manuell powerpoint submitted on 5-28-12
TRANSCRIPT
6/1/2012
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T i d B i C i Triage and Basic Care in Emergency Shelters
Mary‐Elise Manuell, MD, MA, FACEP
University of Massachusetts Medical School
UMass Memorial Medical Center
Disclosures
• I receive funding from the Assistant Secretary for g y
Preparedness and Response (ASPR) Hospital
Preparedness Program through a contract with
the Emergency Preparedness Bureau at the
Massachusetts Department of Public Health to Massachusetts Department of Public Health to
serve as Director of the CEEPET Training Center
at UMass Medical School.
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Two key resources
http://www.emd.wa.gov/plans/documents/Planning_MedicalNeedsShelterPlan.pdf
http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/Emergency_Preparedness/Shelters_Disasters.
Objectives
• Identify the best methods of treatment for the most
common medical problems seen in emergency
shelters
• Explain the level of care that emergency shelter health
care volunteers should be prepared to providecare volunteers should be prepared to provide
• Review the use of appropriate infection prevention
measures to reduce the spread of infectious diseases
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Key questions …
• What are you going to see?
• How are you going to treat it?
• Should it stay or should it go?
• How prevent spread of disease?
http://www2.ljworld.com/photos/galleries/hurricane_katrina/http://www.wunderground.com/blog/NEFLRedCross/comment.html?entrynum=1
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We need to plan for all aspects of the spectrumWe need to plan for all aspects of the spectrum
What are you going to see?How are you going to treat it?Should it stay or should it go?
How prevent spread of disease?How prevent spread of disease?
We need to plan for all aspects of the spectrume eed to p a o a aspects o t e spect u
What are you going to see?How are you going to treat it?Should it stay or should it go?
How prevent spread of disease?How prevent spread of disease?
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Medical Assistance NeededHCP: identify & respond
Medical care that
is provided
Acute conditions or
decompensation of chronic
Self‐sufficient
at home conditions
Medical Assistance
• Identify
• TriageTriage
http://www.majiroxnews.com/2011/06/19/disaster‐victims‐now‐confronting‐a‐menace‐of‐the‐mind/
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Identify
ARC; UASI
Identify
Identify:
• Acute need
• Ongoing assistance
• +/‐ caregiver
• Medications
Can this shelter provide the
assistance and support
needed?
ARC; UASI
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Identify
UASI
Identify
• Completed mostly by p y y
individual
• Medical history, needs
• Vital signs
UASI
• +/‐ caregiver
• Dispo
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Identify
• Medical needs of people in the shelter
• Who needs (or may need) to be transported
hi h l l f to higher level of care
Typical Medical Assistance Rendered
• Basic first aid
• Sustained assistance or medical care
• Not to level of acute care
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Shelter staff training
Basic First Aid, CPR & AED
• Choking, breathing problems
• Unconscious
• Stroke, chest pain, heart attack
• Seizure
• Allergic reactions, etc
• Pregnancy complications, delivery
• Injuries, bites, stings
• etc
Things you might see
• Diabetes
People with chronic well‐maintained
conditions who decompensate
without medications or when their
routines are changed …
• Asthma / COPD
• Heart disease
• Hypertension
• Psychiatric illness
• Seizure disorderg
• Renal Failure / Dialysis
• People on chronic steroids
• Drug / alcohol abuse
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Things you might see
People with acute conditions
• Acute illnesses
– n/v/d; dehydration
– URI, viral illness
– anxietyanxiety
• Injuries related to disaster / evacuation
– Soft tissue, fractures, frostbite
Things you might see
http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm251314.htm
http://lifepregnancy.com/tag/new‐born‐babies/
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Things you might see
• Increased rate of unexpected deliveries during
disaster; increase in premature deliveries
• Shelter planning:
– emergency birthing kit
b b– crib / bassinette
– health and hygiene products for post‐partum women
American College of Obstetricians and Gynecologistshttp://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Women/Preparing_f
or_Disasters_Perspectives_on_Women
We need to plan for all aspects of the spectrume eed to p a o a aspects o t e spect u
What are you going to see?How are you going to treat it?Should it stay or should it go?
How prevent spread of disease?How prevent spread of disease?
6/1/2012
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Depends on …
• Experience of medical provider(s)• Experience of medical provider(s)
• Resources available
• Whether or not transfer to definitive care is
iblpossible
• Your local plans
We need to consider all aspects of the spectrum
• Experienced ff
• +/‐ Experienced ff
• Insufficient ffstaff
• Resources available
staff• Rationing resources
staff• +/‐ resources• No infrastructure
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Common issues
• OTC or person’s prescription medication*
• Increasing fluid intake, rest
• Assisting with daily care
• Comforting words
*Pedi: medication doses are weight‐based
Within scope of practice
Medication Management
• Diabetes
People with chronic well‐maintained
conditions who decompensate
without medications or when their
routines are changed …
• Asthma / COPD
• Heart disease
• Hypertension
• Psychiatric illness
• Seizure disorderg
• Renal Failure / Dialysis
• People on chronic steroids
• Drug / alcohol abuse
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Management of acute conditions
• Gastroenteritis / dehydration
• Infectious illness
• Minor injuries
Things to worry about …
• Abnormal vital signs
• Difficulty breathing
• Diaphoresis
• New confusion, neuro changes
http://www.instructables.com/id/Bright‐Idea‐USB‐drive/
• Severe, uncontrollable pain
• Active bleeding
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Management
• Depends on expertise
of staff and resources
available
• Likely transfer acute • Likely transfer acute
care cases http://allcoloringpictures.com/kids‐776_ambulance.php
Worst case scenario
• Left lateral decub position
• Position of comfort
• Keep baby warm and dry
• Hold a hand
• Food, coffee
• Keep people warm and hopeful
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Condition Ideal In between Last resort / austere
Deformed extremity To ER for x‐rays,d i d li
Splint in same i i b
Support with h hreduction and splint position, maybe
manipulate a bit firstwhatever you have around you ‐‐‐ pillow, box
http://www.hunter‐ed.com/az/course/ch8_first_aid.htm http://lifesaving.xomba.com/how_apply_splint
http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf
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http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf
http://www.fema.gov/pdf/about/odic/fnss_guidance.pdf; Appendix 7
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x 6 pages
UASI Appendix 9
We need to plan for all aspects of the spectrume eed to p a o a aspects o t e spect u
What are you going to see?How are you going to treat it?Should it stay or should it go?How prevent spread of disease?How prevent spread of disease?
6/1/2012
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Depends on …
• What providers are
available
• Provider’s comfort level
• Resources available for
treatmenttreatment
• Access to definitive care
or medical site http://pediatrics.about.com/od/asthma/ig/Asthma‐Photo‐Gallery/Nebulizer‐Treatment.htm
We need to plan for all aspects of the spectrume eed to p a o a aspects o t e spect u
What are you going to see?How are you going to treat it?Should it stay or should it go?
How prevent spread of disease?How prevent spread of disease?
6/1/2012
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Got germs?
• Common cold
• Influenza
• Gastroenteritis
H titi • Hepatitis
• Tuberculosis
http://aroundtheworldblog.blogspot.com/2011/12/danger‐lurks‐for‐airline‐passengers.html
Infection Control
I d i k f di t i iIncreased risk of disease transmission:
• Close proximity (displaced individuals and staff)
• Overcrowding
D i l k f i i i• Decrease in or lack of routine sanitary services
• Environmental conditions
APIC
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Infection Control
• Universal precautions are to be followed at all times per
policy and procedure
• All staff members are to be trained in the proper handling
of patients and supplies
• Staff members are to take appropriate infection control
iprecautions
• Special patient precautions are to be noted at the patient’s
bedside
UASI
Infection Control
• Triage and surveillance:
– identify potentially contagious individuals
– identify people in need of medical care
prevent or limit the emergence or spread of
communicable diseases within the shelter
APIC
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Infection Control
• Ideal:
– standard infection control practices at all types of
facilities
R lit • Reality:
– limited resources and capabilities
ACIP
Infection Control
Planning:
• Equipment that is easy to clean / disinfect
• Involve infection control experts
APIC
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Infection Control
Infectious disease disaster
Non‐infectious disease disaster
APIC
Triage & Surveillance
APIC Appendix B & C
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Infection Control Triage
APIC Appendix D
Isolation Precautions
• Space
• Actions
• Equipment / Environment
APIC
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APIC APpendix G
Isolation Precautions
Designated area for potentially infectious individualsDesignated area for potentially infectious individuals
• Physically separated from rest of shelter by walls on all
sides and a door
• Create area using plastic, other barrier material
• Dedicated shelter staff
• Dedicated entrance / passageway
APIC
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Negative Pressure Rooms
• Controlled air
movement in isolation
areaarea
http://www.health.state.mn.us/oep/training/bhpp/airbornenegative.pdf
Educate
APIC Appendix F
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Hand Hygiene
• Hand washing
• Alcohol Based Hand
Rubs (ABHR)
• Antimicrobial wipes
APIC Appendix I
Hand Hygiene
• When
• Where
• Monitoring compliance
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Environmental Decontamination
Germs can be spread via hands and equipment
when items in environment become
contaminated
• Tables
• Doorknobs
• Toys
APIC
Environmental Decontamination
• Proper cleaning and disinfection: crucial
• Staff need to be trained
• Cleaning plan for each shelter area
• EPA‐registered disinfectant or alternative
APIC
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Environmental Decontamination
• Body Fluid Spills
• Environmental Surfaces
• Toys
APIC
Toys / Play area
• Important part of shelter
• Potential to spread
disease
• Hand hygiene before
entering and when entering and when
leaving area
• Two toy boxes
http://www.bt.cdc.gov/disasters/hurricanes/library/evacplayareas.pdf
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APIC Appendix N
PPE
• Gloves
• Gowns
• Masks and respirators
• Resource management critical
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“Simple Respiratory Mask”
http://wwwnc.cdc.gov/eid/article/12/6/05‐1468_article.htm
Other infection control measures
• Water management
• Food safety
• Waste management / Medical waste
• Pest management
• Pet management
• Post‐mortem care
APIC
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http://www.bt.cdc.gov/disasters/commshelters.asp
Animals
http://www.bt.cdc.gov/disasters/animalspubevac.asp
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What do you need?
APIC Appendix A
http://nursingcrib.com/nursing‐jobs/infection‐control‐nurse/
Key points
• Planning planning planning• Planning, planning, planning
• Expect the unexpected
• Practice in your scope – what you feel
f bl d icomfortable doing
• Keep hands clean
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Key questions …
• What are you going to see?
• How are you going to treat it?
• Should it stay or should it go?
• How prevent spread of disease?
Objectives
• Identify the best methods of treatment for the most
common medical problems seen in emergency
shelters
• Explain the level of care that emergency shelter health
care volunteers should be prepared to providecare volunteers should be prepared to provide
• Review the use of appropriate infection prevention
measures to reduce the spread of infectious diseases