Emergency Department Response: Surge of Children With a Communicable Foodborne or Waterborne Illness

Reverse Triage

Reverse triage would apply to an outbreak of communicable foodborne or waterborne illness as it would with communicable respiratory illnesses. In the event of a foodborne or waterborne pathogen release, a surge of patients may be managed along lines that mimic standard disaster plans (e.g., victims may be handled in a single geographical location of the emergency department (ED) if patient volume permits).⁶ Nonetheless, some variations from standard disaster practice may be required. EDs often have a limited number of toilets for patient use. If victims suffer diarrhea, there may not be sufficient capacity to handle patient demands. Patients that use existing toilets may inadvertently contaminate the facility and increase the potential for transmission. To forestall this likelihood, every room in which a patient is assigned should have a dedicated toilet, either permanent or portable. All clinicians should follow rigorous handwashing discipline before entering and leaving patient rooms, and use gloves for all examinations. Gloved hands should not be placed on light switches, elevator buttons, keyboards, or any other surface that could promote disease spread. 

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Hospital Response to Patient Surge

A surge of children will require significant changes in every aspect of hospital operations. Individuals already within a hospital will need to be relocated to allow efficient operations during a surge. The actual locations should be defined in each individual facility's disaster plan, and telephone numbers for each area should be listed. Table 1 describes potential patient care activities and proposed locations to which patients or hospital personnel may be transported, if determined to be medically appropriate by the incident commander.

In addition to the above, specific elevators should be assigned for the transport of patients. Access to these dedicated elevators should be limited by security staff; their use should be restricted to individuals with an appropriate key or identification number. 

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Employee Responses During a Surge of Bioterrorism Patients

Each department and division within a health care facility should develop a personnel disaster tree, which is an algorithm by which all employees can be contacted in the event of a mass casualty incident. Once the medical physician in charge has identified a patient surge, hospital operators will contact department chairs, division chiefs, and unit directors. These persons will, in turn, contact their associate directors, nurse managers, or another associate. That person will contact two to three individuals under their supervision, each of whom will repeat the practice until all personnel have been notified. An important element of the disaster notification process is to make staffing requests for:

1. Staff who can immediately respond to the disaster.
2. Staff who will be responsible for relieving the current staff at the next operational period.
3. Staff who are not being requested, but should remain on alert in case they are needed.

To serve as a redundant system for employee notification, all employees should report to their immediate supervisor or department manager. If the supervisor or manager is not in the hospital, that person should be contacted by telephone or hospital pager. Each department or workgroup should have specific responsibilities assigned to them; if there are no responsibilities assigned, then members of that department should report to the labor pool. Employees who are called into the hospital should have parking available in the most convenient lot. No employees should make any comment or responses to the media, nor should they respond to requests for patient information. 

It may become necessary to use outside personnel or volunteers to assist with both clinical and non-clinical elements of the disaster response. For clinical licensed professionals, regulatory agencies like the Joint Commission have instituted clear disaster privileging protocols. Federal programs like Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) and local Medical Reserve Corps programs are an attempt to organize potential health care responders should the need arise.

Any non-employee volunteers responding to support the incident by adding the logistic, supply and material distribution, administrative functions, or other forms of emergency response must be clearly identified as disaster volunteers and assigned a supervisor who will oversee their activities. This group of support personnel is typically protected from civil liability by falling under "Good Samaritan" laws.¹⁶ Table 2 describes the proposed responses of individual departments and workgroups within the hospital during a surge of bioterror patients.

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Surge Stress Management

Most individuals—victims, rescue personnel, and health care workers alike—will demonstrate normal stress reactions that may persist for several days or weeks after a disaster.¹⁷ Approximately one-third of survivors will develop severe stress reactions that place them at risk for acute anxiety syndromes in the immediate post-event period and post-traumatic stress disorder (PTSD) in the days to weeks afterward.^17,18 After a critical incident such as a surge of bioterrorism victims, stress management in the form of a mandatory meeting decreases negative effects of the incident on involved staff.¹⁸ The debriefing is a confidential, non-judgmental evaluation of the event, the hospital's response to it, and the staff's feelings about involvement in the event.¹⁸ It also helps the staff process events related to the surge and returns the workplace to normal equilibrium. The leadership of the debriefing session should be drawn from staff trained in critical incident stress management from psychiatry, social services, and other related fields.¹⁸ The debriefing session should ideally occur within 24 hours of the attack, but it may be delayed by necessity for up to 3 to 4 days afterward.¹⁸ Emerging evidence suggests, however, that these meetings may be counterproductive in some individuals; forcing personnel to "re-witness" the event may actually increase their despair and promote psychiatric decompensation.¹⁸ 

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