on the management of mass casualty events and incidents involving hazardous ... in relation to disaster preparedness (Weiner et al, 2005) and to develop a ... Preparation. Response. Recovery. - Risk identification of potential threats and hazards .... Lakhn R, Moore T (2004) Tolleys Handbook of Disaster and Emergency.
Developing disaster management noduies: a coiiaborative approacii Valerie Douglas
Abstract Disasters, whether natural or hutnan induced, can strike when least expected. The events of 9/11 in the US, the 7/7 bombings in the UK, and the anthrax incident in the US on 10th October 2001 indicate that there is a need to have a nursing workforce who is able to respond effectively to mass casualty events and incidents involving chemical, biological, radiological and nuclear substances. Multi-agency collaboration is one ofthe fundamental principles of disaster preparedness and response. It was therefore necessary to take a similar multi-agency collaborative approach to develop modules on the management of mass casualty events and incidents involving hazardous substances. The modules are oflfered to registered nurses and registered paramedics. They can be taken independently or as part of a BSc in nursing or health pathway, on a part-time basis. Since the commencement of the modules in September 2004, registered paramedics and registered nurses w^ho work in a wide range of specialties have accessed them. Key words: Collaboration • Major Incidents menagement • Nurse education
Disasters • Disaster
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isasters are events, often happening without warning which result in human injury, loss of life and damage to infrastructure. During the past decade there have been a number of natural and human induced disasters that have resulted in mass casualties and death. The most recent natural disaster, the tsunami, which followed the earthquake otF the West Coast of Sumatria on 26 December 2{)()4, resulted in an estimated total of 214000 deaths and 142000 people were recorded as missing (Wattanawaituncchai et al, 2003). Human induced incidents can he accidental or deliberate and come in many shapes and sizes.The accidental explosion of a nuclear reactor at Chernobyl in 1996 (Advanced Life Support Group (ALSG), 2O02) caused a radioactive fallout in various countries throughout the world, demonstrating that some disasters can have far reaching effects. The events of Septemher 11 2001 in the US and the London bombings
Valerie Dougia-s is a Lccturvr at the UmvcrMly of Paisley, Schwol of Health, Nursing and Midwifery. University Campus Ayr Aaepted for pubticalion: March 2007
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on 7 July 2005 have also highlighted that deliberate incidents may not be confmed to one location. For example, in London, simultaneous explosions occurred on three underground trains and then approximately 1 hour later a devise exploded on a bus in Tavistock Square (Ryan and Montgomery, 2005). Such events provide new challenges to first responders, the NHS, and nurse educators. Regardless ofthe reason, preparedness is the key to the management of major incidents and disasters (Hayward, 2003a). Frequently, the terms "major incident' and 'disaster' are used synonymously but there are distinct differences between both events. A major incident for the NHS is an event that presents a serious threat to the community and has the potential to cause numbers or types of casualties that require special arrangements to be implemented by hospital, ambulance staff, or local authorities (National Audit Office (NAO), 2002). Although these special arrangements may be effective in the management of a major incident, they can be rendered ineffective during a disaster. Davies (2005) suggests that disasters are events that are outside the normal response, identified within the planned and organized fully functional major incident plan. Such events may necessitate the help of emergency services and voluntary organizations from outside the affected community.
Education And training Disasters or major incidents can affect any part of the healthcare system at any one time. Therefore, professionals must be appropriately trained to provide the correct response (Lee, 2003).The International Nursing Coalition for Mass Casualty Education (INCMCE) suggests that all nurses from novice to expert should have a basic knowledge to respond to mass casualty events. INCMCE was established in the US to address the needs of nurses in relation to disaster preparedness (Weiner et al, 2005) and to develop a competent nurse workforce to respond effectively to mass casualty events (Phillips and Lavin, 2004). Events such as the terrorist attack in London on 7 July 2005 and the accidental explosion at StocUine Plastics factory in Glasgow on 11 May 2004 indicate that the UK also needs nurses who are able to respond effectively to iTiass casualty incidents.
Rea5on for the development of the modules The driving force behind the development ofthe modules was the NAO (2002) report 'NHS Emer^enfy PlanniU'^ in England\ The report highlighted gaps in the preparedness of some NHS Trusts in relation to chemical, biological.
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EDUCATION AND DEVELOPMENT radiological and nuclear incidents. Although the incidents involving these substances discussed in this report may be accidental, terrorists now have the ability to use chemical and biological agents. In 1995, the nerve agent sarin was used in the Tokyo underground attack and more recently in October 2001, letters containing anthrax were sent through the US postal services to the Senate's office at Capital Hill (Bianchard, 2005). In addition, as a result of increased globalization, travel has become more accessible causing diseases such as Severe Acute Respiratory Syndrome (SARS) to be transmitted along international air routes (Lakha and Moore, 2004). Major incidents and disasters can be multidimensional and can therefore have an impact on nurses working in every speciality. Such events may require the contribution of both hospital and community nurses. Community nurses could be involved in the setting up of rest centres or providing hotline advice for members of the public (Crouch, 2003). They can also be involved in providing psychological first aid (World Health Organisation, 2003) and supporting members of the community durmg the recovery phase. Recovery is the fifth activity of emergency management (Table 1) and it encompasses the physical, social, psychological and economic impact of a disaster (Cabinet Office, 2003).
Collaborative approach Hornby (2005) defines collaboration as the art of working vvith another person or a group of people to create or produce something. Multi-agency collaboration can enhance an effective response during a major incident or disaster, hence the reason for using the same approach to develop the modules. This approach includes people with different roles, responsibilities, and skills working together in multi-agency groups (Scottish Executive, 2006). The collaborative process commenced through a consultation with the Nationai Emergencies Planning Officer (Scotland). The purpose of this consultation was to obtain guidance and advice regarding the development of the two disaster management modules. The National Emergencies Planning Officer suggested that the proposed content was relevant and the modules should be offered to registered paramedics and registered nurses. Multiprofessional education such as this is believed to enhance collaboration in practice (Scholes andVaughan, 2002).
Table 1. Five Activities of Emergency Management Assessment Prevention Preparation Response
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Recovery
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Risk identification of potential threats and hazards Measures taken to reduce risks Preparing For responses to emergencies involves planning, training and exercising Dealing with the immediate effects of an emergency Measures that wiii enable the community to return to normality Adapted from: Cabinet Office (2003)
The members ofthe steering group had diverse skills and knowledge. This proved beneficial in the development of the modular content. Some had skills and knowledge related to the management of mass casualties at an incident scene, others had experience in compiling major incident plans or activating the plans within a hospital setting. Initially the steering group met four-weekly over a period of six months and then one month prior to the commencement ofthe Brst module in September 2004.
Outcome of the collaborative process The two modules which were developed contain both theoretical and practica! elements. Each module is delivered one day a fortnight over a 15 week period. The first module focuses on a multi-agency approach to the management of mass casualty events. This includes management of casualties from a pre-hospital and hospital perspective. As one of the key components of this module is preparedness, a practical education exercise at a football stadium is included. Students are able to apply the first four activities of emergency managenient {Tnblc I). This can add some realism to the module, as there have been several mass casualty events at football stadia. For example, in 1989,96 people were crushed
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Establishing a steering group Another important aspect of the collaborative process was to identify individuals who shared the same vision of developing modules on disaster management. After identifying various professionals who were interested in this project, a steering group was set up in December 2003. The main aim of the group was to develop the modular content and explore ways in which it could be delivered in a meaningful way.The members of the steering group consisted of an Einergencies Planning Manager (Scottish Ambulance Service), a Special Operational Response Team Manager (Scottish Ambulance Service), three NHS Board Emergencies Planning Officers, two A&E nurses, and two nurse lecturers from Paisley University.
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Figure I. Tlie Cusualty at the football stadium.
Stulion set up by fhv Scottish Ambulatice Service during the exercise
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to death at a football match at Hillsborough stadium in England (Lakha and Moore, 2004). During the exercise the Scottish Ambulance Service set up a casualty clearing station (Fi^f^ure i).This is beneficial as nurses may be deployed within a casualty clearing station during a major incident as part of a mobile medical team. A mobile medical team is provided by a hospital and can include both doctors and nurses. The exact nature of their work may vary depending on the incident but generally they will be involved in triage, treatment, and preparing casualties for transportation to various hospitals (ALSG. 2002). Triage is also an important component of the module. Tbe term triage means to sieve or sort. The principles of triage are applied when casualties exceed tbe number of skilled rescuers. Primary triage (sieve) takes place where the casualty is found and secondary triage (sort) takes place in the casualty clearing station (ALSG, 2002). Accident and emergency nurses need to understand that major incident triage is different from the triage based on clinical prioritisation, which is normally carried out in a hospital setting (Hayward, 2003b). Triage is an important aspect of disaster management and if carried out correctly it can save the lives of many casualties (Hardin, 2002). The ramifications of major incidents and disasters during the recovery phase are also addressed within this module.
This includes the rehabilitation of individuals who have been injured, the problems associated with damage to the infrastructure and psychosocial issues arising from the disaster. The second module focuses on the management of incidents involving chemical, biological, radiological and nuclear substances. The steering group proposed that some aspects of the modular content should be flexible to allow public health issues (which are topical at the time of delivery of the module) to be included. For example, the management of avian influenza (H5N1) was included in the content of the module delivered in October 2005. This was because it had become a topical issue due the direct transmission of avian influenza (H5N1) from bird to human (Tam et al, 2005). The theory of decontamination of individuals exposed to hazardous substances is feattired within this module. Module participants are able to take part in a chemical incident decontamination simulation with a Scottish Ambulance Service special operation response team. Scottish Ambulance Service operates eight special operation response teams, wbich are placed strategically throughout Scotland to deal with mass casualty events and incidents involving chemical, biological, radiological and nuclear substances. During the simulation event, module participants have the opportunity of putting on personal protective clothing suitable for dealing with chemical incidents {Fi^^urc 2). This enables the module participants to select their correct size and learn the correct technique of putting on this type of clothing.The rationale for incorporating a simulation such as this is that it facilitates a learning process that mimics reality within a safe environment (CiofFi, 2001). Issues such as contaminated casualties leaving an incident scene and arriving at a hospital accident and emergency department are also addressed. In the event of a chemical incident, it is important that accident and emergency staff recognizes what type of chemical it is and ensure that other patients in the department do not become contaminated (Crouch, 2003). The module participants who work in hospital settings are encouraged to examine their own major incident plans for chemical incidents.
Psycholo^cal effects of a disaster
Figure 2. Moitufe participants dressed in protective clothing.
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The NDcioiial Emergencies Planning Officer (Scotland) suggested that the psychological effects of a disaster should be included within both modules. The rationale for this is that registered nurses or paramedics may access one module and this could be the one that does not address psychological issues. It is also important that nurses and paramedics understand the psychological impact which disasters may have on casualties and emergency responders. Stress reactions are common after disasters. Most people recover quickly but others may experience post-traumatic stress disorder at a later stage (Herrmann, 2006). A survey carried out four years after the saran gas terrorist attack on the Tokyo underground system in 1995 showed that 57% of the respondents still had depression, nightmares, flashbacks and panic attacks when they boarded a train (Watts, 1999).
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