COMPETENCIES FOR

REGISTERED NURSES
RESPONDING TO MASS
CASUALTY INCIDENTS


Submitted by:
Olyces Mar Garces
Ma. Roxanee T. Gantuangco









II. Health Care Systems and Policy

1. Define and distinguish the terms disaster and mass
casualty incident (MCI) in relation
to other major incidents or emergency situations.

2. Define relevant terminology, including:
CBRNE,
Chemical, Biological, Radiological, and Nuclear
Defense (often abbreviated to CBRN defense or CBRND)
is protective measures taken in situations in which any
of these four hazards are present. To account for
improvised devices, the term CBRNe (e for explosives)
is used. CBRN defense consists of CBRN passive
protection, contamination avoidance, and CBRN
mitigation.

CBRN weapons/agents are often referred to as weapons
of mass destruction (WMD). However, this is not entirely
correct. Although CBRNe agents often cause mass
destruction, this is not necessarily the case. Terrorist
use of CBRNe agents may cause a limited number of
casualties, but a large terrorizing and disruption of
society. Terrorist use of CBRNe agents, intended to
cause terror instead of mass casualties, is therefore
often referred to as weapons of mass disruption.[1]

A CBRN incident differs from a hazardous material
incident in both effect scope (i.e., CBRNe can be a mass
casualty situation) and in intent. CBRN incidents are
responded to under the assumption that they are
deliberate, malicious acts with the intention to kill,
sicken, and/or disrupt society. Evidence preservation
and perpetrator apprehension are of greater concern
with CBRN incidents than with HAZMAT incidents.

&WMD,
weapon of mass destruction (WMD) or (WoMD) is a
weapon that can kill and bring significant harm to a
large number of humans and/or cause great damage to
man-made structures (e.g. buildings), natural structures
(e.g. mountains), or the biosphere in general. The scope
and application of the term has evolved and been
disputed, often signifying more politically than
technically. Coined in reference to aerial bombing with
chemical explosives, it has come to distinguish large-
scale weaponry of other technologies, such as chemical,
biological, radiological, or nuclear. This differentiates the
term from more technical ones such as chemical,
biological, radiological, and nuclear weapons (CBRN).
&Triage
Triage is the process of determining the priority of
patients' treatments based on the severity of their
condition.
Types:
Simple triage
Simple triage is usually used in a scene of an
accident or "mass-casualty incident" (MCI), in order to
sort patients into those who need critical attention and
immediate transport to the hospital and those with less
serious injuries. This step can be started before
transportation becomes available.
Advanced triage
For classifications, see the specific section for that
topic. In advanced triage, doctors and specially trained
nurses may decide that some seriously injured people
should not receive advanced care because they are
unlikely to survive. It is used to divert scarce resources
away from patients with little chance of survival in order
to increase the chances of survival of others who are
more likely to survive.
Continuous integrated triage
Continuous Integrated Triage is an approach to
triage in mass casualty situations which is both efficient
and sensitive to psychosocial and disaster behavioral
health issues that affect the number of patients seeking
care (surge), the manner in which a hospital or
healthcare facility deals with that surge (surge capacity)
and the overarching medical needs of the event.
Continuous Integrated Triage combines three forms
of triage with progressive specificity to most rapidly
identify those patients in greatest need of care while
balancing the needs of the individual patients against the
available resources and the needs of other patients.
Continuous Integrated Triage employs:
Group (Global) Triage (i.e., M.A.S.S. triage).
Physiologic (Individual) Triage (i.e., S.T.A.R.T.)
Hospital Triage (i.e., E.S.I. or Emergency Severity
Index)
However any Group, Individual and/or Hospital
Triage system can be used at the appropriate level of
evaluation.
Reverse triage
In addition to the standard practices of triage as
mentioned above, there are conditions where sometimes
the less wounded are treated in preference to the more
severely wounded. This may arise in a situation such as
war where the military setting may require soldiers be
returned to combat as quickly as possible, or disaster
situations where medical resources are limited in order
to conserve resources for those likely to survive but
requiring advanced medical care.
[15]
Other possible
scenarios where this could arise include situations where
significant numbers of medical personnel are among the
affected patients where it may be advantageous to
ensure that they survive to continue providing care in
the coming days especially if medical resources are
already stretched. In cold water drowning incidents, it is
common to use reverse triage because drowning victims
in cold water can survive longer than in warm water if
given immediate basic life support and often those who
are rescued and able to breathe on their own will
improve with minimal or no help.
[16]

Undertriage and overtriage
Undertriage is the underestimating the severity of an
illness or injury. An example of this would be categorizing
a Priority 1 (Immediate) patient as a Priority 2 (Delayed)
or Priority 3 (Minimal). Historically, acceptable
undertriage rates have been deemed 5% or less.
Overtriage is the overestimating of the severity of an
illness or injury. An example of this would be categorizing
a Priority 3 (Minimal) patient as a Priority 2 (Delayed) or
Priority 1 (Immediate). Acceptable overtriage rates have
been typically up to 50% in an effort to avoid
undertriage. Some studies suggest that overtriage is less
likely to occur when triaging is performed by hospital
medical teams, rather than paramedics or EMTs.
[17]

Incident Command System (ICS),
The Incident Command System (ICS) is "a
systematic tool used for the command, control, and
coordination of emergency response" according to the
United States Federal Highway Administration
PPE,
Employers are responsible for providing, replacing and
paying for personal protective equipment.
PPE should be used when all other measures are
inadequate to control exposure. It protects only the
wearer, while being worn.
If it fails, PPE offers no protection at all.
Types of PPE
Respirators
Protective gloves
Protective clothing
Protective footwear
Eye protection

scene assessment, and
comprehensive emergency management.
3. Describe the four phases of emergency management:
preparedness, response,
recovery and mitigation.
Preparedness
Preparedness takes the form of plans or procedures
designed to save lives and to minimize damage when an
emergency occurs. This is a continuous cycle of
planning, organizing, training, equipping, exercising,
evaluation and improvement activities to ensure effective
coordination and the enhancement of capabilities to
prevent, protect against, respond to, recover from and
mitigate the effects of natural disasters, acts of terrorism
and other man-made disasters. These activities ensure
that when a disaster strikes, emergency managers will be
able to provide the best response possible.

In the preparedness phase, emergency managers
develop plans of action to manage and counter their risks
and take action to build the necessary capabilities needed
to implement such plans. Common preparedness
measures include:
communication plans with easily understandable
terminology and methods
proper maintenance and training of emergency
services
development and exercise of emergency population
warning methods
preparing shelters and evacuation plans
stockpiling, inventory, and maintain disaster supplies and
equipment



Response
The response phase includes the mobilization of the
necessary emergency services and first responders in
the disaster area. This is likely to include a first wave of
core emergency services, such as firefighters, police and
ambulance crews. Response is defined as the actions
taken to save lives and prevent further damage in a
disaster or emergency situation. Response is putting
preparedness plans into action. Response activities may
include damage assessment, search and rescue, fire
fighting and sheltering victims.

Organizational response to any significant disaster is
based on existing emergency management organizational
systems and processes: the Federal Response Plan (FRP)
and the Incident Command System (ICS).
Recovery
Recovery is defined as the actions taken to return the
community to normal following a disaster. Repairing,
replacing, or rebuilding property are examples of
recovery.

The aim of the recovery phase is to restore the affected
area to its previous state. It differs from the response
phase in its focus; recovery efforts are concerned with
issues and decisions that must be made after immediate
needs are addressed. Recovery efforts are primarily
concerned with actions that involve rebuilding destroyed
property, re-employment, and the repair of other
essential infrastructure. Efforts should be made to build
back better," trying to reduce the pre-disaster risks
inherent in the community and infrastructure.

The Robert T. Stafford Disaster Relief and Emergency
Assistance Act, Public Law 93-288, as amended (the
Stafford Act) was enacted to support state and local
governments and their citizens when disasters
overwhelm them. The disaster process and disaster aid
programs explains the disaster declaration process and
provides an overview of available assistance. PEMA
assistance

There are individual assistance programs that assist
people and businesses following a disaster and help you
get back on your feet. Public Assistance Programs
provides supplemental federal disaster grant assistance
to help state and local governments and certain private
non-profit organizations rebuild
Mitigation
Mitigation is the cornerstone of emergency management.
Its the continuing effort to lessen the impact that
disasters have on people and property. Mitigation is
defined as sustained action that reduces or eliminates
long-term risk to people and property from natural
hazards and their effects.

Mitigation efforts attempt to prevent hazards from
developing into disasters altogether or to reduce the
effects of disasters. The mitigation phase of emergency
management differs from the other phases in that it
focuses on long-term measures for reducing or
eliminating risk. The implementation of mitigation
strategies is a part of the recovery process if applied
after a disaster occurs.

Mitigation measures can be structural or non-structural.
Structural measures use technological solutions like flood
levees. Non-structural measures include legislation, land-
use planning (e.g. the designation of nonessential land
like parks to be used as flood zones), and insurance.
Mitigation is the most cost-efficient method for reducing
the affect of hazards, although not always the most
suitable

4. Describe the local emergency response system for
disasters.
5. Describe the interaction between local, state and
federal emergency response systems.
6. Describe the legal authority of public health agencies
to take action to protect the
community from threats, including isolation,
quarantine, and required reporting
and documentation.
7. Discuss principles related to a MCI site as a crime
scene, e.g. maintaining integrity
of evidence, chain of custody.
8. Recognize the impact MCIs may have on access to
resources and identify how to
access additional resources, e.g. pharmaceuticals,
medical supplies.
III. Illness and Disease Management
1. Discuss the differences/similarities between an
intentional biological attack and
that of a natural disease outbreak.
2. Assess, using an interdisciplinary approach, the short
term and long term effects of
physical and psychological symptoms related to
disease and treatment secondary to MCIs.
IV. Information and Health Care Technologies
1. Demonstrate use of emergency communication
equipment that you will be required
to use in a MCI response.
2. Discuss the principles of containment and
decontamination.
3. Describe procedures for decontamination of self,
others, and equipment for
selected CBRNE agents.
V. Ethics
1. Identify and discuss ethical issues related to CBRNE
events:
Rights and responsibilities of health care providers
in MCIs, e.g. refusing to go to work
or report for duty, refusal of vaccines.
Need to protect the public versus an individual's
right for autonomy, e.g. right to
leave the scene after contamination.
Right of the individual to refuse care, informed
consent.
Allocation of limited resources.
Confidentiality of information related to individuals
and national security.
Use of public health authority to restrict individual
activities, require reporting
from health professionals, and collaborate with law
enforcement.
2. Describe the ethical, legal, psychological, and cultural
considerations when dealing with
the dying and or the handling and storage of human
remains in a mass casualty incident.
3. Identify and discuss legal and regulatory issues
related to:
abandonment of patients;
response to a MCI and one's position of
employment; and
various roles and responsibilities assumed by
volunteer efforts.
VI. Human Diversity
1. Discuss the cultural, spiritual, and social issues
that may affect an individuals
response to a MCI.
2. Discuss the diversity of emotional, psycho-social
and socio-cultural responses to
terrorism or the threat of terrorism on ones self
and others.

Professional Role Development
1. Describe these nursing roles in MCIs:
Researcher
Investigator/epidemiologist
EMT or First Responder
Direct care provider, generalist nurse
Direct care provider, advanced practice nurse
Director/coordinator of care in hospital/nurse
administrator or
emergency department nurse manager
On-site coordinator of care/incident commander
On-site director of care management
Information provider or educator, particularly the
role of the generalist nurse
Mental health counselor
Member of planning response team
2. Identify the most appropriate or most likely health
care role for oneself during a MCI.
3. Identify the limits to ones own
knowledge/skills/abilities/authority related to MCIs.
4. Describe essential equipment for responding to a
MCI, e.g. stethoscope, registered
nurse license to deter imposters, packaged snack,
change of clothing, bottles of water.
5. Recognize the importance of maintaining ones
expertise and knowledge in this area
of practice and of participating in regular emergency
response drills.
6. Participate in regular emergency response drills in the
community or place of employment.