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D D o o m m e e s s t t i i c c P P r r e e p p a a r r e e d d n n e e s s s s
Page 1
An Alternative Health Care Facility:
CONCEPT OF OPERATIONS FOR THE OFF-SITE TRIAGE,
TREATMENT, AND TRANSPORTATION CENTER (OST
3
C)
Mass Casualty Care Strategy for a Chemical Terrorism Incident
Prepared by:
Health & Safety Functional Working Group
CHEMICAL WEAPONS
IMPROVED RESPONSE PROGRAM
March 2001
Cleared for public release, distribution is unlimited.
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U.S. ARMY SOLDIER AND BIOLOGICAL CHEMICAL COMMAND
Aberdeen Proving Ground, Maryland 21010
SBCCOM
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Alternative Health Care Facility
- ii -
Disclaimer
The findings in this report are not to be construed as an official Department of the Army
position unless so designated by other authorizing documents.
The use of trade names or manufacturers' names in this report does not constitute an
official endorsement of any commercial product. This report may not be cited for
purposes of advertisement.
Disclaimer:
The opinions or recommendations expressed in this document are a consensus of the
Chemical Weapons Improved Response Program (CWIRP) Health and Safety
Functional Group and do not necessarily reflect the official position of the U.S.
Department of Defense.
Page 3
Executive Summary
- iii -
The United States Domestic Preparedness Program, instituted by the FY97
Defense Authorization Bill (PL 104-301, September 23, 1996) was established to
increase America's domestic response capabilities to a nuclear, biological, or chemical
(NBC) attack. In an effort to successfully identify issues related to weapons of mass
destruction (WMD), the Department of Defense (DoD) delegated responsibility for
executing this legislation to the U.S. Army Soldier and Biological Chemical Command
(SBCCOM). In combination with the DoD's expertise in WMD, SBCCOM created the
Chemical Weapons Improved Response Program (CWIRP) that would network with
civilian responders to identify key response issues.
One of the most prevalent issues identified by the CWIRP, was a community's
inability to care for an overwhelming number of chemically contaminated patients. Even
when emergency responders successfully decontaminate and triage large numbers of
patients at the scene, it is unlikely that area hospitals are prepared to receive these
patients and treat them within the boundaries of the existing health care system.
Jurisdictions need a plan to carryout victim triage, decontamination, treatment,
transportation, and hospitalization in a time critical manner that improves patient
outcome. Thus, planners must avoid intentionally overwhelming the health care system
and may need to redistribute existing resources to positively influence patient outcome.
In response to this issue, the CWIRP developed an alternative health care facility,
herein referred to as the Off-site Triage, Treatment, and Transportation Center (OST
3
C or
Center). This facility will supplement a community's existing health care system in
managing the overwhelming number of casualties, both actual and psychosomatic,
following a terrorist incident. Specifically the OST
3
C is meant to care for those patients
who have been triaged "Minimal" at the scene, those patients who are worried that they
might have been exposed, and those who self-refer to the Center.
The
Concept of Operations for the Off-Site Triage, Treatment, and Transportation
Center
was written to assist planners, administrators, responders, medical professionals,
public health, and emergency management personnel better prepare for and provide mass
casualty care. This document presents the philosophy of care for the OST
3
C as well as
operational planning considerations. The OST
3
C Concept of Operations is meant to be
flexible and modular. The intention of this document is to provide jurisdictions with a
basic understanding of the OST
3
C so that they can customize the concept to fit their
specific needs and incorporate their version of the Center into the larger response effort.
Emergency planners must undergo a certain amount of preplanning to execute the OST
3
C
concept, practice that plan with supporting agencies, and evaluate and refine the plan
before implementing it in an actual disaster. Some jurisdictions may not enact the
OST
3
C concept but will recognize the need to provide for and plan for some or all of the
critical aspects identified within this document.
The intention of this document is to provide jurisdictions with a basic
understanding of the OST
3
C so that they can customize the concept to fit their
specific needs and incorporate their version of the Center into the larger response
effort.
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The authors gratefully acknowledge the following agencies that have generously
given their time and expertise to the development of
The Off-Site Triage, Treatment, and
Transportation Center Concept of Operation
. In particular, SBCCOM would like to
thank Ms. Irene Lumpkins, Director of Field Health Services, Baltimore City Health
Department, for her contribution and support in developing this concept and for her
chairing the Health and Safety Functional Group.
Participating Agencies:
American Red Cross, Baltimore Chapter, Baltimore, MD
Baltimore City Department of Emergency Medical Services, Baltimore, MD
Baltimore City Department of Public Works, Baltimore, MD
Baltimore City Fire Department, Baltimore, MD
Baltimore City Health Department, Baltimore, MD
Baltimore City Office of Emergency Management, Baltimore, MD
Baltimore City Public School System, Baltimore, MD
Baltimore Mental Health System Inc., Baltimore, MD
Baltimore Police Department, Baltimore, MD
Baltimore Police Department, School Police Division, Baltimore, MD
Columbus Health Department, Emergency Response Division, Columbus, OH
Florida Department of Health, Tallahassee, FL
George Washington University, Washington, DC
Maryland Emergency Management Agency, Reisterstown, MD
Maryland Institute for Emergency Medical Service Systems, Baltimore, MD
Maryland State Department of Agriculture, Baltimore, MD
Navy Environmental Health Center, Norfolk, VA
Phoenixville Borough, PA
United States Public Health Service, Office of Emergency Preparedness, Rockville, MD
United States Public Health Service, Region III, Philadelphia, PA
US Army Medical Services Corps, Joint Regional Medical Planning Office, Ft. George
G. Meade, MD
University of Texas, Southwestern Medical Center at Dallas, Dallas, TX
Yellow Transportation, Baltimore, MD
SPECIAL ACKNOWLEDGEMENT
Patient Flow Concept Development
Philip Forbes, Directors Office, Washington DC Veterans Administration Medical
Center, Washington, DC
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The
Concept of Operations for the Off-site Triage, Treatment, and Transportation
Center (OST
3
C)
is the product of a multi-agency working group, including
representatives from government, military, public health, emergency management
institutions, fire, police, and emergency medical service agencies. The information
presented in this report represents a collaboration of multiple agencies from federal, state,
and local levels in conjunction with scientific technical studies conducted by the U.S.
Army Soldier and Biological Chemical Command (SBCCOM).
The process used to develop the recommendations in this report involved a
comprehensive review of related literature, a series of facilitated tabletop discussions, an
internal panel review by those who would likely staff an OST
3
C, and a full scale
functional exercise whereby an OST
3
C was stood-up in a local school. Additionally, an
independent panel, composed of representatives from other jurisdictions, that may likely
utilize an OST
3
C, also reviewed the concept.
The proposed OST
3
C patient throughput of 80-125 patients per hour, or 400 to
750 patients per six-hour period, is based on the experience of the full-scale exercise.
One hundred and sixteen people, who included law enforcement, decontamination
personnel, runners, medical support, administrative support, transport personnel, mental
health, and OST
3
C Officers, staffed the OST
3
C. The exercise was not specifically
designed to measure patient throughput but rather to test the concept in general.
Jurisdictions inclined to use the OST
3
C concept may use the proposed patient throughput
as a guide, but actual patient flow may differ. Patient throughput is most affected by the
number of staff, the capacity of the decontamination areas, the overall space of the
building, and the ability of officers to dynamically re-assign staff from slower areas to
busier areas.
The concept outlined in this report is neither mandated nor required for
jurisdictions to use when mitigating the consequences of a chemical terrorist incident.
Rather, it is presented to provide technical and operational guidance for those
communities and departments that choose to undertake planning and preparation for
responding to such events. We encourage you to review the data, understand the
implications, and consciously decide what response procedures you would perform.
Once you have made the decision that is best for your community, you should train and
equip your jurisdiction accordingly.
The authors have made every effort to ensure accuracy of the information
contained in this report. The opinions or recommendations expressed in this document
are an informal consensus of the working group participants and do not necessarily
reflect the official position of the U.S. Department of Defense.
This document has been approved for public release. The document may be
freely reviewed, abstracted, reproduced, and translated, in part or in whole, but not for
sale nor for use in conjunction with commercial purposes.
Page 6
- vi -
The use of either trade or manufacturers' names in this report does not constitute
an official endorsement of any commercial products. This report may not be cited for
purposes of advertisement.
U.S. Army Soldier and Biological Chemical Command
Attn: AMSSB-REN-HD-DI (Mr. William Lake)
5183 Blackhawk Road
Aberdeen Proving Ground, Maryland 21010
World Wide Web
http://www2.sbccom.army.mil/hld
Page 7
Foreword
- vii -
The following
OST
3
C Concept of Operations
presupposes that jurisdictions have
conducted standard emergency management planning. This concept is intended to be
part of a
larger disaster response plan and is not intended to function as a stand-alone
tool. Although community authorities may not use the
OST
3
C Concept of Operations
in
the manner it is presented, they will need to address many of the critical components that
the OST
3
C concept identifies.
Emergency managers should conduct an all hazard approach when developing
disaster response strategies. Standard emergency management planning should entail
vulnerability and threat assessments, and resource analysis for all types of hazards, to
include chemical weapons of mass destruction. Planners should identify critical factors
that could affect the response efforts for each type of hazard and develop contingency
plans to mitigate these issues.
Education and communication are key factors of a disaster response plan. The
plan should be conveyed to the public using the most effective and appropriate resources
available. Generally, jurisdictions that focus on educating the public have a more
effective response and citizens exhibit less anxiety.
Catastrophic disasters require planners to coordinate response efforts on a broader
level than typical emergencies. Mutual aid agreements between surrounding counties,
regions, and states must be well defined so that city emergency managers know what
level of support they can expect. Moreover, city emergency planners must have a strong
understanding of the type of infrastructure they will create during a disaster to
successfully integrate the additional resources. In addition, disaster response efforts must
be documented in a particular fashion so that the jurisdiction is granted federal
reimbursement. A meeting with the respective state's representative, who is responsible
for filling out the application for federal support, will help emergency planners prepare to
capture necessary information.
When a disaster warrants the use of an alternative health care facility, like the
OST
3
C, then other services might be needed to support the response effort. These
services include but are not limited to, a Reunification Center, a Family Assistance
Center, casualty transportation services, and mass care shelters. A Reunification Center
functions as an information site and is the central location for people to reunite with
family members. A Family Assistance Center assists medical examiners/coroners in
confirming remain identity, and supports family members of those who died in the
disaster. Casualty transportation services may be beneficial, as patients will need to be
transported from over-crowded hospitals and taken to the OST
3
C, a Reunification Center,
or to their private residence. Mass care shelters provide housing if large numbers of
citizens are without homes due to the disaster.
Our society expects emergency planners and responders to be well prepared in the
event of any type of disaster. Concepts, like those that are described in the OST
3
C, can
facilitate a community's readiness posture.
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Foreword
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Executive Summary .........................................................................................................iii
Acknowledgements........................................................................................................... iv
Preface................................................................................................................................ v
Forward............................................................................................................................vii
Table of Contents ............................................................................................................. ix
1.0 Introduction ................................................................................................................. 1
1.1 Purpose
1.2 Mission
1.3 Background
1.4 Assumptions
2.0 Aspects Influencing Operational Methodology ....................................................... 4
2.1 Similar To A HazMat Response
2.2 Hospitals Will Not Be Able To Handle The Patient Surge
2.3 Re-Distributing Resources During a Disaster
3.0 Facility Requirements................................................................................................. 6
4.0 Organization and Staffing .......................................................................................... 8
4.1 Command: Management Personnel
4.2 General Staffing
4.3 Volunteer Staffing
4.4 Control: Communications
5.0 Scope of Practice........................................................................................................ 15
5.1 General
5.2 Ethics and Liability
6.0 Notification, Activation, and Deployment of Personnel......................................... 16
6.1 Notification
6.2 Activation
6.3 Deployment of Personnel
7.0 Patient Population..................................................................................................... 18
7.1 General
7.2 Unaccompanied Children
7.3 Special Needs Population
8.0 Tracking ..................................................................................................................... 20
8.1 Patient Tracking
8.2 Tracking Patient Belongings
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9.0 Critical Functions...................................................................................................... 22
9.1 Perimeter Security
9.2 Initial Triage/Registration
9.3 Gross Decontamination
9.4 Internal Security
9.5 Detailed Decontamination/Re-Dress
9.6 Re-Triage
9.7 Treatment
9.8 Out-processing
9.9 General Assistance
9.10 Reunification Center
9.11 Transportation
9.12 Temporary Morgue
10.0 Enhanced Capabilities ........................................................................................... 33
10.1 Law Enforcement Investigation
10.2 Victim Assistance
10.3 Pet Management
11.0 Site Shut Down ........................................................................................................ 36
12.0 Conclusion ............................................................................................................... 37
Figures
1 OST
3
C Incident Command System............................................................................... 9
Annexes
A OST
3
C Organizational Chart.....................................................................................A-1
B Performance Objective Matrix.................................................................................. B-1
C Critical Functions and Required Skill Sets ............................................................... C-1
D Patient Flow Diagram................................................................................................D-1
E Mass Casualty Decontamination Algorithm ............................................................. E-1
F Domestic Preparedness EMS Technician Course-Triage Section .............................F-1
G Antidote and Medication List....................................................................................G-1
H Acronyms ..................................................................................................................H-1
I References .................................................................................................................. I-1
Page 11
An Alternative Health Care Facility:
Off-Site Triage, Treatment and Transportation Center (OST
3
C)
Abstract
Given the potential for acts of terrorism it is now imperative that health care systems be
prepared to respond to a chemical weapons attack on a civilian community. An alternative
temporary medical care facility, herein referred to as the Off-Site Triage, Treatment, and
Transportation Center (OST
3
C or the Center) is envisioned to supplement the existing health
care system in managing the overwhelming number of casualties, both actual and perceived,
following a terrorist incident. It has been designed by the Improved Response Program (IRP)
under the auspices of the Department of Defense's Domestic Preparedness Program via a series
of exercises called Baltimore Exercises (BALTEX).
The OST
3
C will be capable of handling approximately 80-125 non-critical patients per hour (or
400 to 750 patients during a six-hour period). In addition to triage and treatment, patients will
also undergo a detailed decontamination meant to remove chemical contaminants. The patient
care endpoint is either transport to a higher level of care facility or discharge to home with self-
care instructions.
The goal of the OST
3
C is to provide care for a specific patient population and thereby improve
overall patient outcome for the community. By re-directing those who are triaged Minimal at the
scene, the psychophysiologic casualties who have no physical injury (anticipated ratio of
psychophysiologic casualty to actual casualties is expected to be at least 5:1), the non-critical
patients that show up at over-crowded hospitals, and the citizens who self-refer directly to the
Center, hospitals can focus on patients who require in-hospital services and the OST
3
C can
focus on patients who need basic symptomatic and supportive care.
The OST
3
C is an interim patient clearinghouse that will be disassembled once the flow of new
patients has diminished to the point that they can be handled by the existing health care system.
1.0 Introduction
1.1 Purpose
The purpose of this document is to describe an alternative health care facility concept
developed by the Improved Response Program (IRP). The information herein may be
used as the basis from which governmental jurisdictions, agencies, or health care systems
can develop an alternative health care facility as part of their own emergency response
plan.
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An Alternative Health Care Facility
2
1.2 Mission
The mission of the OST
3
C is to supplement the existing health care infrastructure by
providing triage, decontamination, treatment, and if necessary transportation to a higher
level of care, for victims of a chemical weapons attack or similar emergency.
1.3 Background
The threat of chemical or biological terrorist attacks against U.S. citizens is of national
concern. The Tokyo subway attack in March 1995 illustrated the likelihood of a
chemical weapons attack against a civilian population and the overwhelming impact
5,500 patients had on the existing health care system. This occurrence, together with
other more recent national and international terrorist incidents, heightens concerns about
the United States' ability to effectively manage incidents involving chemical agents.
It is the intent of terrorists to cause damage and confusion in an attempt to throw society
into a state of chaos. They are more tempted then ever to use weapons of mass
destruction (WMD) for an attack because of their
effectiveness in creating mass casualties and hysteria. It is
impossible to predict exactly which agents will be used,
how they will be disseminated, where they will be
employed, and which population will be targeted. The best
way to effectively mitigate the effects of a chemical WMD
incident is through comprehensive planning, training, and
preparation.
The Tokyo Sarin attack exemplified how even an educated civilized society responds to
an act of terrorism. The ratio of those who thought they were injured to actual casualties
was 5:1. Twelve people died as a result of the incident, less than 200 patients were
treated as hospital inpatients and approximately 1,000 others needed to be evaluated and
treated in the emergency department; yet more than 4,500 additional people sought
medical care.
The overwhelming number of casualties from a WMD incident will put a tremendous
strain on a community's health care system. Victims might leave the scene contaminated
and attempt to seek medical care on their own. They may arrive at their private
physicians' offices, managed care organizations, and local emergency departments
without the benefits of decontamination or triage. They could contaminate their own
homes, their loved ones, and anywhere they may go from the incident site.
The Off-Site Triage, Treatment, and Transportation Center (OST
3
C) supplements the
existing health care system in managing the overwhelming number of casualties, both
actual and psychophysiologic, following a terrorist incident.
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An Alternative Health Care Facility
3
Most hospitals will have difficulty coping with the sudden onslaught of patients and the
need to decontaminate those victims arriving from the scene. In order to cope with these
large numbers of patients, communities should be prepared to activate pre-planned mass
casualty plans.
The IRP, under the auspices of the Domestic Preparedness Program, through a series of
exercises entitled Baltimore Exercises (BALTEX), identified key response issues unique
to a chemical weapon of mass destruction incident. These exercises identified the need
for jurisdictions to formulate response plans that optimize their existing resources by
coordinating them differently during a disaster. One recommendation was to re-direct
less serious, potentially contaminated, and possibly psychophysiologic casualties to an
interim medical facility to avoid purposefully overwhelming the health care system.
In an attempt to manage a large number of casualties, the IRP developed an alternative
health care facility concept. This facility, referred to as the Off-Site Triage, Treatment,
and Transportation Center or OST
3
C, is a casualty clearinghouse that is capable of
handling between 80-125 non-critical patients per hour, or 400-750 victims during a six-
hour period. The OST
3
C facility can be replicated to meet the need to handle a larger
patient population. The duration of the OST
3
C is short-lived, as most chemical agent
casualties will not require extended patient observation or in-hospital patient care.
1.4 Assumptions
1.4.1 The citizens of the United States are subject to an act of chemical
terrorism.
1.4.2 A well-planned chemical agent release is likely to produce a significant
number of casualties that will overwhelm the current health care system.
1.4.3 Some chemical agents (e.g., mustard agent) produce delayed signs and
symptoms of contamination. Patients exposed to theses types of agents
are more likely to cross-contaminate those with whom they come in
contact.
1.4.4 Most chemical agent liquid exposures (e.g., nerve agent) will produce
immediate signs and symptoms. Those patients who have been exposed to
nerve agent and only present with mild signs and symptoms will likely not
die from agent exposure.
1.4.5 A terrorist attack involving a chemical WMD will have instantaneous
effects on the community's emergency response system.
1.4.6 Local hospitals can expect to receive contaminated victims directly from
the scene.
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An Alternative Health Care Facility
4
1.4.7 Potentially contaminated victims will self-refer to the closest medical
facilities and private medical care providers.
1.4.8 There will be a large number of ambulatory psychophysiologic casualties.
1.4.9 A mass casualty management system that rapidly integrates existing
medical resources will be needed to care for victims.
1.4.10 People will be reluctant to go to an alternative health care facility and will
still attempt to enter traditional hospital emergency departments.
1.4.11 During a large-scale chemical terrorist incident the standard of care may
temporarily change to provide the most effective care to the greatest
number of people affected.
1.4.12 The local health department will play a role in assisting hospitals by
supporting the activities of alternative health care facilities.
1.4.13 Most health departments have medical staff trained to a minimum of the
first responder level.
2.0 Aspects Influencing Operational Methodology
2.1 Similar To A HazMat Response
Responding to a terrorist attack, which involves the use of chemical agents, is similar to
a hazardous materials (HazMat) response, with the exception of the following:
*
There exists the potential for an extremely large number of casualties because of the
deliberate nature of a terrorist incident.
*
Since the incident is a deliberate attack, there is a
concern that secondary devices will be employed
targeting responders.
*
The entire incident is a crime scene requiring the
collection of criminal evidence and suspicious
victim belongings. The preservation of a proper
chain of custody must be maintained for all
evidence.
Managing a chemical weapons (CW) incident requires addressing all these concerns;
therefore those providing patient care at the OST
3
C need to be aware that patients could
be suspects and their belongings may be evidence.
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An Alternative Health Care Facility
5
As with a large HazMat incident or any multiple casualty incident, it is imperative for
the emergency response community to ascertain whether or not the hospitals in the area
will be able to cope with the sudden surge of patients. With appropriate training and
forethought these responders will be in a better position to evaluate the impact that will
be placed on the health care system.
2.2 Hospitals Will Not Be Able To Handle The Patient Surge
Traditionally in any type of HazMat incident, hospitals provide the bulk of
decontamination and treatment for victims. In a CW incident however, it is
questionable if hospitals will be able to handle the patient surge, as HazMat incidents
produce only a few casualties and CW incidents can produce a multitude of patients.
Most hospitals are not prepared to decontaminate a large number of potentially
contaminated patients. Such an influx of patients may threaten the integrity of the
hospitals and the safety of their personnel. If a few hospitals shut down in a particular
health care system, due to internal contamination, then the system may no longer be in
a position to care for the remaining casualties.
Maintaining the current or routine patient load for a community is an important
consideration during a mass casualty incident. For example, there will still be people
who will suffer from heart attacks (possibly even more than normal, which occurred in
the 1996 Centennial Park bombing in Atlanta, (Nordberg, 1996)), medical emergencies,
motor vehicle collisions, traumatic incidents, etc. The health care system must continue
to accommodate the so-called "unaffected community."
In addition to the patients transported from the incident scene, the health care system
will be inundated with the following populations:
*
Large numbers of psychophysiologic patients.
*
Victims who have left the scene and seek treatment
on their own.
*
Friends and family members seeking information
regarding casualties.
In order to accommodate the patient surge, hospitals should look to initiate their own
disaster plans. Those disaster plans may include discharging patients that can be
moved to outlying facilities or to their respective homes. Other options may include
relocating some of the in-patient populations, who are stable enough, to a ward unit or
unused portion of the hospital. Further options may include transferring patients to an
alternate location outside the hospital to make room for patients arriving from the
incident.
Hospitals will not be able to accommodate the patient surge from a terrorist incident
involving chemical weapons of mass destruction. This was evident in the 1995 Tokyo
Sarin incident that resulted in over 5500 patients trying to enter the health care system.
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An Alternative Health Care Facility
6
2.3 Re-Distributing Resources During a Disaster
Ideally, hospitals should continue to provide care for those patients who need a level of
treatment that only a hospital is most suited to provide. Hospital resources even under
disaster conditions cannot be easily replicated, supplied, or staffed. The traditional
mission of a hospital may shift during a disaster from rendering care for the community
at large to rendering care for acute patients.
A more generally accepted premise in disaster management is to provide treatment for
triaged Minimal patients outside traditional emergency departments. Minimal
casualties require considerably less resources thereby making it easier to provide
appropriate care in non-traditional settings. Minimal casualties generally do not require
in-patient services, or extensive medical tests, nor do they demand acute care treatment.
Well before hospitals are taxed beyond their capability or when the health care system
is forced to handle a patient load beyond its designed ability, a jurisdiction should
establish a means to treat casualties outside the boundaries of the traditional hospital
realm. One example of an alternative health care facility is the OST
3
C.
Emergency managers must determine when opening one or more alternative health care
facilities is beneficial. Several factors influence when a community should set-up an
OST
3
C or when treating casualties outside the normal hospital setting is beneficial.
Such factors include but are not limited to:
*
The size/magnitude of the incident.
*
The geographic distance from the incident site to a planned alternative health care
facility site.
*
The need to care for patients within a reasonable period of time.
*
The expected surge of patients will likely occur within the first six hours of the
incident.
*
The length of time needed to stand-up an OST
3
C.
*
The optimal number of patients that can be treated per hour in proportion to the
number of staff available to operate each Center.
3.0 Facility
Requirements
An
ideal
OST
3
C
has the following resources. It can be established however, with considerably
fewer resources and adapted to fit a jurisdiction's assets and disaster plans.
*
Separate male and female locker rooms and showers.
*
Large open areas to support helicopter delivery of state and federal resources.
*
Spacious parking facilities.
*
Good internal access roads, allowing for emergency vehicle ingress and egress.
*
Electricity, preferably with generator backup.
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An Alternative Health Care Facility
7
*
Internal and external water supply (e.g., fire hydrant).
*
Access to sanitary sewer system.
*
Easily identifiable to the public.
*
Large enough facility to co-locate multiple services within one campus, (e.g., patient
decontamination/treatment, crisis intervention, law enforcement investigation, animal
decontamination).
*
Gymnasium or large room.
*
Bathrooms.
*
Heating/Air Conditioning/Ventilating System that can be sectored off to avoid cross
contamination.
*
Securable internal and external rooms.
*
Chairs.
*
Tables.
*
Areas to post information (e.g., chalk and bulletin boards).
*
Public announcement systems.
*
Cafeteria/food service facility.
*
Auditorium.
*
Copy machine.
*
Fax machine.
*
Hard-wired phone lines.
Examples of buildings that may have much of the recommended items or buildings that can be
modified to facilitate an OST
3
C include fitness centers, medical buildings, hotels, college
dormitories and campus facilities, motels, high schools, and middle schools. Even warehouses
and tents can be converted into an OST
3
C, providing a jurisdiction is prepared to allocate
extensive resources to set up such a facility. Of the aforementioned facilities, high schools and
middle schools contain much of the needed equipment and may be an optimal choice for many
jurisdictions.
For any building to be readily available as an OST
3
C, there should be a specific memorandum of
understanding (MOU) in place between the lead agency, which would be designated by a
jurisdiction's emergency management agency, and the superintendent of the facility. A
jurisdiction may need a separate memorandum for each building that is designated as a possible
OST
3
C.
Planners may want to identify possible alternate health care facility sites based on the locations
of suspected terrorist targets or based on pre-existing resources that would supply staff and
equipment to the OST
3
C, such as a hospital. Planners should be careful to outline buildings that
have not been previously committed as disaster assets (e.g. Red Cross Shelters, National Guard
Armories). An OST
3
C should be easily recognized and its location should be accessible by the
Facilities that have the following items are optimal: male shower/locker room, female
shower/locker room, large parking areas, good access roads, easily identifiable by the public,
large gymnasium or similar area, electricity, heating, securable internal and external rooms for
storage, and internal and external water supply.
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8
general public. Ideally, it should be located close to the population it would serve although
outside of the affected or contaminated area. It should be close to public transportation for those
individuals who self-refer.
If the initial incident is an alleged terrorist attack, then building security is a major facility
requirement. Planners must choose a building that can be secured and its access roads easily
controlled. Officers should consider that terrorists might employ secondary devices targeting
patients and staff, thus they should routinely perform sweeps of the facility and the surrounding
grounds as part of their perimeter security effort.
Memorandums of understanding (MOU) should address how the point of contact for each
building will be notified, how the building will be evacuated if necessary, and if any specific
personnel from the building are needed to staff the OST
3
C such as the building maintenance
engineer.
Once buildings have been identified as potential OST
3
Cs, the lead agency should review those
buildings and determine how patients will move in and through the building/campus. The
jurisdiction should make notes regarding the particular needs for each building, specifically for
buildings that do not have the aforementioned resources.
The potential exists that the facility may become contaminated during its use. Wooden floors for
example, are specifically subject to irreversible contamination, as they are porous. Jurisdictions
may choose to use older buildings first so that new facilities are not razed or closed down if the
building cannot be fully decontaminated. Even if a building is fully decontaminated, the
jurisdiction may need to temporarily close down a building due to the initial stigma that may be
associated with a supposed "contaminated" building.
4.0 Organization and Staffing
The command and control for the OST
3
C is modeled after the Medical Aid Station Incident
Command System (MASICS). MASICS is a medical management plan based on the nationally
recognized Incident Command System/Incident Management System (ICS/IMS) intended for use
during medical crises.
It is important to note however, that the MASICS management plan must be altered to prevent
cross-contamination at the OST
3
C. Those who staff the Warm Zone (contaminated portion) of
the Center must remain in the Warm Zone and those who staff the Cold Zone (uncontaminated
portion) of the Center must remain in the Cold Zone. Annex A delineates a proposed
organizational chart, but jurisdictions may revise the chart to suit their resources and
terminology. Each jurisdiction should determine necessary key positions to accomplish each
function.
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4.1 Command: Management Personnel
4.1.1 OST
3
C Commander
Overall command and control falls under the auspices of OST
3
C Commander. A
jurisdiction's emergency management agency (EMA) must designate a lead
agency for the OST
3
C. Agencies that may be best suited as the lead agency
include a community's emergency management agency, fire department, EMS
department, third party EMS service, or health department. The lead agency will
assign the role of the OST
3
C Commander.
Critical functions of the OST
3
C Commander include:
*
Manage and control the overall operation of the facility.
*
Coordinate the operation of the Center so it can function at the highest level of
efficiency possible, given available staff and equipment.
*
Report staffing and resource needs to the lead agency.
*
Appoint officers for the other command functions. (
See Figure 1.0).
Figure 1.0-OST
3
C Incident Command System
4.1.2 Safety Officer
The Incident Command System requires the use of a Safety Officer. The
critical function of the Safety Officer is to monitor safe practice at the Center
and mitigate any safety issue before undo harm is posed to personnel or
patients. Like other operations involving contaminated zones, the lead agency
may determine to staff additional safety officers in specific zones to avoid
Operations
Chief
Planning
Chief
Finance
Administrator
Logistics
Chief
Safety Officer
Information
Officer
OST
3
C
Commander
Medical
Director
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10
cross-contamination. The IRP also recommends there be a Safety Officer in the
Cold Zone and the Warm Zone of the Center.
4.1.3 Information Officer
The critical functions of the Information Officer are to release information to
patients and the media in accordance with the jurisdiction's protocols. This
officer will be responsible for both internal briefings for patients and external
briefings for the public as a part of the Incident Commander's public affairs
plan. The OST
3
C Information Officer must be linked to the Joint Information
Center (JIC) so that all information regarding the incident is consistent,
accurate, and released to the public in a controlled manner. The Information
Officer generally disperses information regarding the incident, hotline/help-line
numbers, and information regarding the location of those transferred from the
Center. Public confidence is strengthened when the same individual makes
these announcements at regular intervals.
4.1.4 Operations Chief
Critical functions under the Operations Chief include security, triage,
decontamination, treatment, and patient out-processing. Jurisdictions may use
sectors or zone operation chiefs to accommodate the Warm and Cold Zones of
the Center and divide critical functions accordingly.
The Warm Zone Sector Chief should oversee the following critical functions of
the OST
3
C operation:
*
Perimeter security.
*
Traffic control.
*
Initial triage.
*
Gross decontamination.
The Cold Zone Sector Chief should oversee the following critical functions of
the OST
3
C operation:
*
Internal security/detention.
*
Detailed decontamination/redress.
*
Re-triage.
*
Treatment.
*
Out-processing.
*
General assistance.
4.1.5 Logistics Chief
Critical functions within logistics include transportation, facility maintenance,
communications, and supply. Transportation must be coordinated as patients
will arrive from the scene by bus or will self-refer. They may arrive by private
vehicle, bicycle, commercial transportation, or foot. Transportation also
includes coordinating patients requiring transfer to outlying hospitals.
Transferring patients to area hospitals requires coordination with the on-scene
Transportation Officer as to which hospitals are available to receive patients.
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11
Additionally the transportation component must organize transport for citizens
to a Reunification Center or home.
Another logistics critical function includes developing and maintaining an
internal and external communications system at the Center. The system may
include 2-way radios, cell phones, laptops, computer network, palm pilots,
runners, or whatever technology the jurisdiction presently uses.
The facility must also be maintained. Logistics must coordinate for the
mundane needs of staff and patients such as bathrooms, water supply, chairs,
tables, food service, and securable rooms. The IRP recommends that a person
who is familiar with the facility provide maintenance support for the OST
3
C.
Logistics must also organize and coordinate pharmaceutical and supply
acquisition and distribute such items throughout the Center, both in the Warm
and Cold Zones. Staff must create an approach to deliver equipment in the
Warm Zone of the Center without perpetuating cross-contamination.
4.1.6 Planning Chief
Critical functions within the planning section include maintaining a liaison role
between the multiple agencies that support the Center and the OST
3
C
Commander. Agencies need one point of contact to discuss personnel and
supply support. Often the OST
3
C Commander will be engaged in coordinating
the efforts of the Center and will not be immediately available for this function.
Another critical function of planning is organizing the staff and assigning them
to appropriate positions. Medical licenses and credentials must be verified
before staff are assigned. Furthermore, those assigned within the Warm Zone
must be given personal protective equipment (PPE).
Since the Planning Chief is directly involved with each agency and with
assigning staff, he/she will know the current capability of the Center. Once the
Center is fully staffed and the maximum number of patients is being treated per
hour, the Planning Chief may request that other Centers open to handle
additional patients if necessary.
Lastly, the Planning Chief must develop a means to track patients through the
Center. This task can be delegated to others assigned within this division, but
such information regarding how many patients are entering the system, is
necessary to planning the overall needs of the Center.
The Incident Command System helps jurisdictions organize the OST
3
C and
divides tasks within each respective officer's span of control.
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4.1.7 Finance Administration
The finance section has the responsibility for accounting for the costs associated
with the operation of the OST
3
C. It is important that all personnel at the OST
3
C
document employee hours and associated costs to include supplies,
pharmaceuticals, transportation, food, etc., to facilitate disaster relief money
reimbursement. Additional functions will include:
*
Staff time keeping.
*
Filing compensation claims.
*
Authorizing the purchase of supplies.
4.1.8 Medical Director
The medical director has the responsibility for overseeing all medical aspects
associated with patient care at the OST
3
C. The medical director should be
located specifically in the treatment area, assisting other providers with patient
treatment, and should be in direct radio contact with triage personnel stationed
in the Warm Zone of the Center. The medical director reports directly to the
Operations Chief but can provide the OST
3
C Commander input and should be
considered part of the command staff.
4.1.9 Inter-Agency Command Post
Establishing an OST
3
C requires coordinating several agencies from one
jurisdiction. The OST
3
C Commander must establish an Inter-Agency
Command Post. The Commander must brief all chiefs and officers regarding
their primary objective and to whom they directly report. Each agency should
present their current capability and their ability to accomplish their designated
objective. Such briefings should be held on a regular basis.
Following the briefing, chiefs/officers should meet with those who will support
their designated objective. Officers should hand out written job descriptions,
relay if staff need to wear PPE, specify to whom they report, confirm from
whence patients originate, and where patients need to go, before the Center is
ready to receive patients. The IRP recommends that officers provide staff, in
writing, any specific information that is different from what they are
accustomed to performing on a daily basis (e.g., administering antidote
treatment therapy).
4.2 General Staffing
There are many critical factors jurisdictions must consider when composing a
compliment of staff to work at the OST
3
C. Each jurisdiction will have different
resources from which to draw, therefore the specifics for staffing the OST
3
C should be
planned by the jurisdiction.
One factor that directly affects the number of staff needed is the number of OST
3
Cs a
jurisdiction may establish at one time. The IRP identified that a community must be able
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13
to process the majority of casualties within the first six hours following an incident. Thus
a jurisdiction may need to open more than one OST
3
C. The decision to open multiple
Centers will be based on an estimated number of patients and the availability of personnel
and supplies. Moreover, the geographic location of the incident or location of assets may
influence the decision to open several Centers to accommodate the patient surge.
The maximum number of patients that can be evaluated
and treated within the first six hours is directly
proportional to the number of personnel who staff a
Center. Other variables that strongly influence the
number of patients that can be decontaminated and
treated include ambulance transportation availability, the
maximum capability of gender specific showers, and
how quickly patients can be transferred from the Center
to home or a Reunification Center.
All OST
3
C staff should receive Domestic Preparedness (DP) Awareness and Operations
training and be familiar with the OST
3
C Concept of Operation. Annex B outlines
training performance requirements, based on the 120 City Domestic Preparedness
Training Program, called the Performance Objective Matrix, (Supporting Information
Section, of the CWIRP Playbook, 2001). In exigent situations, when jurisdictions are
unable to staff the Center with people who have received this training, the general staff
should be assigned positions that are closely related to their regular job function.
(For
more information regarding the type of staff an OST
3
C requires, see Annex C. Annex C
correlates the required skill set staff need to perform each critical function.)
Another critical factor when selecting staff is their ability to perform assigned tasks while
wearing Personal Protective Equipment (PPE). There are specific safety requirements
associated with PPE that individuals must meet, especially with respirators (29 Code of
Federal Regulation 1910.120, 1910.134). Again, the jurisdiction may need to assign staff
that are already accustomed to wearing PPE to specific roles in the Warm Zone of the
Center, whereas others can be assigned within the Cold Zone.
Sources that may be able to allocate medical providers include volunteer fire and EMS
departments, private ambulance companies, allied health agencies, and health
professional education institutes (e.g., physician/medical school, nursing, nurse
practitioner, physician assistant, and paramedic schooling programs). Veteran's
Administration hospitals, home-health agencies, and temporary nursing agencies may
also be able to medically support the efforts of the OST
3
C. Laboratories,
epidemiologists, and health departments may have staff that could support data collection
and tracking functions.
Some jurisdictions may not have the capability to support an alternative care facility due
to a lack of staff. Under disaster circumstances, jurisdictions may request specific
institutions (i.e., hospitals and clinics), to allocate a certain number or percentage of staff
to disaster relief functions. For example, Florida State Sheriff's Department has a
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14
Statewide Emergency Mobilization Plan that mandates in the event of a Level I Disaster,
each law enforcement agency will assign a voluntary number of their work force to the
disaster relief effort; in a Level II Disaster, 5% of the work force is required, and in a
Level III Disaster, 10% of the work force is required to support disaster relief efforts
(Florida Sheriff's Association Statewide Task Force, 1999). The magnitude of the
disaster will determine the level of disaster and thereby the number of staff to mobilize.
Jurisdictions should consider applying the Florida mobilization concept to staff
alternative health care facilities. Though it may appear that a hospital's capability is
decreased as its in-house staff is assigned to a disaster effort that will only be the case,
preliminarily. Overall, the larger incident will be better managed and consequently fewer
patients will flood the hospitals, thereby creating less strain on the health care system.
4.3 Volunteer Staffing
Volunteer organizations can be a good source for additional staff. Some jurisdictions
may already have established a disaster volunteer compliment of personnel. The more
prepared this pool of personnel are, the easier it will be to assign them to an alternative
health care facility or any disaster relief function. Jurisdictions may need to offer
volunteer workman's compensation coverage, train them on Domestic Preparedness
Awareness and Operations, and pre-credential them to facilitate overall placement at the
OST
3
C. A recommended list of training performance requirements is listed in Annex B
called the Performance Objective Matrix. This matrix is based on the 120 City Domestic
Preparedness Training Program (Supporting Information Section, CWIRP Playbook,
2001).
When a jurisdiction must depend on a large contingent of volunteer support, the IRP
recommends that the lead agency assign key personnel to leadership positions and place
volunteers in support roles.
Should citizens arrive at the OST
3
C attempting to volunteer their services, the OST
3
C
Commander or Planning Chief should direct them to the larger part of the Incident
Command structure that supports assigning volunteers. Those in charge of logistics for
the entire incident will be better prepared to assign personnel to areas that have the
greatest need. Moreover, jurisdictions must verify medical credentials/license, training
and suitability before assigning persons to medical positions.
4.4 Control: Communications
The OST
3
C must have a communication system. The form of communication, e.g., 2-
way radios, cell phones, runners, or networked computers, will depend on the
jurisdiction's available resources. Like any disaster, communications is vital to the
Under disaster circumstances, jurisdictions may need to initiate MOUs with specific
institutions to allocate a certain number or percentage of staff to the disaster relief
effort.
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15
overall operation at the OST
3
C. The lead agency is responsible to provide a
communication system that works and that their people know how to use.
As in any disaster the lead agency should prepare a backup communication system. If
that system entails the use of runners, the logistics chief must educate staff how to
effectively use them.
Implementing a communication system, which is already in place or a type of technology
that personnel are already accustomed to using, is the most helpful. Some jurisdictions
may have elaborate communication systems with palm pilots, barcode readers, networked
computer laptops, etc. Other jurisdictions may still use paper systems. Whatever
technology is used, the OST
3
C should staff the appropriate level of technological support.
5.0 Scope
of
Practice
5.1 General
General care provided at the OST
3
C will be performed at the basic life support (BLS)
level. Jurisdictions can determine additional aspects to providing general supportive care
based on their assets. If a jurisdiction has the capability to provide a contingent of
advanced life support (ALS), the medical director for the OST
3
C should allocate these
resources to the treatment area to stabilize patients who become critical.
The OST
3
C is not intended to be a definitive care site nor is it intended to operate at the
level of a traditional emergency department. Staff should conservatively assess a
patient's chief complaint, vital signs, and pre-disposing medical history when
determining if a patient should be sent to a higher level of care facility.
Although the OST
3
C operates at the basic life support level,
jurisdictions may want to broaden its scope of practice to
include administering chemical agent antidote. Ultimately
jurisdictions must determine how much antidote to allocate
to the OST
3
C effort and if the antidote is for patients or
staff. If jurisdictions do allocate a small cache of antidote,
the IRP recommends that jurisdictions place it where
patients are initially triaged to help stabilize those who
arrive in critical condition.
General care at the OST
3
C will be performed at the basic life support level. The OST
3
C is
not intended to provide definitive care.
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5.2 Ethics and Liability
Depending on the magnitude of such an event, the level of care that American citizens are
accustomed to will temporarily change to effectively care for the greatest number of
victims. Medical decisions at every level will be made swiftly and will be based on
limited information and can only be enacted based on limited resources. In response to a
chemical mass casualty incident, planning should clearly indicate the level of care that
will be provided at specific treatment facilities.
Jurisdictions should develop guidelines regarding the scope of practice and document
them as part of their jurisdiction's plan for responding to chemical terrorism. These
guidelines should be formulated with state licensing and public health agencies and
approved prior to use.
Jurisdictions should consider developing guidelines pertaining to the OST
3
C with ethics
professionals and the state's attorney general. Aspects that affect a citizen's basic
expectations regarding level of care, patient confidentiality, and patient privacy, may
concern citizens to the point of pursuing litigious outcomes in the aftermath of the
disaster. Although the community would not directly dispute that the enormity of the
disaster will likely affect the availability of resources, they will grow concerned when
there is a change from the medical norm. Plans developed with input from the
aforementioned officers will minimize litigation resulting from implementing the OST
3
C
concept.
6.0 Notification, Activation, and Deployment of Personnel
6.1 Notification
Jurisdictions must determine the lead agency to manage and coordinate OST
3
C efforts. A
representative of the lead agency should be assigned the task of maintaining the plan so
that it does not become antiquated. Though it need not be a full time duty, appointing a
responsible lead agency will help the community's readiness posture.
The lead agency should establish a notification process to activate those other agencies
that will support the OST
3
C. The notification process should follow pre-established
protocols and call-down lists. Automated emergency phone calls, reverse 911 systems
and/or automated fax notifications are methods to notify supporting agencies of an
OST
3
C activation.
Part of the notification process includes informing hospitals where the incident occurred,
the chemical agent, the impact of the incident, the level of personal protective equipment
hospital personnel should wear, signs and symptoms that warrant treatment, treatment
modalities, as well as specific information regarding the OST
3
Cs. Regarding the OST
3
C,
the notifications should specify the following:
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17
*
The location of the OST
3
Cs.
*
The purpose of the OST
3
C.
*
Its anticipated duration of operation.
*
What kinds of patients should be re-directed to the OST
3
C.
The lead agency should also notify mass transportation assets and inform them of the
aforementioned information, if they will be used in conjunction with establishing the
OST
3
C.
The public must also be informed of the OST
3
C. The media should be briefed and their
help enlisted in disseminating accurate information to the public. The lead agency should
request that the Public Information Officer at the Emergency Operations Center (EOC)
announce the OST
3
C's purpose, location, and duration of operation. Involving the media
early will help inform the community that they can obtain care quickly and it will instill
the public's confidence that an alternative health care facility will be able to help them.
6.2 Activation
The amount of time a jurisdiction needs to establish an OST
3
C can greatly influence its
effectiveness in mitigating a mass casualty incident. If it takes an extensive period of
time to establish an OST
3
C, it may not be a valuable tool. The OST
3
C should be
operational within approximately one hour of notification. Activation procedures will
entail the lead agency deploying specific pre-packaged resources/equipment that can be
automatically delivered to or stored at an OST
3
C site, or requiring supporting agencies to
deploy pre-packaged disaster items.
To decrease the amount of time needed to open an OST
3
C, the IRP recommends that staff
and resources should not be mobilized at one central location but rather at each agency's
headquarters or other pre-determined location. Each supporting agency should mobilize
their own required staff and resources and be responsible to check their personnel's
credentials/identification and deployment readiness. Each agency should maintain their
own personnel rosters and staff assignments at the OST
3
C and share the information with
the OST
3
C Commander. Once agencies are mobilized they should report directly to the
OST
3
C and send an agency representative to the OST
3
C Command Post.
6.3 Deployment of Personnel
Assigned personnel should report directly to the OST
3
C. An agency representative
should report to the Planning Chief and brief the chief of their present capability. The
Planning Chief should remind the agency of their primary mission, hand out written
Jurisdictions must determine the lead agency to manage and coordinate OST
3
C efforts.
A representative of the lead agency should be assigned the task of maintaining the plan
so that it does not become antiquated.
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18
objectives/tasks, request that they assign personnel to specific jobs, obtain a staff roster
from the agency and request that those assigned to leadership roles report to the
command post at a specific location and time.
7.0 Patient
Population
7.1 General
The intent of the OST
3
C is to care for the following types of patient populations:
*
Triaged Minimal patients from the scene that have been
transported by EMS.
*
The self-referring patient population upon hearing a
public announcement.
*
The psychophysiological patient.
*
The non-critical patients that arrive at area hospitals but
would be more appropriately cared for at the OST
3
C.
For the purposes of this concept, Minimal will be defined as a known casualty that was at
the incident site and falls within the triage parameters of Minimal versus Immediate or
Delayed. In general, patients who fall within the Minimal category can breathe
spontaneously, are oriented to their surroundings and have adequate circulatory/tissue
perfusion.
Psychophysiological patient is defined as persons who present at health care facilities
with the intent of receiving a medical evaluation and treatment. Often these patients may
not have been part of the initial incident nor have they sustained a physical injury. The
psychophysiological patient generally does not have any physical ailments but do believe
that they may have some physical injury and are concerned that they have been harmed.
These patients do need a medical evaluation and emotional support.
Non-critical patients fit the same description as Minimal, however, hospital personnel do
not always triage patients in the same manner as EMS providers. Patients generally fall
into other sub-categories such as acute/critical, monitored, and non-critical/fast track.
Non-critical patients do not require in-patient hospitalization. Based on the assumption
that many patients will leave the scene and arrive at area hospitals seeking care, those
patients that hospital personnel deem non-critical may be more appropriately cared for at
the OST
3
C. This is especially true when an excessive number of patients are waiting for
care at a hospital.
The OST
3
C is intended to care for patients that were triaged Minimal at the scene, the
psychophysiological patient, the non-critical patients who show up at over-crowed
hospitals and those who self-refer.
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Patients transported from the incident scene to the OST
3
C may have received at best an
initial triage evaluation but no treatment. Self-referring patients will not have been
evaluated at all. It is possible that even though the Center is not intended to receive
critical patients, Immediate or Delayed self-referring patients may arrive.
Most of the patients who arrive at the OST
3
C may not have been decontaminated. Some
patients, especially the elderly, may have refused to remove their clothes or to be wet
down at the incident scene. Parents with young children may not have wanted them
exposed to environmental elements especially in inclement weather. Therefore, providers
will not know if patients are contaminated.
7.2 Unaccompanied Children
It is likely that the OST
3
C, as well as all health care facilities, will
receive unaccompanied children during a disaster. Children may have
been separated from their parents at the scene and arrive at the OST
3
C
without them; or families who arrive at the Center may be separated
from their children when directed to the detailed decontamination
area; or critical patients requiring immediate transfer to a higher level
of care may result in unaccompanied children.
Jurisdictions must plan to manage unaccompanied children. One suggestion is to buddy
mental health providers with those children that show up unaccompanied. In situations
when children may become separated from their parents after they arrive at the Center,
jurisdictions may choose to process families according to the family member having the
highest triage category to prevent separation. In either case, staff will need to make
provisions for managing unaccompanied children, which may include contacting
extended family members that can care for the child and watching the children until they
are taken home.
7.3 Special Needs Population
Elderly and handicapped patients may also arrive at the OST
3
C seeking care. These
patients can fall into the Minimal or non-critical triage category but have difficulty
ambulating at the Center, (e.g., the blind). Staff must take into consideration that the
OST
3
C demands a lot of walking and navigating through the building. Additionally,
decontamination areas will be slippery and staff may be needed to physically assist
patients. Moreover, jurisdictions may purposefully choose older buildings, which may
not be handicapped accessible.
Options may include:
*
Staffing the OST
3
C with additional patient assistant volunteers.
*
Re-directing all physically challenged persons to traditional emergency departments.
*
Setting up OST
3
Cs in handicapped accessible buildings.
*
Making existing buildings more handicapped accessible with portable wheelchair
ramps and portable outside showers.
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8.0 Tracking
8.1 Patient Tracking
Most factors that influence patient tracking at the OST
3
C are similar to what a
jurisdiction would confront for other mass casualty incidents (MCI). There are a few
issues, however, that may likely present during a chemical terrorist incident (as well as at
the OST
3
C) that would not necessarily present during other MCIs.
One critical factor to consider when tracking patients is that a terrorist incident can create
an excessive number of patients. To triage 500 patients in the same manner that EMS
would triage 50 patients may be too time consuming and ill effective. If it takes
approximately 30-60 seconds to triage each patient (using the START Triage method)
and track them by a roster, it would take over four hours to triage 500 patients.
Jurisdictions may need to use other methods of collecting triage data. Howard County
Fire and Rescue Services in Maryland is experimenting using a tape recorder to expedite
the process. Minimal casualties speak and spell their name into a tape recorder which
cuts the time spent per person down to approximately 15 seconds.
Patients that are processed at the OST
3
C must be tracked and their medical
status/evaluation documented. Some jurisdictions may choose to begin patient tracking
after patients have undergone decontamination and treatment, leaving all data collection
until the end of the process. Other jurisdictions may determine that they must capture
only a name and a triage tag number/identifier, at the beginning of the process (e.g.,
during initial triage). If patients leave the Center before they have completed the process,
then a more accurate list of who arrived at the OST
3
C is available. Overall, patients that
arrive at the OST
3
C may have been waiting and thus will want to be treated right away.
Patients may no longer tolerate the "system" when paperwork hinders their ability to
obtain treatment.
Tracking methods may include the use of a triage tag or medical chart number.
Jurisdictions should implement tracking systems that they are accustomed to using or
systems that can compile large quantities of data. If jurisdictions use triage tags and
triage tag numbers as unique patient identifiers, then these tags must be waterproof.
Some jurisdictions may redesign their entire tag while other jurisdictions may simply
place a non-waterproof triage tag into a plastic zip-lock bag and attach it to patients via a
plastic bracelet.
Some jurisdictions may refrain from using a triage tag at all unless the patient is serious
enough for ambulance transport. The majority of patients who will arrive at the OST
3
C
will arrive walking and thus can be easily identified as Minimal. Those having difficulty
will be more obvious in a crowd of walking patients, and should be officially triaged by
standard practice.
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8.2 Tracking Patient Belongings
Each jurisdiction should develop a mechanism for tracking patients' personal belongings.
As patients prepare for gross decontamination by removing their clothing, their personal
items should be separated as durable or non-durable. Some examples are as follows:
Durable
Non-durable
Keys
Clothes
Cell phones
Shoes and socks
Electronic devices
Jackets
Purses/wallets
As the goods are separated, they should be bagged according to the proper category,
assigned a tracking number, and tagged with the patients' name. After the tracking
process is completed, the items should be retained until law enforcement determines that
they are not wanted as evidence. If patients refuse to turn over their belongings, they
should report to a police officer to have their items checked for weapons and other
paraphernalia before entering the building with their personal items. When the patient is
discharged from the Center, the out-processing station can give the patient instructions
about cleaning their goods.
In some communities, the authorities may never intend to return non-durable items to the
owner. Although it may seem futile for staff to bag and tag non-durable items, there may
be evidence in the collected goods.
If a jurisdiction plans to return items, durable or non- durable, then those items must be
cleaned before they are given to the respective owner.
8.3 Patient Charting
For those patients that are brought to the treatment area, the OST
3
C must officially
document the patient's medical status and collect patient demographic data. Jurisdictions
may determine to start official patient charting earlier but the IRP suggests that it begin at
the second triage area. As patients are re-triaged and directed toward the appropriate
treatment area, Minimal patients could start to fill out the demographic portion of their
chart should they need to wait for an available health care provider. Patients that have
conditions that are more serious would not be expected to fill out their own chart, and
medical personnel should try to capture this information particularly if the patient is
transferred to a higher level of care.
The chart will be completed at the out-processing station. Any information that patients
or staff were unable to obtain, personnel at this area can fill in while patients review their
discharge papers.
Jurisdictions should consider a charting method that they are already accustomed to
using. If the charting methods are not practical or applicable for use at the OST
3
C then
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jurisdictions should consider implementing a charting system that can already compile
the necessary data.
9.0 Critical Functions Within The OST
3
C
Jurisdictions should design their own patient flow at the OST
3
C. Each location may require a
slightly different approach or have different priorities when allocating resources. Each building
that emergency planners identify may present particular challenges, such as narrow corridors, or
doorways, and stairs that do not allow stretchers or wheelchairs to pass easily. Additionally,
inclement weather may influence whether or not a jurisdiction establishes an outside gross
decontamination function.
(See Annex D for a general patient flow diagram that incorporates
the critical functions outlined in this section.)
The following section delineates and describes the critical aspects of an OST
3
C. Each
jurisdiction should consider these critical functions when planning their version or application of
the OST
3
C concept. The OST
3
C, by design, is meant to be modular and flexible, leaving the
jurisdiction to determine when and where functions should occur and if they are applicable.
(See
Annex C for a description of the following critical functions and the associated skill sets required
to perform the function.)
9.1 Perimeter Security
Due to the nature of the incident the alternative health care center may require a full
compliment of security efforts. Terrorists may want to target large groups of citizens and
emergency workers. Those with knowledge of a community's response plan may see the
Center as an ideal secondary target. Perimeter security is needed to maintain order, deter
criminal acts, and provide for the safety of the public.
Those providing perimeter security become gatekeepers to the
Center. Security will need to ensure that only authorized and
properly credentialed staff enters the facility grounds. All
entrances should be locked or have security in place to control
entry into the building. Security should establish separate
entrances for victims and staff. Signs should be posted directing
them to their respective entrance.
It will also be difficult for officers to differentiate between patients and others wanting to
enter the OST
3
C. Officers are inclined to decrease their level of suspicion when patients
convey an acute medical condition, making it difficult to distinguish between those who
are really patients and those whose presence is counterproductive to the operations of the
Center. Jurisdictions should create a system that helps security personnel identify staff
and patients.
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Jurisdictions should also determine if law enforcement agencies are needed to check
patient belonging bags for dangerous items (e.g. weapons), when patients refuse to
relinquish personal items.
Perimeter security efforts also include directing traffic and controlling traffic patterns.
Though most of the OST
3
C's patients will arrive by bus and/or ambulance from the
scene, many citizens may arrive in their private vehicles, taxis, public buses, or foot.
Officers must determine ambulance and bus drop off points, and private citizen vehicle
parking.
Persons who arrive in their own vehicles may have unknowingly cross-contaminated
their vehicles. Jurisdictions must determine if they are going to release contaminated
vehicles or if they will be quarantined. Security personnel may need to direct these
citizens where to park and then watch over the vehicles so that citizens do not re-enter
them. Security may have difficulty with persons who refuse to allow their vehicles to be
quarantined. Should security be faced with such a situation, they should strongly direct
patients to drive away from the Center without disrupting those who are entering and
those who are exiting.
Once patients leave the Center they should not be allowed to re-enter. Patients should be
directed away from the Center to avoid re-contamination.
The number of security officers needed, at the OST
3
C, will depend on the size of the
facility/surrounding grounds and the number of functions they are assigned. Local law
enforcement should primarily provide perimeter security but other agencies may be able
to support their efforts. School crossing guards, private security agencies, traffic
controllers for stadium/concert events, and the Department of Public Works may be able
to provide barricades, cones, directional signs, and personnel to supplement traffic
control efforts.
Personnel who may come into contact with contaminated patients should wear Level C
personal protective equipment (PPE). Personnel should pay particular attention to
wearing butyl rubber gloves instead of latex, given that chemical agents can penetrate the
latter.
The IRP recommends that an OST
3
C establish two or three security checkpoints. Placing
officers at the entry point to the grounds and before patients enter the building ensures
more control and helps to maintain order. Multiple checkpoints may also make it easier
for security personnel to recognize perpetrators posing as patients.
9.2 Initial Triage/Registration
Jurisdictions must determine the method of triaging patients and how to track patients as
they arrive at the Center. Plans should consider the best method for categorizing patients,
but some form of initial categorization should take place as patients enter the Center.
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Although the OST
3
C is designed to treat Minimal patients, it is possible that some
patients may deteriorate medically during their transfer to the Center. Self-referring
patients may show up in a critical state. Jurisdictions should determine if Immediate or
Delayed patients should undergo a gross decontamination and be immediately transferred
by ambulance to a traditional hospital emergency department. If no transportation is
immediately available, then these patients should undergo a gross decontamination and
wait in the treatment area until transport is available.
(See Annex E for A Mass Casualty
Decontamination Algorithm.)
Plans should include how to handle patients that have difficulty ambulating. It is possible
that some patients triaged Minimal are not incapacitated from the chemical exposure but
just need physical assistance. Those staffing this area may need wheel chairs or
assistants to help patients get from one location to another.
Pre-hospital care providers should perform initial triage as they are accustomed to triage
tag use, and categorizing patients into groups. Those performing initial triage must wear
Level C PPE. Providers should pay particular attention to wearing butyl rubber gloves
instead of latex, given that chemical agents can penetrate the latter.
If jurisdictions plan to supply an antidote cache at the OST
3
C, the initial triage area is an
ideal location for the medication. Patients arriving as Immediate or Delayed would
benefit from the medication and could be stabilized before undergoing a gross
decontamination. Additionally, it is more likely that staff in the Warm Zone will suffer
from cross-contamination than staff stationed in the Cold Zone. Thus, if the antidote is
strategically located at the initial triage area then both patients and staff would benefit.
9.3 Gross Decontamination
Not all the patients that arrive at the OST
3
C will have undergone a gross
decontamination. Avoiding contamination is important. A gross decontamination station
outside the building will prevent most of the contamination from entering the building.
Jurisdictions will need to determine if a gross decontamination station is necessary
providing that patients can enter a building and obtain a detailed decontamination inside.
Some planning considerations for determining whether or not to have a gross
decontamination station include:
*
Gross decontamination significantly reduces chances of cross-
contaminating the building, those staffing the detailed shower
area, ambulance personnel, and vehicles used to transport
patients.
*
Personnel have access to immediate decontamination if they
become cross-contaminated in the Warm Zone.
*
A gross decontamination does not need to be used on all patients
but can be used for critical patients, patients that have difficulty
ambulating, and for staff who become cross-contaminated.
*
If a gross decontamination station is established for all patients
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who have not undergone a gross decontamination previously, then it may be easier to
have all patients proceed through gross decontamination versus creating an additional
category of patients (e.g., Minimal with a gross decontamination and Minimal
without a gross decontamination).
*
If gross decontamination is required for all patients, then the registration/patient
belonging process that has been previously described may be more suitably
performed right before patients undergo gross decontamination.
Jurisdictions can choose to develop the gross decontamination aspect to the OST
3
C as
elaborately as their resources allow. If jurisdictions choose to set up a gross
decontamination station, then they should consider the IRP's
Guidelines for Mass
Casualty Decontamination During A Terrorist Chemical Agent Incident
as the minimum
standard. It indicates that high volumes of water such as that provided by a low-pressure
fire hose are essential to providing adequate decontamination. Those performing gross
decontamination should follow standard decontamination guidelines and not simply seek
to equip this area with garden hoses and/or untrained personnel.
As with any decontamination line, patient privacy is a major concern. Jurisdictions may
not have the resources to set up privacy screens as they have limited resources to provide
even the most basic decontamination line. Without some privacy it is likely that patients
will not be willing to disrobe in full or in part.
The IRP recommends that gross decontamination should consist of patients disrobing
down to their undergarments, bagging and tagging their belongings and placing them in
55-gallon drums or similar containers for safe handling
(See Section 8.2 Tracking Patient
Belongings for more details regarding this function)
. Then patients should proceed
through the decontamination line. Immediate and Delayed patients should proceed
through the line before triaged Minimal patients. At the end of the decontamination,
personnel should provide patients with a form of bodily cover that allows patients to
remove their undergarments. A trash bag that has been altered with holes for their head
and arms is the simplest form of cover. By placing the head through the plastic bag,
patients can remove their undergarments with some modesty intact, and then put their
arms through the side holes before proceeding into the building for a detailed
decontamination.
The gross decontamination aspect should be operated by an agency familiar with HazMat
operations and mass casualty decontamination efforts. Typically, each state has a
department of the environment capable of supporting decontamination efforts. Other
states have HazMat type industries that staff decontamination teams who could support a
decontamination effort in a disaster. Some jurisdictions have a small contingent of
HazMat decontamination specialists as part of their department of public works.
IRP Guidelines pertaining to chemical agent removal states:
Large volumes of water provided by a low-pressure fire hose are essential to providing
adequate gross decontamination.
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Jurisdictions should choose an agency that would not typically be used at the actual
incident site to perform decontamination at the OST
3
C.
9.4 Internal Security
The OST
3
C must be supported by internal security efforts in order to maintain control
and foster patient flow through the Center. Patients may become unruly and disruptive if
they have to wait in long lines, are unwilling to shower in the detailed decontamination
shower, or are unable to locate other family members. It is also possible that those who
perpetrated the terrorist incident may present as patients seeking care or it is possible that
others responsible for criminal acts will be among the patient population. It may be
necessary to establish a detention area for those persons who become particularly
disruptive. Simply providing a police presence may deter certain troublesome acts.
Internal security shares many responsibilities that external perimeter security provides,
such as performing sweeps for secondary devices, or barricading those portions of the
building that are off limits; but they must perform these duties within the confines of the
internal building in order to prevent cross-contamination.
Internal security must help patients avoid unintentionally re-contaminating themselves.
Once patients leave the Center they should not be allowed to re-enter and should be
directed away from the Warm Zone of the Center.
Officers stationed at patient entrance ways should wear Level C PPE to avoid cross
contamination.
9.5 Detailed Decontamination / Re-Dress
The two major purposes of the OST
3
C are to ensure that all patients from a chemical
incident receive a complete and thorough decontamination as well as medical screening
and treatment. All personnel entering the OST
3
C system should undergo a thorough
decontamination.
The detailed decontamination provides the following aspects of decontamination that are
otherwise not available:
*
A segregated decontamination area for males and females that provides semi-privacy.
*
An enclosed decontamination area away from the elements that also provides semi-
privacy (group shower).
*
Removal of all remaining clothing worn at the incident scene.
*
Decontamination using soap.
*
Warm water shower that will help reduce the possible effects of hypothermia
associated with outside cold-water decontamination.
*
Cool water shower that will help reduce heat stress associated with environmental
conditions or wearing PPE apparel.
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OST
3
C personnel should monitor patients as they undergo detailed decontamination to
control patient movement and prevent a bottleneck. Patients should disrobe quickly,
spend no more than five minutes in the shower, and then quickly re-dress. Some patients
may be inclined to spend more time showering, as they may believe that a short shower
will not free them from contamination causing a backup in patient flow. Once patients
are thoroughly decontaminated they will enter the Cold Zone portion of the Center and
re-dress in paper scrub outfits or similar clothing.
Provisions must be made for patients who have difficulty ambulating. Showers are
particularly hazardous since they are slippery when wet.
Showers are generally not designed to prevent cross-contamination. Often patients must
cross locker rooms to get to the showers and then cross the locker room to exit the area.
A jurisdiction may need to assign staff to the shower area to direct patients coming in and
going out the same doorway to prevent cross-contamination. Depending on the layout of
the facility, privacy screens could be used to segregate hallways off for either the
disrobing or redress area.
Jurisdictions must provide patients with some type of body cover before they proceed
through the Center. Paper scrub outfits, hospital scrub outfits, clothing from
consignment/second hand stores or churches, or Tyvek
suits are just a few options.
Jurisdictions should also consider providing space blankets and foot covers.
9.6 Re-Triage
A critical aspect to caring for patients is that they must continually be re-assessed until
they have been thoroughly evaluated and treated. Patients exposed to chemical agents
may develop delayed symptomatology. All personnel should be mindful of watching for
patients who have deteriorated and assist them accordingly.
Once patients have dressed they are ready to have a medical evaluation. Based on how
the treatment area is established, staff members should direct patients to the most
appropriate treatment location. Re-triaging patients should not take an extensive amount
time but it is a necessary function. Also it is likely that patients will be confused as to
where to go next, thus re-triaging patients while simultaneously directing them to a
treatment area may help prevent bottlenecks from developing.
Staff must use a formal triage method to assess casualties to determine which treatment
area is best. The IRP recommends that jurisdictions use the START Triage system
(See
Annex F)
and sort casualties into one of the following four categories:
The following critical functions make up the OST
3
C: perimeter security, initial triage,
gross decontamination, detailed shower decontamination/redress, re-triage, treatment,
transportation to a higher level of care, patient discharge, general assistance, and
internal security.
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Immediate
- those who need to be admitted to a hospital following initial
treatment and stabilization. These patients will have the highest priority for
transportation to a hospital. Patients who fit this category should be brought to
the Immediate Treatment Area.
Delayed
- those who require limited medical intervention for stabilization.
These patients may eventually be admitted to a hospital or discharged following
temporary medical observation. These patients should be brought to the
Delayed Treatment Area.
Minimal
- those who require a general assessment. These patients should be
directed to the Minimal Treatment Area.
Deceased
- those patients that arrive deceased or die at the OST
3
C. They will
be placed in the temporary morgue.
As patients are triaged and directed to the appropriate location, personnel should hand
them a clean, pre-arranged medical chart and pen. One time saving practice is for
patients to fill out the demographic portion of their medical chart if they are able and if
they must wait for any length of time.
9.7 Treatment
The OST
3
C must evaluate and treat patients who arrive at the Center. Staff should
transfer patients that have more critical conditions than the OST
3
C can treat, to traditional
hospital emergency departments.
Treatment at the OST
3
C is based on what each jurisdiction is able to provide at the
Center. At a minimum, the OST
3
C should provide basic life support (BLS) and if
jurisdictions have a small contingent of advanced life support staff and equipment then a
sub-area within the treatment area should be made available.
Jurisdictions should consider arranging their treatment area based on the triage
categories. For example, if staff use typical EMS triage practices and triage tags then
they would name the treatment sections Immediate, Delayed, and Minimal. If they only
categorize patients into critical and non-critical then treatment area subdivisions should
be named accordingly. Despite categorizing the treatment area, all treatment should take
place in the same general area if possible so that stations can share staff and resources.
The IRP recommends that jurisdictions use the START Triage method and subsequently
use the three corresponding treatment sub-areas.
Comprehensive patient documentation begins when patients arrive in the treatment area.
Staff must complete the medical portion of the chart for all patients and the demographic
portion of the chart if patients are transferred from the facility.
The treatment area should be set up similarly as to how the jurisdiction will re-triage
patients.
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An Immediate Treatment Area will care for critical patients that need a more extensive
evaluation and who have a potentially life threatening status. Critical patients must have
beds/stretchers on which to lie. Personnel with a minimum of Advanced Cardiac Life
Support (ACLS) certification ability should staff this area. Staff should stock each bed
with ACLS equipment and medication
(See Annex G for an antidote and medication list
for advanced medical providers to administer)
. The medical director should specifically
provide oversight for these patients. This area is meant to stabilize patients only and
arrange for their transport to a higher level of care. Staff will collect patient demographic
information, which would normally be captured at an out-processing area. Immediate
patients waiting for transport should not be moved to the holding area, as their medical
condition is too unpredictable and requires more extensive observation.
Delayed patients will need a more in-depth, subjective
cardiac and respiratory evaluation. A Delayed area should
also have beds/stretchers and be able to handle more patients
then the Immediate area but not as many as the area for
Minimal casualties. Ideally, it should have EKG monitors,
respiratory flow meters, oxygen, and access to a minimal
supply of medication.
Optimally, those staffing this area
should know how to perform advanced life support (ALS).
A Minimal area should use tables and chairs and be capable of processing 12 or more
patients at one time. Staff may include nurses, medical students, and pre-hospital care
providers. Emergency Medical Technicians (EMTs) and paramedics are particularly
good at performing quick and in-depth subjective patient assessments without relying on
a patient chart as a prompt.
Patient treatment will be based on the following findings:
*
Method of agent exposure (vapor or liquid).
*
Symptomatology.
*
Vital signs.
*
Pertinent medical conditions that may be exacerbated by the chemical agent exposure.
*
Medications and medical allergies.
The lead agency must provide caregivers chemical agent guidelines that contain the
following information for each type of chemical exposure:
*
A fact sheet on the agent including antidote.
*
Pertinent medical conditions that are complicated by the agent exposure.
*
Actual treatment modalities to include basic life support and advanced life support
procedures, and hospital provider treatment.
The treatment area should include a holding area for those patients waiting to be
transferred. The holding area should be staffed with personnel who can stay with patients
and observe them for any deterioration in their medical status. Generally, a 7:1 ratio of
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patients to health care providers will be adequate. Staff should gather all demographic
information that would normally be collected during patient out-processing, prior to
patient transfer.
All Minimal patients that do not need to be transferred to an outlying hospital will
continue through the OST
3
C process.
When specific areas are under used, the IRP recommends that personnel in lead
roles/chiefs redistribute staff from slow treatment areas to help in the Minimal or holding
areas. Typically the area for critical patients will not be busy if ambulance transport is
readily available. Minimal patients however, should not be brought to other areas;
instead staff should re-locate to the Minimal area and provide support.
***Special Considerations
Patient treatment will include more than just physically evaluating casualties. Patients
may suffer from severe mental distress after having been a victim of a terrorist incident.
The incident may exacerbate any underlying mental illness. The medical director, in
addition to mental health support personnel, should be prepared to medically sedate, treat,
provide emotional support, and/or transfer these patients to facilities capable of
evaluating their condition.
Another special consideration is implementing tele-medicine interlinks at the OST
3
C to
support patient treatment. This link may be helpful when physicians are not available to
staff the Center directly.
9.8 Out-Processing
Once patients have been decontaminated and received treatment, they are ready to be
discharged. Staff should obtain patient demographic/tracking data, and then officially
discharge patients from the Center.
This information should include as a minimum:
*
Patient identification number/medical chart number/triage tag number.
*
Name.
*
Date of birth.
*
Address.
*
Phone number.
*
Emergency point of contact.
*
Social security number.
The discharge process should include as a minimum:
*
Staff specifies that the patient could have been exposed to a particular agent.
*
Staff informs the patient of signs and symptoms that warrant them re-entering the
medical system.
*
Staff informs the patients how to re-access care if they become symptomatic at a later
time.
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*
Staff provides the patient written self-care instructions.
*
Staff obtains patient's signature, which specifies that the patient is being discharged
from the Center, and then staff enters the date and time of discharge.
Patients may make inquires regarding transportation home, how to find other family
members, how to best obtain medication re-fills to replace contaminated medication
bottles, etc. Staff out-processing patients should direct patients, with these types of
inquiries, to the general assistance area.
Jurisdictions should gather patient demographic data with information systems that can
compile large quantities of data. Palm pilots, lap top computers, bar code readers, bubble
dot forms, are just a few types of systems that can facilitate information gathering.
Additionally, out-processing patients requires a controlled and quiet atmosphere. Patients
may need a semi-private setting before they feel comfortable asking questions or
relinquishing personal demographic information.
9.9 General Assistance
After the staff has officially discharged patients from the Center, patients may still need
some basic assistance before they are ready to leave. The jurisdiction should consider the
following aspects in addition to providing patients a means of getting home:
*
A collection point where patients can gather before they are transferred home or to a
Reunification Center.
*
A location where family members can reunite.
*
A rest point where patients can sit and for the first time
rest.
*
A family assistance desk where patients can talk to
someone regarding individual concerns and gather
information.
*
A place where patients can make a phone call.
*
The ability to obtain metal health support.
*
A location where patients can get more appropriate clothing, other than a paper scrub
outfit, if it was not provided earlier in the process.
All patients will need transportation home. Patients, who drove themselves while they
were contaminated, cannot re-enter the same vehicle until the lead agency declares it free
of contamination. Other patients who arrived via bus left their vehicles at the incident
site. Jurisdictions should plan to transfer all citizens from the OST
3
C either home or to a
Reunification Center.
Jurisdictions should make arrangements with the local phone company to set up a mobile
phone bank (out-going calls only) at the OST
3
C. Patients will want to inform relatives
that they are okay and where they can be picked up.
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The IRP recommends that a jurisdiction staff pre-hospital care providers in the general
assistance area. It is possible that a patient's medical status may deteriorate and require
more medical assistance.
Some type of family assistance desk or help desk that can assist patients with special
needs should be co-located where patients are waiting to be transferred to the
Reunification Center or home. Mental health support personnel should staff this desk, as
they can interact with patients in a non-threatening manner and begin to engage in
"defusing" types of conversations when handing out information packets. Information
should include explaining when and how a patient can re-enter the health care system,
and phone numbers for hotline/help-line crisis intervention.
9.10 Reunification Center
When an incident is so large that it requires the use of an OST
3
C, jurisdictions should
consider standing up a Reunification Center, at a separate location, to support the OST
3
C
as well as the entire incident. Family members need a location where they can meet up
with their loved ones or obtain information regarding their location and status. The
OST
3
C may be unable to arrange each individual's ride home but can make sure that all
patients get to a Reunification Center. The Reunification Center can become an
information hub that collates the status and location of all casualties, and creates a list of
missing persons.
Depending on the number and type of functions jurisdictions want the Reunification
Center to handle, emergency planners may request the American Red Cross (ARC) to
establish it. Typically, the ARC establishes mass care shelters to support individuals
displaced from their homes for an extended period due to a catastrophic events.
However, the ARC is accustomed to providing lodging, food, clothing vouchers, and
emotional support and may be the best agency to initiate a Reunification Center.
Jurisdictions should incorporate their ARC Chapter in their OST
3
C planning and ask
them in what way they are willing to support mitigating the consequences of a chemical
WMD attack.
9.11 Transportation
The OST
3
C is not designed to provide care equal to
that of an emergency department, consequently
patients requiring a higher level of care should be
immediately transferred to a traditional hospital.
The OST
3
C should have dedicated ambulances to
perform patient transfers. It may be difficult for 911
Jurisdictions should plan to provide some general assistance for patients since they
will have no way of getting home and will only be wearing what the facility has provided
them.
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units to provide this service because they will most likely be fully engaged responding to
or supporting mutual aid efforts surrounding the incident scene. Jurisdictions may need
to use commercial and/or volunteer units.
As patients are sent from the scene to nearby hospitals, the OST
3
C Transportation Officer
must send patients to hospital emergency departments that are not overwhelmed. These
hospitals may be over 45 minutes away thereby slowing ambulance turn-around time.
When the Emergency Medical System (EMS) is unable to accommodate transferring
patients via routine methods, the Transportation Officer should seek to use alternate
methods of patient transport to avoid mass numbers of patients waiting to be transferred.
Jurisdictions need to decide acceptable means of patient transportation during disaster
situations but some options may include loading two patients in each available
ambulance, or potentially staffing two medical providers on a mini-bus with four to six
mildly symptomatic patients.
It is possible that there will be more patient transfers than originally anticipated,
particularly if the medical staff is instructed to cautiously evaluate patients.
The OST
3
C transportation component must also provide a means of getting patients home
or to a Reunification Center. Jurisdictions may develop MOUs with private
transportation agencies, or the public mass transit to support this effort.
9.12 Temporary Morgue
It is possible that patients will die at the OST
3
C or will arrive pulseless and apneic. The
OST
3
C will need to make provisions for the deceased. These provisions may include
using a refrigerated truck as a temporary morgue, arranging local law enforcement to
secure the temporary morgue, maintaining a chain of custody, and filling out specific
paperwork. Other procedures should include a physician signing the death certificate,
staff documenting the time of death, and staff reporting the death to the lead investigating
agency and medical examiner.
Any death that occurs during the same period as the terrorist incident may be case
evidence. Jurisdictions should request the input of the medical examiner/coroner as to
the best way to handle remains and to preserve evidence.
10.0 Enhanced Capabilities
The following are not critical functions of the OST
3
C, however they do support specific
community concerns. Each jurisdiction may choose to implement the following aspects as well
as any other function that lends to caring and comforting the community and/or supporting other
facets of the incident.
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An Alternative Health Care Facility
34
10.1 Law Enforcement Investigation
The OST
3
C will become a key location for managing casualties from a terrorist incident.
It, therefore, lends itself to being an ideal location for law enforcement investigators to
interview patients that may be witnesses or have pertinent information regarding the
crime.
Gathering information regarding the incident certainly
supports the community at large but investigating the crime
is not the primary mission of the OST
3
C. If a jurisdiction
determines that the OST
3
C should include law enforcement
investigations then it should take place after patients have
been out-processed from the Center. Patient care should not
be jeopardized for investigation activities.
Investigators must determine where they can best interview patients and how to
determine which patients should be interviewed. Investigators may decide to station an
officer, where patients are out-processed, who can ask patients if they have any
knowledge regarding the chemical terrorist incident. Depending on the number of
citizens that state they have some knowledge of the incident and how quickly detectives
are able to interview citizens, the officer may need to prioritize which citizens are
interviewed first. If the line to interview citizens is long, then the officer may start to
gather some preliminary information, such as name, address, and phone number,
allowing detectives to interview only those who present with the most relevant
information, at the OST
3
C.
Another suggestion is that law enforcement can provide out-processing personnel with
red flag questions, which they can ask patients after completing the patient chart. If a
patient responds, "yes" to any of the questions then they should be directed to the
investigation area. Samples of these types of questions are listed below; however
investigators should provide the actual questions based on the current incident.
*
Did you see/hear anything unusual?
*
Did you take any photos or videos?
*
Did anyone ask you to bring or carry anything into the event?
Law enforcement investigations should take place in an office or small room.
Investigators require a quiet and controlled setting to perform their interview and discuss
pertinent information to the case. Once the interview has ended, investigators can direct
patients to the general assistance area.
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An Alternative Health Care Facility
35
10.2 Victim Assistance
Due to the terrorist nature of the incident, patients are prone to stress and anxiety that can
affect their emotional well being as well as their physical state. Some patients may
become distraught to the point that they can no longer process information, interpret
directions, or understand where to go and what to do next. The IRP recommends that
jurisdictions provide mental health counselors who can "buddy" with patients, who are
mentally distraught and require assistance, in the Cold Zone of the Center.
Other recommendations include providing mental health counselors who can rove the
general assistance area looking for patients that are distraught or unable to care for
themselves. They should engage in "defusing" types of conversations, help them when
possible, and arrange for further intervention with an outside agency where applicable.
Jurisdictions may also choose to organize an official briefing for patients that address the
following:
*
Announcements pertaining to the incident and what is officially known.
*
The whereabouts of family members who have been transported from the Center.
*
Hotline phone numbers and crisis intervention numbers.
*
Information regarding the chemical agent exposure and when a patient's medical
status warrants re-entering the health care system.
*
A location or phone number that patients can obtain critical incident stress debriefing
counseling or mental health support.
*
Critical Incident Stress Defusing that specifies what happened, what symptoms
victims may experience in the next few days that are a normal response to stress, and
what significant signs of stress warrant psychological intervention. If a jurisdiction
provides a defusing for citizens, they should consider implementing the International
Critical Incident Stress Foundation (ICISF) model.
10.3 Pet Management
It is possible that some people will bring their pets to the OST
3
C expecting personnel to
help them. It may be beneficial for jurisdictions to establish some elementary form of
decontamination and pet care at the OST
3
C, particularly if they
think that citizens will become unwilling to go through the
Center unless their pet is taken care of. Jurisdictions should
look to Animal Control or local veterinarians to supply
portable kennels, staff, and equipment to temporarily care for
animals at the Center. The following principles should be kept
in mind when incorporating pet management into the plan:
*
Animal drop-off point.
*
How to identify animals with their owner.
Each jurisdiction will determine what enhanced capabilities their OST
3
C will have.
Page 46
An Alternative Health Care Facility
36
*
Animal decontamination efforts.
*
Medical evaluation/treatment regimens.
*
Holding animals when an owner has been transferred to a hospital.
*
Animal retrieval procedures that prevent re-contamination.
*
Handling Seeing Eye Dogs and other specialty dogs to include: if these animals need
a more extensive evaluation, if they should be separated from their owner, etc.
*
Food and water (depending on the length of time animals are held in kennels).
*
Location of kennels with regards to inclement or extreme weather, i.e., placing
kennels in shade when temperatures are hot.
*
MOUs with pet product distributors/stores for supplies not normally supplied by the
local animal control department.
The following issues should be kept in mind when establishing a plan to decontaminate
animals:
*
Animal handlers should wear the same level of PPE that is required for others in the
Warm Zone.
*
The method of decontamination may be as simple as spraying animals with water for
five minutes or it may be agent and/or animal specific.
*
Decontamination efforts should supersede treatment efforts just as in adult treatment
because decontamination is treatment when an animal is exposed to a chemical agent.
*
Decontamination efforts should have a specific Warm Zone and Cold Zone.
11.0 Site Shutdown
Once all patients have been absorbed into the health care system the OST
3
C Commander must
request permission from the Incident Commander to "stand down" the facility.
*
The lead agency should contact the medical examiner to transfer the temporary morgue to his
supervision.
*
Remove all hazardous waste.
*
Arrange to have all durable items that citizens relinquished, to include their vehicles,
decontaminated.
*
Return all durable items.
*
Contact the lead investigating agency regarding the final disposition of contaminated non-
durable clothing items, as they may be evidence or may provide investigators information
regarding the case.
*
Arrange for the Environmental Protection Agency to test for residual contamination before
the building is returned to its former utility.
The primary medical mission in a chemical weapons disaster is to provide casualty triage,
decontamination, treatment, and transportation to definitive health care facilities, without
intentionally overwhelming the health care system.
Page 47
An Alternative Health Care Facility
37
If contamination is still present and it appears that it will be long lasting, the lead agency, in
conjunction with local and state authorities, will make a decision as to the building's long-term
viability.
12.0 Conclusion
The OST
3
C is one tool that a jurisdiction may use when mitigating the affects of a chemical
terrorist incident. It is designed to be a flexible, temporary, stand-alone facility that can be
replicated when any one Center exceeds its capacity. Multiple OST
3
Cs can be established
throughout the local health care infrastructure. The primary medical mission in a chemical
weapons disaster is to provide casualty triage, decontamination, treatment, and transportation to
definitive health care facilities, without intentionally overwhelming the health care system. Once
victims have been absorbed into the health care system, the OST
3
C can be disestablished .
Page 48
An Alternative Health Care Facility
38
Annexes
A. OST
3
C Organizational Chart
B. Performance Objective Matrix
C. Critical Functions and Required Skill Sets
D. Patient Flow Diagram
E. Mass Casualty Decontamination Algorithm
F. Domestic Preparedness EMS Technician Course ­ Triage Section
G. Antidote and Medication List
H. Acronyms
I. References
Page 49
ANNEX A- OST
3
C Organizational Chart
- A 1 -
Safety Officer
(Warm Zone)
OST
3
C Commander
Information
Officer
Operations Chief
Planning Chief
Finance
Administrator
Logistics Chief
Food Services
Safety Officer
(Cold Zone)
Treatment
Detailed Decon
Re-Triage
Internal Security
Out-Processing
General Assistance
Transportation
Communications
Pharmaceuticals
Supply
Facility Maint.
Medical Director
Perimeter
Traffic Control
Initial Triage
Gross Decon
Cold Zone Sector
Chief
Warm Zone Sector
Chief
Page 50
Alternative Health Care Facility
B-1
ANNEX B Performance Objectives Matrix
Performance Requirements
Legend for requirements:
-basic level
advanced level
specialized
Competency level
Awareness
Operations
Technician/
Incident
Employees
Responders
Specialist
Command
Examples
Facility workers,
hospital support
personnel,
janitors, security
guards
Initial
firefighters,
police officers,
911 operators/
dispatchers
Incident
response teams,
EMS, basic
HazMat
personnel on
scene
Incident
response team
specialists,
technicians,
EMS
advanced, and
Incident
commanders
Areas of Competency
Ref.
medical
specialists
1. Know the potential for terrorist use of NBC
weapons:
- What nuclear/biological/chemical (NBC)
weapons substances are.
- Their hazards and risks associated with them.
- Likely locations for their use.
- The potential outcomes of their use by a
terrorist.
- Indicators of possible criminal or terrorist
activity involving such agents.
- Behavior of NBC agents.
C, F,
M,
m, G
2. Know the indicators, signs, and symptoms for
exposure to NBC agents and identify the agents
from signs and symptoms, if possible.
C, F,
M, m
2a. Knowledge of questions to ask caller to elicit
critical information regarding an NBC incident.
G, m
(911 only)
2b. Recognize unusual trends which may indicate
an NBC incident.
G, m
3. Understand relevant NBC response plans and
standard operating procedures (SOP) and your
role in them.
C, F,
M, m
4. Recognize and communicate the need for
additional resources during an NBC incident.
C, m,
G
5. Make proper notification and communicate the
NBC hazard.
C, F,
M, m
6. Understand:
- NBC agent terms.
- NBC toxicology terms.
C, F,
m
(EMS-8 only)
7. Individual protection at an NBC incident:
- Use self-protection measures.
- Properly use assigned NBC protective
equipment.
- Select and use proper protective equipment.
C, F,
M, m
8. Know protective measures and how to initiate
actions to protect others and safeguard property in
an NBC incident.
F, M
8a. Know measures of evacuation of personnel in
a downwind hazard area for an NBC incident.
M, G
Page 51
Alternative Health Care Facility
B-2
Performance Requirements
Legend for requirements:
-basic level
advanced level
specialized
Competency level
Awareness
Operations
Technician/
Incident
Employees
Responders
Specialist
Command
9. CB decontamination procedures for self,
victims, site/equipment, and mass casualties:
- Understand and implement.
- Determine.
C, F,
M, m
self
10. Know crime scene and evidence preservation
at an NBC incident.
F, M,
m
(except 911)
10a. Know procedures and safety precautions for
collecting legal evidence at an NBC incident.
F, G,
m
11. Know federal and other support infrastructure
and how to access in an NBC incident.
C, F,
M, m
(911 only)
12. Understand the risks of operating in
protective clothing when used at an NBC incident. C, F,
m
13. Understand emergency and first aid
procedures for exposure to NBC agents and
principles of triage.
F, M
14. Know how to perform hazard and risk
assessment for NBC agents.
C, F,
M, m
15. Understand termination/all clear procedures
for an NBC incident.
C, F,
m
16. Incident Command System/Incident
Management System
- Function within role in an NBC incident.
- Implement for an NBC incident.
C, F,
M
17. Know how to perform NBC contamination
control and containment operations, including for
fatalities.
C, F,
M, m
17a. Understand procedures and equipment for
safe transport of contaminated items.
G, m
18. Know the classification, detection,
identification, and verification of NBC materials
using field survey instruments and equipment, and
methods for collection of solid, liquid, and gas
samples.
C, F,
M, m
19. Know safe patient extraction and NBC
antidote administration.
F, m
(medical only)
(medical
only)
20. Know patient assessment and emergency
medical treatment in an NBC incident.
M,
m, G
(medical only)
(medical
only)
21. Be familiar with NBC related public health
and local EMS issues.
G
(medical only)
(medical
only)
22. Know procedures for patient transport
following an NBC incident.
F, G
(medical only)
(medical
only)
23. Execute NBC triage and primary care.
G
(medical only)
(medical
Page 52
Alternative Health Care Facility
B-3
Performance Requirements
Legend for requirements:
-basic level
advanced level
specialized
Competency level
Awareness
Operations
Technician/
Incident
Employees
Responders
Specialist
Command
only)
24. Know laboratory identification and diagnosis
for biological agents.
G
(medical
only)
25. Have the ability to develop a site safety plan
and control plan for an NBC incident.
C, F
26. Have ability to develop an NBC response
plan and conduct exercise of response.
G, m
Legend for references:
C - 29 CFR 1910.120 (OSHA Hazardous Waste Operations and Emergency response)
M - Macro objectives developed by a training subgroup of the Senior Interagency Coordinating Group
m - Micro objectives developed by U.S. Army Chemical & Biological Defense Command
G - Focus Group workshop
F - NFPA Standard 472 (Professional Competence of Responders to Hazardous Materials Incidents) and/or
NFPA Standard 473 (Competencies for EMS Personnel Responding to Hazardous Materials Incidents)
Page 53
Alternative Health Care Facility
- C 1 -
ANNEX C
Critical Functions and Required Skill Sets
OST
3
C Command
*
Provide 80-125 patients per hour with detailed decontamination, medical
treatment, and general assistance.
*
Perform overall command and control for the Center.
*
Ensure highest level of efficiency possible given staff and resources.
*
Report facility requirements to lead agency to maintain operation.
*
Report patient and staffing activity.
*
Ensure that staff certifications and licenses have been verified.
*
Plan for continual needs of the Center.
*
Mitigate operational concerns to ensure mission.
*
Provide safe work environment (e.g., prevent cross contamination, mitigate
secondary device deployment).
A. OST
3
C Commander
*
Report all activities and needs to the lead agency.
*
Assign personnel to Operations, Logistics, Planning, Finance, Safety, and
Information.
*
Establish a command post and communicate with officers regularly.
*
Ensure that the OST
3
C functions at the highest level of efficiency with
given staff and resources.
*
Utilize the ICS.
B. Safety Officer
*
Survey the site/Center to ensure that people have a safe environment to
work in and intercede where necessary.
*
Survey the site/Center to ensure that personnel are working in a manner
that promotes safety and intercede where necessary.
*
Monitor both the Warm Zone and the Cold Zone.
*
Evaluate operations based on OSHA Safety Directives and Regulations
pertaining to workspace, hazardous materials, PPE, and medical
operations.
*
Utilize the ICS.
C. Information Officer
*
Brief the Incident Commander's Public Information Officer (PIO) about
the OST
3
C's status.
*
Direct news media to the PIO to obtain information.
*
Provide patients information (e.g., hotline phone numbers for criminal
investigation, family assistance).
*
Utilize the ICS.
Page 54
Alternative Health Care Facility
- C 2 -
D. Operations Chief
*
Oversee the operation of both the Warm and Cold Zone and facilitate the
needs of each sector's Operations Chief. Warm Zone is responsible for-
perimeter security, traffic control, initial triage/registration, gross
decontamination. The Cold Zone is responsible for internal
security/detention, detailed decontamination/redress, re-triage, treatment,
out-processing, and general assistance.
*
Utilize the ICS.
E. Planning Chief
*
Become point of contact for all agencies that are requested to support the
OST
3
C.
*
Assign each agency a list of critical tasks that they must accomplish.
*
Ensure that the mission to decontaminate 80-125 patients per hour is
successfully planned.
*
Predict future needs of the Center.
*
Implement a patient tracking system
*
Utilize the ICS.
F. Finance Administrator
*
File all reports necessary to obtain local, state, and/or federal relief funds.
*
Account for the costs of operating the Center (e.g., staff, supplies,
equipment).
*
Initiate state and federal reimbursement procedures.
*
Become representative for the lead agency.
*
Utilize the ICS.
G. Logistics Chief
*
Oversee transportation , communications, food services, pharmaceuticals,
supplies, and facility maintenance.
*
Provide Level C PPE for all persons reporting to the Warm Zone.
*
Procure all necessary supplies to include, pharmaceuticals, food, drink,
and transportation.
*
Utilize the ICS.
H. Medical Director
*
Oversee medical aspects of the OST
3
C.
*
Specifically provide medical direction for triage personnel, and treatment
personnel.
*
Position should be in the uncontaminated portion of the Center but should
have direct radio contact with those medical providers in the contaminated
portion of the Center.
*
Provide input to the OST
3
C Commander
*
Directly report to the Operations Chief.
Page 55
Alternative Health Care Facility
- C 3 -
Perimeter Security
*
Establish and maintain control of the external perimeter of the OST
3
C.
*
Coordinate activities to include sweeps for secondary devices.
*
Coordinate security requirements of temporary morgue with investigating law
enforcement agencies and chief medical examiner.
*
Verify staff identifications.
*
Monitor quarantined private citizen vehicles.
Critical Skill Set
*
Sworn law enforcement officer.
*
Perform duties wearing PPE.
Traffic Control
*
Control ingress / egress.
*
Direct traffic in and around the OST
3
C/site.
*
Maintain controlled points of entry for reporting staff and patients.
*
Establish landing zone, staff parking, patient parking, ambulance staging, and
supply delivery area.
Critical Skill Set
*
Perform duties wearing PPE if required.
Initial Triage
*
Triage all patients who arrive at the Center utilizing the local jurisdiction's
method.
*
Direct all patients to the gross decontamination area making sure that those
who are identified as Immediate (red) or Delayed (yellow) go through the
gross decontamination before those who are categorized Minimal (green).
*
Obtain assistance for non-ambulatory patients.
Critical Skill Set
*
Triage multiple patients.
*
Utilize the jurisdiction's triage method.
*
Administer antidote treatment to critical patients if medical direction allocates
responsibility to providers.
*
Perform duties wearing PPE.
Page 56
Alternative Health Care Facility
- C 4 -
Gross Decontamination
*
Perform gross decontamination for victims.
*
Decontaminate triaged Immediate or Delayed before any Minimal patients.
*
Establish a means for patients to disrobe, and bag, and tag their belongings.
*
Provide assistance for those persons who need physical assistance.
*
Track personal belongings, to include durable and non-durable items.
Critical Skill Set
*
Perform gross decontamination on multiple patients following HazMat
Operations Guidelines and/or SBCCOM's gross decontamination guidelines.
*
Perform duties wearing PPE.
*
Enforce order when persons become uncooperative when asked to remove
clothing and relinquish personal items.
Internal Security
*
Assist building evacuation utilizing the building's disaster plan.
*
Sweep building and grounds for explosive devices before staff arrive.
*
Secure building keys to provide access to necessary areas.
*
Post officers at specific areas needing attention.
*
Coordinate efforts with law enforcement agency.
*
Patrol interior of OST
3
C to promote order and patient flow.
*
Establish a detention/holding area.
*
Secure exit points so that as patients leave they are not allowed to re-enter.
*
Establish division of labor- staff entry point, contaminated patient entry point,
decontamination exit point, roving, detention area, any location that becomes
a holding area.
Critical Skill Set
*
Enforce order.
Detailed Decontamination/Redress
*
Ensure patients are thoroughly decontaminated.
*
Provide assistance for non-ambulatory patients via wheelchairs and
volunteers.
*
Avoid cross-contamination particularly with regards to entry/exit points into
the detailed decontamination area and with the use of wheel chairs.
*
Provide bodily cover for patient redress (e.g., clothing, scrub outfits,
emergency blankets, foot covers).
*
Assist patients who require physical assistance.
Critical Skill Set
*
Mitigate cross contamination.
Page 57
Alternative Health Care Facility
- C 5 -
*
Direct patients through a detailed decontamination process and deal with
potentially unruly patients.
*
Aid patients who have medically deteriorated and require assistance.
Re-Triage
*
Re-triage patients into categories that correspond with designated treatment
areas.
*
Help patients requiring physical assistance.
*
Direct patients to appropriate location within the treatment area.
Immediate patients are to go to Immediate treatment area.
Delayed patients will go to Delayed treatment area.
Minimal patients will go to chairs at Minimal treatment area.
Critical Skill Sets
*
Perform quick triage.
*
Aid those persons requiring physical assistance.
Treatment Area: Immediate Sector
*
Treat all Immediate patients that arrive in the treatment area.
*
Transfer critical patients to appropriate hospitals via ambulance.
*
Stabilize patients.
*
Gather patient demographic data on patients who are transferred from the
Center.
*
Establish direct medical oversight.
*
Administer antidote treatment if applicable.
Critical Skill Set
*
Medical Director should be board certified in Emergency Medicine.
*
Support staff should treat patients according to ACLS protocols.
*
Support staff should administer antidote treatment if applicable.
Treatment Area: Delayed Sector
*
Treat all Delayed patients that arrive in the Delayed treatment area.
*
Transfer critical patients to appropriate hospitals via ambulance.
*
Stabilize patients.
*
Gather patient demographic data on patients who are transferred from the
Center.
*
Direct other patients to patient out-processing.
*
Assist all patients who require physical assistance.
Page 58
Alternative Health Care Facility
- C 6 -
Critical Skill Set
*
Assess patients as critical or non-critical and determine if they need a higher
level of care.
*
Evaluate EKG, lung capacity, and blood glucose.
*
Treat basic airway concerns to include nebulizer treatments, and oxygen
administration.
*
Assess basic vital signs.
Treatment Area: Minimal Sector
*
Treat all Minimal patients that arrive in the Minimal treatment area.
*
Transfer critical patients to appropriate hospitals via ambulance.
*
Direct other patients to patient out-processing.
*
Assist all patients who require physical assistance.
Critical Skill Set
*
Assess patients as critical or non-critical and determine if they need a higher
level of care.
*
Assess basic vital signs.
Treatment Area: Holding Sector
*
Monitor all patients waiting to be transferred.
*
Gather any information needed by patient out-processing prior to transport.
*
Provide basic medical intervention for those patients who are unstable.
Critical Skill Set
*
Assess basic vital signs.
*
Recognize critical signs and symptoms that require medical intervention.
Out-Processing
*
Collect patient demographic information and complete patient medical record.
*
Go over patient self-care instructions.
*
Discharge patient from the Center.
*
Ask law enforcement investigation questions, if applicable.
*
Direct appropriate patients to law enforcement investigation if applicable.
*
Direct all other patients to a general assistance area.
*
Assist patients requiring physical assistance.
Critical Skill Set
*
Gather data utilizing the jurisdiction's means of data collection (e.g., palm
pilots, computers, written sheets, bubble forms, etc.).
Page 59
Alternative Health Care Facility
- C 7 -
Law Enforcement Investigation
*
Conduct initial interviews of patients.
*
Prioritize citizens for interview.
*
Direct patients to a general assistance area.
*
Share pertinent information with appropriate players to include the lead
investigating agency, their own department, and the OST
3
C Commander.
Critical Skill Set
*
Detective or other sworn law enforcement officer.
General Assistance
*
Arrange for the special needs of patients who enter the OST
3
C.
*
Organize patient transportation to home or a Reunification Center.
*
Observe patients for signs of stress or medical deterioration.
*
Provide a phone bank for outgoing calls only.
*
Provide area where family members can reunite.
*
Provide a means for patients to obtain information regarding the incident and
a means for them to ask questions.
*
Assist patients with special needs if the jurisdiction is able.
*
Allocate a certain number of personnel who can assist patients who are
distraught and unable to get through the Center without some emotional
support (in the Cold Zone only).
*
Assist patients requiring physical assistance.
*
Consider providing an official Critical Incident Stress Defusing (CISD), for
patients.
Critical Skill Set
*
Staff providing medial care should be capable of rendering BLS for those
patients who may medically deteriorate.
*
Staff providing mental health intervention should be social workers to help
those patients who are not able to care for themselves due to significant stress.
*
Staff providing CISD should be trained professionals in CISD.
Temporary Morgue
*
Provide an area to temporarily store human remains if needed.
*
Establish means of securing human remains and notifying appropriate
agencies- lead investigating agency, medical examiner, OST
3
C Commander.
Critical Skill Set
*
Ability and authority to maintain a chain of custody.
Page 60
Alternative Health Care Facility
- C 8 -
Supplies/Resources
*
Obtain supplies for the OST
3
C.
*
Deliver supplies to areas within the Warm Zone.
*
Restock medications, antidote treatments.
*
Obtain equipment that makes the OST
3
C friendly for those requiring physical
assistance (e.g., wheel chairs, stretchers, stair ramp covers, etc.).
*
Establish means for maintaining the building.
*
Establish a means for backfilling needed supplies.
*
Establish a communication system.
Critical Skill Set
*
Assign key personnel who can accomplish each duty as previously
determined- communications, pharmaceuticals, supplies.
*
Contact local suppliers who can back fill resource needs, to include
transportation needs, PPE needs, pharmaceutical needs.
*
Perform duties wearing PPE if required.
Transportation
*
Responsible for coordinating all transports to hospital facilities.
*
Record all bus arrivals from the scene.
*
Coordinate hospital availability with Incident Scene Transportation Officer.
*
Coordinate transportation to Reunification Center or home.
*
Oversee ambulances.
*
Oversee para-transit vehicles.
Critical Skill Set
*
Utilize multiple ambulance and transportation options.
*
Determine capability of area hospitals.
*
Interact with the Incident Scene Transportation Officer.
Page 61
Page 62
ANNEX E
Mass Casualty Decontamination Algorithm
E-1
Notes: Immediate decontamination may only involve removal of clothing unless victim is grossly contaminated with liquid
agent. Once initial triage and/or decontamination prioritization is performed and adequately trained responders are
available, ambulatory victims should be placed in a separate collection area and proceed through gross decontamination
after more critical patients. It is recommended that all non-ambulatory victims who are exhibiting serious chemical signs
and symptoms receive highest priority for decontamination.
Yes
Expectant (Priority 4) Lowest
Decon Priority
No
Immediate Decon
and Interventions
(Highest Priority)
No
Yes
No
No
Yes
Yes
Yes
Yes
RED
BLACK
RED
Respiratory Effort
Present?
No
Respirations Compromised
(< 12/min or > 26/ min
Circulatory System Intact?
Ambulatory
Non - Ambulatory
Serious signs / symptoms,
chemical, medical
Serious signs / symptoms,
chemical, medical
Rapid Decon and
Treatment
High Priority,
Non ­ ambulatory 1
st
Yes
Delayed Decon and
Treatment
Medium ­ High
Priority, Non ­
Ambulatory 1
St
Moderate signs/symptoms
or liquid exposure / dose
proximity to release point
Moderate signs/symptoms
or liquid exposure / dose
proximity to release point
Delayed Decon and
Treatment
Medium ­ High
Priority, Non ­
Ambulatory 1
St
Minimal signs / symptoms
or vapor exposure/dose
proximity to release point
Minimal signs / symptoms
or vapor exposure/dose
proximity to release point
Yes
Yes
No
No
Low Priority
Decon and Treatment
Non ­ Ambulatory 1
St
Minimal signs / symptoms,
no vapor or liquid
Minimal signs / symptoms
no vapor or liquid exposure
GREEN
No
No
YELLOW
Page 63
Alternative Health Care Facility
- F 1 -
ANNEX F
Domestic Preparedness EMS Technician Course- Triage Section
1. START Triage System
Many jurisdictions across the U.S. are using the Simple Triage and Rapid Treatment
(START) system for triage. Individuals with very little medical training can
effectively use the system. START merely requires an understanding of basic first aid.
Under START, all victims who are able to walk on their own ("walking wounded")
are directed by the first emergency personnel on the scene to a designated area upwind
of the hazard area and are labeled as
Minimal
(green tag). This reduces the number of
victims to be evaluated. These victims will require supervision and might be detained
to obtain further assessment and possible decontamination.
The remaining victims will be evaluated using the START triage system. This should
take no longer than 1 minute per patient and will focus on three primary areas:
Respiratory status
Perfusion and pulse
Neurological status
A. Respiratory Status
As the responder moves through each level of assessment, any condition that is