Editor's note: This article first appeared in ADVANCE For Nurses. It is the first in a series of articles on disaster preparedness for bedside nurses.
Hurricanes, earthquakes, tornados, floods, acts of terrorism and other disasters can strike anytime, anywhere and can hit with or without warning. Lack of preparation undermines both the safety and well-being of nurses and the patients under their care.
Information about what to do when a disaster strikes in the community and how to do it effectively is available. However, there is little information to specifically guide the nurse left at the patient's bedside.
In this first installment of a special three-part series, disasters and the hospital-based nurses' role in data handling, stress response and disaster resources will be covered.
What are disasters?
The American Nurses Association and the American Red Cross define disasters as events caused by man-made or natural forces that cause infrastructure systems to fail, which results in significant disruption to the health and safety of the community or to the nation. In addition, these situations cannot be alleviated without the assistance of others.1,2
Natural disasters can include weather phenomena such as tornados, hurricanes, earthquakes, landslides, and avalanches, which occur as a result of erosion or severe weather patterns.
Natural disasters hit several parts of the nation in 2012. For instance, in the aftermath of Hurricane Sandy in October, President Obama declared federal disasters areas from the New York area along the coast to Pennsylvania.3
Man-made disasters may be either accidental or deliberate. A wrecked railroad car carrying hazardous chemicals that overturns due to a collision is a man-made disaster, yet is regarded as accidental. The deliberate crashing of two planes into the New York City Twin Towers of the World Trade Center and the Pentagon on Sept. 11, 2001 was man-made and planned, not accidental.
Another way to look at disasters is by number of casualties. A multiple casualty incident is one in which there are more than two but fewer than 100 persons injured. A mass casualty incident is a situation with 100 or greater casualties. Mass casualty incidents significantly overwhelm available emergency medical services, facilities and resources. Multiple and mass casualty incidents can be either man-made or natural disasters.
Many organizations conduct disaster drills to prepare for disasters. The nurse needs to be able to respond to disasters in the community as well as keep safe those who are already in the hospital. What is your role as a nurse at the bedside during a disaster? The key is to know the organizational plan and to stay informed during the disaster.
In 2011 the Joint Commission on Accreditation of Healthcare Organizations introduced standards that define institutional responsibilities for emergency management, challenging healthcare agencies to examine the relationships between medical care and public health systems. They said that organizations need plans for both internal and external responses.
One area of healthcare operations that may be different when disaster strikes, is the chain of command. The chain of command is a line of authority within the ranks of an organization. During a disaster response, the chain of command is much different from the one used in day-to-day operations and may not even be under the control of your organization. An outside agency, such as the Federal Emergency Management Agency, may be employed in its place. It is important that this command structure is clear and available to all nurses.
Regardless of your specific nursing role (acute care nurse, public health nurse, school nurse, ambulatory nurse, long-term care nurse, occupational health nurse, or student nurse), you may be asked to perform work during an emergency that is not part of your daily job routine. Those in charge must quickly determine how many casualties they can handle. Predicting the severity of the casualties coming to you as well as your location's capacity to care for the critically injured is important. Generally, one third of acute casualties are critical while two thirds are treated and released.
During & After a Disaster
As the bedside nurse, patient safety is the top priority and you need to know your organization's disaster response plan.
Most plans call for you to get to the lowest floor possible or, in the event of a tornado, to an interior, windowless area, and direct patients who can ambulate to a safe location. If you cannot go to a windowless area, close window blinds or drapes, move beds away from windows where possible, put beds in their lowest position, and give patients extra pillows and blankets to protect them from flying debris.
All staff should know what outlets are connected to the emergency electrical supply. All hallways must be kept open so staff can meet patient needs. Do not use elevators, as you can be trapped if power goes out.
Nurses need to remain calm, provide reassurance to the patients and listen for instructions.
Mass Casualty Events
Following a mass casualty event, upside down triage is used. In this method, care is based on the urgency and type of condition. Interventions are restricted to opening the airway, controlling severe hemorrhage, and elevating patients' lower extremities.
The focus is removing the victim from immediate danger. Emergency department nurses are on the front line as the injured are moved into the hospital setting. Additionally, nurses need to be familiar with putting on personal protective equipment and working in this attire for long periods.
During a mass casualty event, rapid assessments and interventions demand personal confidence in your ability to make a diagnosis and react. Necessary observations can be categorized under four words: observe, palpate, listen, and smell. The focus becomes the greatest good for the greatest number. Walking survivors are among the first to be treated since they have the best chance of survival.
The Emergency Nurses Association recommends the use of the five-tier triage system for managing casualties. It is thought to be safer and more stable than other models. The five-tier triage system categorizes patients according to the Emergency Severity Index and is a flowchart algorithm based on patient acuity and resources needed. Recommended responses change as questions are answered about the victim. In a multiple casualty event, severely injured or ill patients are treated first, with less serious injuries or illnesses treated afterwards.
Triage is needed to assess the situation at hand. Patients are classified for receiving care according to the severity of the illness or injury. It is a balancing of patient needs with the realities of the situation, such as supplies and personnel. Triage is a continuous process, requiring reassignments as treatments, time, and conditions change.
The ED nurse needs to use all of their assessment skills in a different manner. They need to observe for color changes, deformities, wounds, penetrations, or unusual chest movements, as well as palpate for possible deformities, tenderness, pulsations, spasms, and temperature.
When a patient is unconscious, assume that the patient has a spinal injury. Then you can listen for changes in breathing patterns or adventitious sounds and check breathing for possible airway obstruction, remembering to be cautious if there is possible spinal cord injury.
Patients with injuries causing severe blood loss need to be assessed quickly to determine if a tourniquet was used at the scene, or if immediate intervention is needed to save their lives. Each victim must be evaluated for shock, taking measures to prevent and control it. Finally, they need to smell for unusual odors. A fruity smell indicates diabetic coma or prolonged nausea and vomiting.
Nurses at the bedside or in the emergency room during the time of a disaster must remember to keep their current patients safe as the newly injured move to in-patient status.
In part two of this series, the process of data handling and dealing with stress will be addressed.
References for this article can be accessed here.
Charlene Romer is an adjunct instructor and Toni Hebda is a professor, both in the MSN Degree Program at Chamberlain College of Nursing.