential for transfer of CMSS (Medicare) funding with the Hospital Chief Medical Officer (CMO). Decisions regarding CMS funding transfers will be based on the programs current funding source for a particular resident or clinical fellow.
- Each program will maintain a contact list, outlining 5 points of contact for all house staff in the program. The Program Director and/or the DIO will determine and confirm the location of all residents; determine the means for ongoing communication with each; and notify emergency contacts of any resident who is injured or cannot be located.
- The DIO will access information on the ACGME website to provide Program Directors with assistance in communicating, and documenting resident transfers, program reconfigurations, and changing participating sites. All major changes to accredited programs must have prior written approval by the Designated Institutional Official (DIO). Major changes are outlined in the ACGME Institutional Requirements sections III.B.10(a-k), and the ACGME Common Program Requirements sections II.A.4n(1-10).
Communication with ACGME
- On its website, the ACGME will provide phone numbers and email addresses for emergency and other communication with the ACGME from disaster affected institutions and programs. The DIO shall ensure that each Program Director and resident is provided with information annually about this emergency communication availability.
- In general:
The DIO will call or email the Institutional Review Committee Executive Director with information and/or requests for information.
Program Directors will call or email the appropriate Review Committee Executive Director with information and/or requests for information.
Residents will call or email the appropriate Review Committee Executive Director with information and/or requests for information, IF they are unable to reach their Program Director or DIO.
POLICIES APPLICABLE TO EXTREME EMERGENT SITUATIONS
DECLARATION OF AN EXTREME EMERGENT SITUATION:
Declaration of an extreme emergent situation may be initiated by a Program Director or by the DIO. Declaration of a qualifying local disaster is made by the DIO, in collaboration with the hospital CEO, the COO, the CMO, affected Program Directors, and Department Chairs. When possible, an emergency meeting of the GMEC shall be convened for discussion and decision-making as appropriate.
After declaration of an extreme emergent situation:
- The Program Director of each affected residency/fellowship program shall meet with the DIO and other university/hospital officials, as appropriate, to determine the clinical duties, schedules, and alternate coverage arrangements for each residency program sponsored by the Institution. ACGME’s guidelines for development of those plans should be implemented, including:
Residents and fellows must be expected to perform according to the professional expectations of them as physicians, taking into account their degree of competence, level of training, and context of the specific situation. Residents who are fully licensed in this state may be able to provide patient care independent of supervision in the event of an extreme emergent situation, as further defined by the applicable medical staff by-laws.
Residents are also trainees/students. Residents/fellows should not be first-line responders without consideration of their level of training and competence; state licensing board training certificate supervision requirements, if applicable; the scope of their individual license, if any; and/or beyond the limits of their self-confidence in their own abilities.
- Program Directors will remain in contact with the DIO about implementation of the plans to address the situation, and additional resources as needed.
- The DIO will call the ACGME IRC Executive Director if (and, only if) the extreme emergent situation causes serious, extended disruption that might affect the Institution/Program’s ability to remain in substantial compliance with ACGME requirements. The ACGME IRC will alert the respective RRC. If notice is provided to the ACGME, the DIO will notify the ACGME IRC Executive Director when the extreme emergent situation has been resolved.
- The DIO will meet the Internal Review Subcommittee (IRS) of the GMEC to establish monitoring to ensure the continued safety of residents and patients through the duration of the situation; to determine that the situation has been resolved; and to assess additional actions to be taken (if any) to restore full compliance with each affected resident’s completion of the educational program requirements. The actions of the IRS will be reported to the full GMEC at its next regularly scheduled meeting.
Original GMEC Approval: October 12, 2009
GMEC Approved Revisions: November 14, 2011