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Difficulty: Very hardEmergency Response Plan

A Level 1 Trauma Center is notified of a multi-vehicle pileup involving a passenger bus and a chemical transport tanker. The facility's emergency operations plan is activated due to a mass casualty incident (MCI) with potential hazardous materials exposure. The emergency department (ED) charge nurse is coordinating the reception of victims.

Which actions by the charge nurse are appropriate? (Select all that apply.)

  1. Instruct security personnel to initiate a facility lockdown and route all arriving victims to a single, secured decontamination entry point.Answer
  2. Relocate stable clients currently receiving care in the ED to a designated internal inpatient staging area.Answer
  3. C
    Direct emergency medical services (EMS) to bypass outdoor decontamination and bring victims with impending airway collapse directly into the ED resuscitation bays.
  4. D
    Assign an available unlicensed assistive personnel (UAP) to perform initial START triage tagging for the large volume of ambulatory walk-in clients.
  5. Upgrade a victim arriving with a pre-hospital 'delayed' (yellow) tag to 'immediate' (red) status upon observing a new onset of confusion and a respiratory rate of 34 breaths/min.Answer
  6. F
    Prioritize the immediate transfer to the operating room for an arriving victim with an 'expectant' (black) tag who has an open head injury and agonal respirations.

Answer

The appropriate actions are: instructing security to initiate a facility lockdown, relocating stable ED clients to create surge capacity, and upgrading a deteriorating client to an 'immediate' (red) tag based on specific vital sign changes.
During a chemical mass casualty incident, initiating a facility lockdown is a critical first step to prevent un-decontaminated victims from entering and contaminating the hospital. Relocating stable ED clients is necessary to create immediate surge capacity for incoming critical casualties. Finally, upgrading a client to an 'immediate' (red) tag is correct because, according to the START triage algorithm, a respiratory rate greater than 30 breaths/min or a new altered mental status (confusion) indicates an immediate life threat requiring rapid intervention.

Step-by-Step Solution

1
Analyze the scenario.
A mass casualty incident involving a chemical spill requires the activation of the emergency operations plan, strict hazardous materials (HAZMAT) protocols, and disaster triage principles.
Understanding the context of chemical exposure dictates that facility protection is just as vital as patient care.
2
Evaluate facility protection strategies.
The facility must be locked down to prevent contaminated walk-in clients from entering. Furthermore, decontamination must occur for ALL victims prior to facility entry, regardless of the severity of their injuries.
Bringing a chemically contaminated victim directly into the ED will expose staff and other clients to the hazardous material, potentially causing the entire emergency department to shut down.
3
Evaluate surge capacity strategies.
The ED must rapidly clear beds to accommodate incoming critical casualties by moving stable clients to designated inpatient staging areas.
Disaster response requires maximizing available critical care resources.
4
Evaluate delegation and triage principles.
Initial triage cannot be delegated to UAPs. Using the START method, victims are prioritized based on Respirations, Perfusion, and Mental Status (RPM). A respiratory rate over 30 or altered mental status requires a Red tag. Clients with non-survivable injuries are given Black tags.
Triage requires nursing judgment. Disaster triage uses a utilitarian approach to conserve resources for salvageable clients.

Key Concept

Disaster management involves protecting the facility from contamination, expanding surge capacity, and applying utilitarian triage principles (greatest good for the greatest number) using the START algorithm.
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Emergency Response Plan

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