UNIT 1/Chapter15. Safety, Infection Control, and Disaster Readiness for Disasters and Security Threats
Emergency Preparedness and Disaster Management
A disaster is defined as a mass casualty or interfacility event that temporarily overwhelms or interrupts the normal flow of services of a hospital.
Health care facilities must prepare for both internal and external emergencies.
Internal emergencies include:
Loss of electric power or potable water.
Loss of communication ability.
Disruption of computer information systems.
Severe damage or casualties within the facility related to fire, weather (tornadoes, hurricanes), explosions, or terrorist acts.
Internal emergency readiness requires evacuation and relocation plans, procedures to notify extra personnel, safety and hazardous materials protocols, and infection control policies.
External emergencies include:
Natural disasters: hurricanes, floods, volcano eruptions, and earthquakes.
Health crises: disease epidemics.
Man-made accidents: industrial accidents, chemical plant explosions, major transportation accidents, and building collapses.
Terrorist acts: including biological and chemical warfare.
External emergency readiness involves a plan for participation in community-wide emergencies and disasters.
The Joint Commission and Emergency Preparedness
The Joint Commission has established emergency preparedness management standards across various types of health care facilities.
Institutional emergency preparedness plans must include specific procedures for the following:
Notifying and assigning personnel.
Notifying external authorities of emergencies.
Managing space and supplies while providing security.
Isolating and decontaminating radioactive or chemical agents.
Evacuating and setting up alternative care sites when the environment cannot support adequate client care.
Critical processes when an alternative care site is necessary include:
Client information, care packaging, medications, and supplies.
Admissions, medical records, and client tracking.
Interfacility communication and transportation of clients, staff, and equipment.
Cross-privileging of medical staff.
Performing triage of incoming clients.
Managing clients during emergencies including service control, client information, discharge, and transportation.
Interacting with family members, the media, and responding to public reactions.
Identifying backup resources and orienting/educating personnel on the emergency plan.
Providing crisis support for workers: access to vaccines, infection control recommendations, and mental health counseling.
Performance monitoring and evaluation are required, including:
Conducting two emergency preparedness drills each year.
Drills must include an influx of clients beyond those already being treated.
Drills must cover either an internal or an external disaster.
Participation in one community-wide practice drill per year.
Nursing Role in Disaster Response Plans
Emergency response plans are developed by a planning committee that reviews potential natural and man-made emergencies specific to the community.
Nurses participate in the development of these plans as part of a cross-section of the health care team.
Plans must include:
Clear criteria for activating the disaster plan.
Outlined roles for every employee.
Established administrative control.
A designated area for the command center.
A designated incident control manager.
The use of common terminology for communication.
Nurses are expected to create a personal emergency action plan for their own family needs.
Triage Principles during Mass Casualty Events
Mass casualty triage differs from day-to-day emergency room triage. Casualties are separated based on their potential for survival, and treatment is allocated accordingly.
Triage Categories:
Emergent or Immediate (Highest Priority): Clients with life-threatening injuries who have a high possibility of survival once stabilized.
Urgent or Delayed (Second Priority): Clients with major injuries that are not yet life-threatening. These clients can wait between and for treatment.
Non-urgent or Minimal (Third Priority): Clients with minor injuries that are not life-threatening and do not need immediate attention.
Expectant (Lowest Priority): Clients who are not expected to live. They are allowed to die naturally. Comfort measures are provided, but restorative care is not.
Discharge and Relocation Protocols
During emergencies (fire or mass casualty), decisions are made to discharge or relocate clients to free up beds for higher priority needs.
Prioritization for discharge:
Ambulatory clients requiring minimal care are discharged or relocated first.
Clients requiring assistance are next, with arrangements made for the continuation of their care.
Unstable clients or those requiring intensive nursing care are not discharged or relocated unless they are in imminent danger.
Fire Safety and the RACE Mnemonic
If evacuation is necessary, horizontal evacuation is performed first. Vertical evacuation to other floors occurs if safety cannot be maintained.
Immediately turn off oxygen () and electrical equipment to remove fuel sources.
Ambulatory clients should be asked to assist in removing clients who are in wheelchairs.
The RACE Mnemonic guides actions:
R - Rescue: Rescue the client and others from the immediate area.
A - Alarm: Sound the fire alarm to activate the EMS response system. Alarms often automatically shut down systems that increase fire spread.
C - Contain: After clearing the area, close the door to the fire location, all fire doors, and any open windows. Fire doors should remain closed as much as possible.
E - Extinguish: Attempt to extinguish small fires with a single fire extinguisher, a blanket, or water. Complete evacuation occurs if the fire cannot be put out.
Extinguishing attempts should only be made by personnel trained in fire extinguisher use and only if the fire can be handled by one extinguisher.
Severe Weather Protocols (Tornadoes and Thunderstorms)
Draw shades and close drapes to protect against shattering glass.
Lower beds to the lowest position and move them away from windows.
Place blankets over all clients who are confined to beds.
Close all doors.
Relocate ambulatory clients to hallways or secure locations designated by the facility.
Do not use elevators.
Monitor weather warnings via television, radio, or the Internet.
Biological Exposure and Bioterrorism
Biological mass casualty events can be unintentional (e.g., COVID-19) or intentional (bioterrorism involving pathogens targeting people, livestock, or crops).
Management keys: Recognition, use of Personal Protective Equipment (PPE), decontamination, and isolation.
Detection indicators: Appearance of a disease not typical for the time/place, atypical manifestations, or occurrence in a specific group/community.
Isolation Measures:
If the toxin is unknown, wear full PPE including a respirator.
Transport clients only if essential for treatment.
Specific Biological Pathogenic Manifestations and Treatment
Inhalational Anthrax:
Manifestations: Fever, cough, shortness of breath, muscle aches, mild chest pain, meningitis, shock, and sweats.
Prevention: Anthrax vaccine for high-risk individuals.
Treatment: Ciprofloxacin and Doxycycline (IV or PO). May include one or two additional antibiotics such as Vancomycin or Penicillin, and anthrax antitoxin.
Cutaneous Anthrax:
Manifestations: Starts as an itchy lesion; develops into a vesicular lesion that becomes necrotic with a black eschar. Fever and chills occur.
Prevention: Anthrax vaccine for high-risk individuals.
Treatment: Ciprofloxacin and Doxycycline.
Botulism:
Manifestations: Difficulty swallowing, double vision, slurred speech, descending progressive weakness, nausea, vomiting, abdominal cramps, difficulty breathing, and a sensation of a thickened tongue.
Treatment: Airway management, antitoxin, and elimination of the toxin.
Viral Hemorrhagic Fevers (e.g., Ebola, Yellow Fever):
Manifestations: Fatigue, kidney failure, elevated temperature, nausea, vomiting, diarrhea, and internal/external bleeding.
Prevention/Protection: Yellow fever vaccination; barrier protection/isolation precautions; insect repellent.
Treatment: No cure; supportive care only. Minimize invasive procedures.
Plague (Yersinia pestis):
Pneumonic: Fever, headache, weakness, pneumonia, chest pain, cough, and bloody/watery sputum.
Bubonic: Swollen, tender lymph glands, fever, headache, chills.
Septicemic: Fever, chills, prostration, abdominal pain, shock, disseminated intravascular coagulation (DIC).
Precautions: Contact precautions until decontaminated or buboes stop draining; droplet precautions until after starting antibiotics.
Treatment: Streptomycin, Gentamicin, Tetracycline, or Doxycycline.
Smallpox:
Manifestations: High fever, fatigue, severe headache, rash, chills, vomiting, and delirium.
Prevention: Vaccination possible within of exposure.
Precautions: Contact and airborne precautions.
Treatment: Supportive care (skin care, hydration, pain/fever meds); antibiotics for secondary infections.
Chemical and Hazardous Material Incidents
Chemical Incidents:
Gather history: name/concentration of chemical and duration of exposure.
Protection: Use PPE and maintain ABCs (Airway, Breathing, Circulation).
Decontamination: Cut off clothing and bag it. Irrigate skin/hair/eyes with running water.
Dry Chemicals (Lye, White Phosphorus): Do NOT use water, as it may activate the chemical. Brush the agent off the skin instead.
Hazardous Materials:
Identify materials using the Emergency Response Guidebook or Safety Data Sheets (SDS) manual.
Attempt to contain the material before the Hazmat team arrives.
Decontamination: Water is generally the universal antidote. For biological hazards, use water and antibacterial soap. Bag all contaminated clothing and materials.
Radiologic Incidents
Exposure factors: Duration of exposure, distance from the source, and amount of shielding.
Facility protection: Cover floors, furniture, air vents, and ducts.
Personnel protection: Water-resistant gowns, double gloves, caps, shoe covers, masks, goggles, and respirators/PAPRs. Use dosimetry badges to monitor exposure.
Initial survey: Use a radiation meter to determine contamination levels.
Client decontamination: Remove clothing head-to-toe and place in airtight containers with radiation warnings. Wash with soap and tepid water prior to facility entry. Contain all water runoff.
Security Threats: Bomb Threats and Active Shooters
Bomb Threat (Phone call):
Extend the conversation. Listen for background noises (music, traffic, planes) and voice characteristics.
Ask where and when the bomb is set to explode.
Note if the caller knows the facility layout.
Bomb Threat (Email):
Do not turn off the computer or log off. Leave the message on the screen, take a screenshot, and notify security.
Suspicious Objects:
Do not touch. Isolate the device by closing doors and clearing the area. Provide master keys and floor plans to authorities.
Active Shooter (Run, Hide, Fight):
Run: Evacuate if there is a clear path. Leave belongings. Prevent others from entering.
Hide: If evacuation is impossible, stay out of sight. Lock/block doors, silence phones, and remain quiet.
Fight: As a last resort, throw items, yell, or attempt to wound the shooter.
Police response: Keep hands visible and do not move wounded people.
Security Systems and Nursing Role
The International Association for Healthcare Security and Safety provides recommendations for security plans.
Common security measures:
Identification systems for all staff, volunteers, students, and contractors.
Electronic security in high-risk areas (e.g., Maternal-Newborn to prevent abduction).
Key code access and wristbands that electronically link parents and infants.
Closed-circuit television cameras (CCTV) integrated with alarms.
Active Learning Scenario: Biological Pathogens
Anthrax Manifestations: Fever, cough, shortness of breath, muscle aches, meningitis, shock.
Anthrax treatment: Ciprofloxacin plus additional antibiotics like Vancomycin or Penicillin.
Botulism Manifestations: Difficulty swallowing, double vision, slurred speech, descending weakness, GI distress, breathing Difficulty.
Botulism treatment: Airway management, antitoxin, toxin elimination.
Pneumonic Plague Manifestations: Fever, headache, weakness, rapid pneumonia, chest pain, bloody sputum.
Pneumonic Plague treatment: Immediate treatment with Streptomycin, Gentamicin, or Tetracyclines.