Hospitals throughout the United States are required to have a disaster management plan in compliance with The Joint Commission. Despite this obligation, few orthopaedic (or surgical) departments have developed response plans that could coordinate and could integrate with their hospital’s disaster plan. Repeated headline events such as the active shooter, terrorist bombings, and natural disasters serve to underscore the need for disaster and mass casualty preparedness. We offer the following guidelines to address the basic elements for disaster response planning by a department, including critical areas of communication, resource allocation, personnel assignments, and overall team coordination. We include details of the notification and alert system; response, with delineation of lines of authority, logistics, and establishment of a command center; casualty flow, which outlines roles and assignments; and recovery. On the basis of time-tested disaster management principles, the response guidelines are outlined for both academic and non-academic orthopaedic departments. They are not intended to supersede the hospital disaster plan. Rather, they are intended to provide guidance for how an orthopaedic department can respond and can assist the hospital and all other departments during a disaster to effectively and efficiently provide optimal care for the injured patient population. Included are general areas that require advanced consideration (e.g., leadership positions and communications) and a platform with terminology that mirrors the Incident Command System in use nationally. We clarify that these guidelines are not to reinvent the Incident Command System but are a means to engender interest in preparation and a review of the common language of disaster response, thereby encouraging orthopaedic surgeons to increase their knowledge and efforts in this area. As General George S. Patton said1, “Plans must be simple and flexible. They should be made by the people who are going to execute them.”
The importance of disaster planning continues to be highlighted by high-profile domestic natural and man-made disasters as well as an increase in the use of random violence as a means of promoting social and political agendas. These events have revealed potential shortcomings in our local, regional, national, and international emergency response systems. The need for improved preparedness and disaster management training has been shown2. Effective planning helps to restore order to a chaotic situation. However, a 2008 Medical Group Management Association (MGMA) survey found that up to 30% of hospital-based and private or community medical practices had no emergency plans3. The potential need for rapid and organized response persists despite non-optimal circumstances4,5. Orthopaedic surgeons specialize in the pathophysiology and management of musculoskeletal injuries and may be called on to play a pivotal management role in certain disaster scenarios depending on the nature of the event. There would be little orthopaedic need following a disease outbreak or a hazardous materials spill. However, expertise in musculoskeletal injury management would likely be required following a plane crash, building collapse, hurricanes, and tornadoes. Terrorism is on the rise. Historically, the most common forms of terrorist violence in the United States are bombings and shooting massacres with injury complexes that also fall within the orthopaedist’s purview6. It is logical and proactive for individual departments to develop a disaster management plan that will integrate with but not replace the hospital’s overarching response plan. We do not propose that an orthopaedic department should run the response. The concepts presented here mimic the Incident Command System model used nationally and internationally for disaster management. This is by design, as it will help to educate the surgeon with regard to the common language of disaster management and to identify a number of functions and positions that might not be considered in advance. Also, as with the Incident Command System, all designated functions, positions, and personnel requirements are modular and scalable depending on the scope of the event, to be deployed as needed. Certainly, the utility of utilizing surgeons as orthopaedic commanders in the post-anesthesia care unit or on the floors would depend on the scope of the disaster (a surge of twenty casualties compared with a disaster involving hundreds of casualties) and availability of manpower. It is important to remember that all hospitals and programs are different. A surge to one hospital may be considered a disaster to another hospital depending on event size, available resources, and personnel7. Finally, when a department recognizes the basic need for a plan and develops one, it is important that the plan be reviewed by all members periodically (at least once a year). Some routine rehearsal or drill should also be incorporated to perfect subtleties prior to the first actual event or before the next event (if a disaster response has already occurred).
Rationale for an Orthopaedic Disaster Management Plan
The purpose of a specific orthopaedic disaster management plan is to provide a response template for both internal (i.e., the hospital is the disaster site) and external (i.e., the hospital is a primary receiving center) disaster situations. The plan should identify the responsibilities of individuals within the Department of Orthopaedic Surgery in the event of a disaster situation and should provide a means of integrating orthopaedic response activities with those of other departments and the hospital.
An orthopaedic disaster management plan should follow the same fundamental concepts that are universally applicable to all disasters. One of the most important principles is the concept of an all-hazards approach8. The implication is that, at any given time, several types of hazards may pose a potential threat to any given community or hospital based on a Hazard Vulnerability Analysis that identifies those potential threats. Each identified hazard or threat is assessed for the likelihood of it occurring and for the severity of impact that it may have on the hospital, community, health-care providers, and critical facility operations. An all-hazards approach should create a plan with the flexibility to adapt to any type of event. There should not be multiple plans.
The following guide for the development of an individual departmental disaster management plan can be used for academic departments with a full complement of faculty, residents, and physician extenders or can be scaled down for smaller, nonacademic, or community departments.
Orthopaedic Disaster Response Template
General Structure and Hierarchy
Mass casualty incidents are dynamic and often large enough to overwhelm the local community’s resources8. The Incident Command System was developed in the 1970s to coordinate direct lines of authority and command when numerous jurisdictions responded to a series of wildfires in Southern California9,10. The Incident Command System and its more recent version, the Incident Management System11, have been in use by the Fire Service and Emergency Management for more than three decades. The Joint Commission requires medical treatment organizations to identify the potential emergencies that could affect them and to develop a plan that addresses the four phases of emergency management activities (mitigation, preparedness, response, and recovery). These emergency management plans must also address command structures, backup communications systems, building evacuations, and coordination with other community health-care organizations and emergency responders12. The Incident Command System is a valuable tool that allows commanders to compartmentalize the response into functional sections with preassigned personnel while maintaining an acceptable hierarchy of control. This management structure is both modular and scalable. The primary sections are operations, planning, logistics, and finance. Medical activities fall under the aegis of the operations section.
Disaster Notification and Alert
A notification system is required to implement the hospital and/or departmental disaster plan(s). The hospital and departmental plan should clearly identify which individuals are responsible for alerting the support staff and what are the means by which this is done. Clear protocols and redundancy are key components of a robust response system, as some elements may fail in an unpredictable fashion. Scenarios should be rehearsed to identify potential shortcomings. Each member of the Department of Orthopaedic Surgery should have access to a preestablished departmental contact list with a master copy readily available to the Department of Orthopaedic Surgery administration and hospital operator.
It is important that everyone understands alert terminology. In general, an alert is a type of notification and is typically classified as standby or activation. A standby alert indicates that a disaster is potentially occurring (Table I). A standby may evolve into activation. This tells staff that a disaster has occurred requiring implementation of the disaster plan. All departmental staff should report to areas that have been preassigned to them. The activated Hospital Incident Command System begins to organize the response.
TABLE I -
Disaster Alert Terminology: Suggested Notification Wording
|The orthopaedic disaster plan is on standby.
| Disaster may be evolving; prepare for potential activation.
| Department members are notified and are placed on standby.
| Department of Orthopaedic Surgery staff should secure daily responsibilities.
| Stop new patient encounters including clinics and elective surgery cases.
|The orthopaedic disaster plan is activated; report to your assigned station.
| A true disaster exists.
| Implement hospital and Department of Orthopaedic Surgery disaster plans.
| Activate Department of Orthopaedic Surgery notification system.
| Collect reliable data on the depth and breadth of the event.
| Members report to designated assembly points for assignments.
| Clinics and all non-emergent surgery are cancelled.
Each hospital creates its own notification terminology and all medical and ancillary staff should be familiar with the meaning of the alerts (e.g., code triage compared with disaster code). Many state systems are adopting universal terminology for these notifications to reduce confusion. There has been speculation that direct statements as to the nature of an alert may be more beneficial than code words (e.g., “active shooter, hospital lobby” instead of “Code Silver, hospital lobby”).
When a disaster is declared, members of the Department of Orthopaedic Surgery should continuously collect real-time information about the disaster from reliable sources to determine the character of the event and possible Department of Orthopaedic Surgery resource requirements. At a level-I trauma center, the on-call resident should rapidly notify the department chair or the chief of orthopaedic trauma and/or the on-call attending surgeon. A determination is then based on all available early information whether no alert, a standby alert, or an activation alert is warranted for the rest of the department (Table II). At level-II and level-III hospitals or community hospitals, this task would fall to the in-house or on-call senior orthopaedic surgeon. It is important to remember that not all activations will require a strong orthopaedic presence (e.g., a plane crash compared with a chlorine gas leak).
TABLE II -
Suggested Notification List for Department of Orthopaedic Surgery Following a Standby or Activation Alert
|Level-I Trauma or Academic Center
|1. Department chair or trauma chief
||1. On-call orthopaedist or department head
|2. Additional trauma and on-call attending surgeons
||2. Back-up orthopaedists
|3. Trauma fellows (if applicable)
||3. Operating room coordinator or charge nurse
|4. All residents and fellows
||4. Physician extenders
|5. Surgical coordinator
|6. Physician extenders
In the event that a Department of Orthopaedic Surgery supports a number of hospital facilities, the staff (attending surgeons, residents, physician assistants or nurse practitioners, and so forth) should proceed to their currently assigned hospital unless recruited to another facility by the orthopaedic incident commander. This is important because numerous hospitals are utilized to handle the patient care burden during disaster and mass casualty situations; failure to do so may leave satellite hospitals short-staffed. For each hospital, an assembly point should be predesignated. Staff and residents should proceed to that assembly point and should then be allocated to various points of need by the senior orthopaedic leader on-site.
Orthopaedic Departmental Disaster Response
When the hospital goes into a disaster mode, clear lines of authority and decision-making must quickly be established to promote a well-coordinated response. The Hospital Incident Command System is initiated, a predetermined command center is established, and the person in charge of managing the hospital’s response (the incident commander) should be present throughout the event. The incident commander coordinates the efforts of the four critical subordinate groups during the response: planning, operations, logistics, and finance. In the Hospital Incident Command System model, medical care falls under the aegis of the operations section; here, the Department of Orthopaedic Surgery response is directly coordinated between the hospital’s operations section leader and the Department of Orthopaedic Surgery incident commander (Table III). Overall coordination of orthopaedic care within the system rests with the designated senior surgeon who is physically in the hospital.
TABLE III -
Suggested Hierarchy for the Role of Orthopaedic Incident Commander
|1. Chief of Department of Orthopaedic Surgery
|2. Chief of orthopaedic trauma or designee
|3. On-call orthopaedic attending surgeon or designee
|4. On-call orthopaedic trauma fellow or designee
|5. On-call orthopaedic chief resident or designee
|6. On-call senior orthopaedic resident or designee
In the event that the disaster plan is activated, all Department of Orthopaedic Surgery response members should report to a previously determined Orthopaedic Departmental Emergency Command Center taking the selected travel precautions and bringing appropriate personal supplies (Table IV). This command center should be in a central, accessible area but separate from the hospital’s triage center or emergency room and incident command center. Emergency generator power outlets as well as multiple forms of communication should be available in the Orthopaedic Departmental Emergency Command Center. In case of a disaster internal to the hospital, a secondary command center (removed from the hospital grounds) will need to be considered.
TABLE IV -
Important Considerations for Returning Staff
|Avoid major roads that may become bottlenecked.
|Park in assigned lots and do not use street parking.
|Always have proper identification clearly displayed.
|Enter through secured employee entrance.
|Bring emergency travel bag.
| Personal hygiene items and medication
| Flashlight or headlight and batteries
| Cell charger
| Clothing change
| Some food (e.g., energy bars) and bottled water
| Marking pens (for writing information on bandages, splints, or casts)
The first job of the orthopaedic incident commander is to organize the Orthopaedic Departmental Emergency Command Center and to develop a roster of available personnel. The Orthopaedic Departmental Emergency Command Center is the center for all Department of Orthopaedic Surgery communications and should be in close contact with the hospital’s incident commander and operations chief. Care is required to maintain proper alignment of efforts within the overall disaster response.
It is important to remember that, during a disaster, power outages may occur and many standard electronic means of communication may become overloaded and/or inoperable. Each program should have redundant communication plans and equipment available. An internal radio system composed of two-way radios that operate on their own frequencies should allow for communication between major orthopaedic control positions (Table V). These radios may serve as the primary communication system among the key areas of the hospital (Orthopaedic Departmental Emergency Command Center, Emergency Department, operating rooms, and wards) to reduce telephone hard-line traffic. These radios should be kept charged in the Orthopaedic Departmental Emergency Command Center where they will be distributed accordingly at the time of the disaster. Department members should understand how the radios work and test in advance their reception capability throughout the hospital. Key communication hub numbers (e.g., operating room, Emergency Department, and wards) should be listed in the Appendix of the Departmental Disaster Plan and kept available in the Orthopaedic Departmental Emergency Command Center (Table VI).
TABLE V -
Primary Orthopaedic Control Positions
|1. Orthopaedic incident commander: Department of Orthopaedic Surgery response team leader responsible for integrating the Department of Orthopaedic Surgery disaster plan with the hospital’s incident command structure.
|2. Emergency Department or triage controller: Adjunctive Department of Orthopaedic Surgery leader who prioritizes patient triage flow and staffing assignments based on the influx of casualties and available resources. Goal is to provide the greatest good for the greatest number of casualties.
|3. Operating room controller: Responsible for operating room and post-anesthesia care unit patient flow with initial goals of damage control orthopaedic principles.
|4. Ward or intensive care unit controller: Goal of prioritizing postoperative or non-surgical walking wounded care and maintaining a working disaster patient log with the Emergency Department controller.
|5. Satellite hospital controller: Senior auxiliary hospital member who communicates with orthopaedic incident commander on interhospital transfer or resource allocation.
|6. Logistics officer: Advocates a balanced team approach by creating a shift work schedule and continually reassessing the Department of Orthopaedic Surgery resource requirements and supplies.
TABLE VI -
Items Included in an Appendix for the Departmental Disaster Plan
|1. The location of the Orthopaedic Departmental Emergency Command Center
|2. A complete departmental roster with full contact information
|3. A phone tree for attending surgeons, residents, physician assistants, and nurse practitioners
|4. Alternate routes to the hospital
|5. Suggested travel bag items
|6. Two-way radio user and channel information
|7. Key communication numbers (i.e., Hospital Incident Command System or intensive care unit, Orthopaedic Departmental Emergency Command Center, operating room, Emergency Department, wards)
Personnel Hierarchy for Casualty Flow
A successful disaster response is predicated on the availability of knowledgeable support members. Adequate staffing of the Emergency Department and the operating rooms is critical for casualty flow and surgical care. Each member should have a clearly defined role and pre-disaster training. It cannot be stressed enough that this is a team project with communication as a cornerstone. The orthopaedic disaster plan is a subsidiary of the hospital plan. Members of the orthopaedic disaster response team should strive to mesh seamlessly with the hospital response teams and activities.
Orthopaedic Incident Commander
The orthopaedic incident commander must work as the orthopaedic team leader and integrate his or her department’s assets with the hospital’s incident command structure, assuring continuity of departmental activities and response priorities. The orthopaedic incident commander should closely monitor orthopaedic clinical operations to conserve resources for casualty care and will coordinate critical personnel duties and effectively communicate mission goals.
In addition to the orthopaedic incident commander, there are five additional major orthopaedic leadership positions that should be considered (Table V). The requirement for these positions is dependent on the magnitude of orthopaedic injuries. The orthopaedic incident commander is responsible for assigning each of the five orthopaedic leadership roles as necessary plus a designated liaison to the hospital emergency command center.
Orthopaedic Emergency Department Controller
Ideally, the orthopaedic Emergency Department controller should be a seasoned attending surgeon who assists the designated hospital Emergency Department triage officer with managing patient prioritization and flow based on updated resource availability. This individual should be conversant in common triage principles and methodologies such as the Simple Triage and Rapid Treatment (START) system (Table VII)13,14 and should understand that the goal of triage is to provide the greatest good for the greatest number of casualties, avoiding valuable resource consumption for complex injuries with unfavorable survival rates or on injuries that can be managed at a later time. To maintain optimal casualty flow, the orthopaedic Emergency Department controller should minimize the use of laboratory testing and radiograph or advanced imaging as much as possible during the period of acute casualty influx. Casualties should be rapidly triaged to the operating room, intensive care unit, wards, admission holding areas, or interhospital transfer coordination areas on the basis of their physiological needs and the hospital’s surge capacity.
TABLE VII -
Basic Triage Categories
||Severely injured patients who require urgent, life-saving treatment (for airway, breathing, and circulation) given available resources: absent spontaneous breathing or respiratory rate >30 breaths or <8 breaths per minute, absent radial pulse or capillary refill more than two seconds or altered mental status with inability to follow commands
||Those injured who are not in immediate need of immediate life-saving interventions and those in whom treatment can be delayed: spontaneous breathing with respiratory rate <30 breaths per minute, palpable radial pulse with capillary refill less than two seconds, and capable of following commands
||Minor injuries with no imminent need for treatment: walking wounded
||The most severely injured with no spontaneous breathing or those unlikely to survive based on the severity of injuries, available resources, or both
Orthopaedic Operating Room Controller
The orthopaedic operating room controller will work together with the hospital’s surgical coordinator or controller to move patients through the operating room and the post-anesthesia care unit based on prioritization and resource availability. The operating room controller provides the incident commander and logistics officer with continual updates regarding orthopaedic casualties and resource needs. Damage control procedures should be the initial priority to optimize resource consumption in the early phase.
Orthopaedic Ward or Intensive Care Unit Controller
The ward or intensive care unit controller is responsible for the overall care of patients in the wards or intensive care unit admitted with musculoskeletal injuries including orthopaedic care and logistics of admission or transfer to a lower level of care. A working disaster patient log should be maintained by the Emergency Department controller.
Satellite Hospital Controller
If a satellite hospital or surgical center is required to support the primary hospital’s relief efforts, the satellite hospital controller would coordinate and would communicate with the incident commander to complete tasks. This person is typically a staff member of the auxiliary facility who is familiar with the main hospital’s orthopaedic disaster plan. This individual operates under the direction of the orthopaedic incident commander and reports on additional resources available at the satellite site. Additional staff may be recruited as needed.
The logistics officer will be responsible for creating a reasonable schedule of shift coverage for duration of the disaster. Staff should be assigned to twelve-hour shifts to keep the team focused and free of fatigue-related incidents. The logistics officer will continually assess the department’s mission and is responsible for obtaining the resources, equipment, and staff required to carry out the department’s functions; this includes medical supplies and equipment, food, and supplies for incident personnel. Direct communication with the orthopaedic incident commander is critical.
Disaster Recovery Phase
Once the hospital incident commander has given clearance, the orthopaedic incident commander will initiate a deactivation process to scale down or to stand down the emergency response resources. The individual controllers should report an up-to-date status of the census and treatment conditions from their sections. Only the hospital’s incident commander has the authority to clear staff to return to routine operations. A formal all-clear notification will be distributed among the duty sections with a confirmed response that the disaster-specific duties have ceased.
After-action review (“hot wash”) and process improvement are vital after any disaster response. The value of information learned from each event is predicated upon proper documentation throughout the response and upon completion of the response. This formal process is designed to maximize learning and to enable constructive criticism for future improvements in patient care. Each orthopaedic controller should complete an after-action report in a timely manner, and information from the collected reports must be forwarded to the incident commander, the chief of orthopaedics, and hospital administration. The chief of orthopaedic trauma or chief of orthopaedics should take the responsibility for updating the department’s disaster response plan and for the staff’s continued education in this area.
The physical and emotional expense of responding to a natural or man-made disaster can be immense. Psychoemotional care is an important aspect of the recovery process and should be a mandatory part of the departmental plan. Early detection for those who will benefit from these services is critical. Hospital pastoral care and social services should coordinate a series of Critical Incident Stress Debriefing sessions to ensure that all staff who participated in the response have the opportunity to attend at least one session (Table VIII).
TABLE VIII -
Key Recovery Concepts
|After-action review and reporting
Numerous accounts of natural disasters (i.e., hurricane or tornado) and man-made mass casualty scenarios (i.e., active shooter or terror bombing) have highlighted the need for disaster preparedness. Musculoskeletal trauma remains a prominent part of disaster response15-17. Although surgical education includes multidisciplinary training and triage in the setting of mass casualties according to the American College of Surgeons, few surgeons have experience in disaster response18. Efficient and well-orchestrated disaster preparedness demands pre-event training and education. There are many institutional Emergency Operations Plans available on the Internet (e.g., for colleges and universities), but few that specifically include departments of surgery. These might be useful to review as part of the planning process19,20. We were able to find only one for an orthopaedic department. Tulane University Health Sciences Center has developed the Elite Code Grey Team. This has a different emphasis and serves as a model for a team-based training program of residents in crisis management utilizing a year-long curriculum focused on disaster management21.
We are continuously threatened by the possibility of natural and man-made disasters. Every Department of Orthopaedic Surgery (particularly those affiliated with trauma centers) should have a component of disaster response training in its program. Knowledge of the hospital’s disaster plan and how the department is integrated into it should be an educational requirement. It is essential to have an understanding of the paradigm shift in patient care from unlimited resources to limited resources to appropriately triage and to treat a large volume of casualties. Rehearsal, preplanned communication pathways, and integration of orthopaedic surgery’s response with the hospital’s incident command structure as a team effort cannot be overemphasized. Communication redundancy, complacency, lack of preparation, and failure to rehearse in advance are some of the major barriers to an effective response when a disaster occurs.
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