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Archive for September, 2010

Residency Disaster Plan

MSSM Emergency Medicine Residency Emergency Response Plan
I. Upon notification of an activation of the Medical Center Plan E or Elmhurst Hospital Center the Residency Leadership will activate its emergency response plan. The plan is initiated by the Residency Director, Site Directors or Chief Residents.
II. Each site chief should contact the Residency Site Directors to coordinate staffing.
III. The Residency Site Director will coordinate with Mount Sinai or Elmhurst Emergency Department’s Administrative Staff during normal business hours or an Attending physician on duty during evenings to determine the Department’s staffing needs.
IV. In the event that additional resident staffing is needed, the Chief Residents will coordinate to contact the off-duty residents, beginning with the residents who are on sick-call.
V. During a crisis, the Chief Residents may designate the responsibility of contacting the off-duty residents to another resident or residents [utilizing the telephone/pager contact tree]. Off-duty residents will be contacted through the following means:
a) Pager
b) Home phone
c) Cell phone
d) E-mail
e) Someone may go to their home address
VI. In the event of an emergency during which telephone or e-mail communication is possible, off-duty residents should either contact, or wait to be contacted by a Chief Resident, prior to reporting to the hospital. This will enable the Departments to allocate staffing appropriately between Mount Sinai and Elmhurst, prevent staffing surges, and permit planning in the event that increased staffing is needed for a prolonged period of time.
*Note: In the event of an emergency, off-duty Emergency Medicine Residents who are assigned to other, essential, services such as the RICU, CCU, or Surgery, should report to their respective services. Off-duty residents, who are assigned to non-essential blocks such as OB/Anesthesia, Toxicology, or electives, will be considered available to provide staffing coverage in the ED.
**Note: Residents who are on-duty in the ED when the emergency response plan is activated must stay on-duty until relief arrives. All shifts will be 12 hour shifts with a one for one relief. Residents who are schedule for next shift after plan activation should plan to report for that shift and notify chief residents of availability, Senior residents originally assigned to eight-hour shifts will work twelve-hour shifts when plan is activated and until emergency response plan is demobilized.

External Disaster Assignments/ Set up

1) Clear ED of all patients ASAP (to OR/ ICU/ floors/ Psychiatry/ Dx Clinic/ D/C)
2) Assign 2 people to Decon Closet to start setting up external triage/ warm and cold zones.
a) Tape off between warm and cold zones, area for walking wounded staging and undressing, area for litter and ambulatory decon.
b) Set up external triage point in warm zone with triage tags.
c) Set up sawhorses in warm zone litter decon (4 horses; 2 for each backboard)
d) Put out undressing supplies in front of decon areas (walking wounded undressing area, litter and ambulatory decon.
e) Put down sides of decon shower.
f) Put out redressing supplies in cold zone for decon’d walking wounded, litter and ambulatory decon

3) People should be assigned to start getting into PPE (minimum 4 to decon but ideally 4-8 to decon, 1 nurse and 1 PA or resident assigned to external triage).
4) Assign med student to go to Emergency Management closet to information on WMD event and photocopy/ distribute information to staff.
5) Assign PA or resident to Diagnostic Clinic if closed +/- an attending (ideally medicine resident). Assign at least one ED PA/ resident to each room (ie: cardiac/ trauma/ A/ B room). Assign additional Medicine/ Surgery/ ENT/ Ortho/ NSG/ Anesthesia residents to each room as staffing becomes needed (remember senior representatives of each service should be in ED facilitating patients to be moved out of ED as soon as stabilized).
6) Escort to bring stretchers/ wheelchairs/ team 700 cart to cold zone.
7) Assign a nurse to cold zone ED entrance to direct decon/ tagged patients to appropriate rooms in ED (ie: cardiac, trauma, B, A, Diagnostic Clinic).
8) Disaster carts will need to be placed somewhere. They are very large. Likely hallway outside of fast track is best place to position them until they are needed. (ie: Biomed cart, Respiratory Therapy cart, Central Sterile cart. There is also a linen cart in holding, blackout cart and food cart).

Key to Decon Shed (EMS ramp outside): Hospital Police “Key #8”
Key to Decon Cage (hallway radiology corridor): Dr. Kesslers Office/ Shelf over desk
Key to Dr. Kessler’s Office: Hospital Police

Key Points during a disaster: Chain of Command

1) The Executive Director (AOD) in consultation with the Department of Emergency Medicine Director of Service (or designee) will determine the need for initiating the External Disaster Plan.

– once notified of a possible External Disaster, the Director of Service of the Emergency Department or the senior Emergency Medicine attending physician will consult with the AOD whether to activate the External Disaster Plan, usually activated when 10-15 casualties are expected.

2)Executive Director calls Telecommunications to signal the DISASTER SIGNAL
(4-4-4) and notify the telephone operator of the External Disaster Plan declaration.

3) Executive Director/ AOD consults with the Director of Service in the ED about:
-Site of Disaster?
-Type of Disaster?
-How many casualties?
-Types of injuries?
-Present status of the ED (# critical, noncritical, staffing levels).

4) The Command Post A1-15 (alternate site E1-49) gets set up (Activated by the AOD). The Telephone extension for either site is 41423. From here on out anything the ED attending needs (staff, supplies, updated info within hospital or outside hospital) is to be gotten/ requested through the Command POST.

Physicians in the Emergency Department:

1) The Director of Service of the ED or senior EM attending organizes/ supervises the medical care of all External Disaster patients. He/ She assigns and reassigns attendings and house staff to all rx areas.

2) Assign a physician to establish and operate a triage area at the ambulance entrance. If decon is needed these people need to be in appropriate PPE.

3) Refer non-emergency patients to the DX Clinic if open. If not open assign a physician to the DX Clinic.

4) Sort patients appropriately to:
-the ED/ Psychiatric ED
-ICU
-OR
-Post Anesthesia Care
-Diagnostic Clinic
-Patient Care Units
-Mortuary
5) Coordinate transfer to:
-Burn Units
-Hyperbaric Units
-Replantation

6) Rule of thumb: Stabilize the acute life threatening emergencies in the ED then move ASAP to appropriate unit or area. Ambulatory patients send to Diagnostic Clinic.

7) If you need more staff call the Command Post to have staff called in. Those staff members report to the command post for red arm band to gain ED access.

8) Know your Universal Triage Tag categories (red = emergent; yellow = urgent; green = walking wounded; black = expectant).

Nurses Duties

1) Call Command Post (CP) to give update on personnel, # pts awaiting exam/ undergoing rx/ awaiting admit.
2) Call CP to request supplies/ staff.
3) Ensure readiness of ED/ Trauma/ Cardiac room
4) Supervise gathering of stretcher at ambulance entrance
5) Assign nurse to assist triage (NOTE: senior ED attending directs triage)

Obtaining and Assigning Necessary Personnel/ Equipment

1) Charge nurse calls CP if needs nurses
2) Call CP for stretcher bearers and aides to transport pts
3) Patient property collected by admitting clerks with HP. Direct patients to bag own property especially if need decon. (Valuables bagged separately and kept with patients). LABEL BAGS. KEEP NONVALUABLES OUTSIDE UNDER HP SUPERVISION. THIS IS CONTAMINATED. THIS IS EVIDENCE FOR NYPD.
4) Most senior Medicine, Surgery, ENT, Ortho, NSG, Anesthiology, Bell attending report to CP for red arm band and report to ED for help getting patients to OR, ICU’s, floors, etc.
5) Clerks create disaster charts and staple corner of Universal triage tag to chart or copy #.

Decontamination:

1) AOD is contacted if the ED or CP determine that arriving patients are possibly contaminated with hazardous materials. AOD instructs HP to direct all persons or vehicles possibly contaminated to Decon area.
2) Set up warm and cold zones and CLEARLY MARK these areas. Only personnel in proper PPE shall operate in warm zone.
3) Do not allow patients to wander. Patients directed to undress themselves COMPLETELY and remove all valuables/ put in separate bags (both labeled. Valuables remain with patient, rest says outside under HP watch).
4) The AOD determines need for diversion/ additional FDNY/EMS resources and makes appropriate call.
5) ED attending and AOD determine need to deploy portable decon shower inside or outside building (if inclimate weather set up across from family room. 2 fans blowing toward decon set up on either end of corridor and +/- shut down ventilation system).
6) Ed attending detail triage team to cold zone
7) ED attending detail medical staff member as resource person to gather and disseminate info (STAT copies from ED/ decon closet or Emergency MGMT Closet for medical management of the particular WMD event taking place)
8) Contact Poison Control as needed (212-POISONS).
9) Escort should bring adequate stretchers, wheelchairs, and Team 700/ Disaster cart to cold zone.
SPECIAL DECON CONSIDERATIONS
1) 80% of patients from WMD event will self refer to hospital. Detail screening team (HP and medical staff) assigned to each entrance WITH BULLHORN to redirect THROUGH THE OUTSIDE OF BUILDING to decon area.
2) If possibly terrorism related:
– perpetrator(s) may be harmed and may now be in the ED intent to cause more harm
– keep all clothing outside, labeled, under HP watch for NYPD arrival and safety inspection
– If law enforcement need room HP to set up B1-13.
3) At the conclusion:
– All those in level B/C suit need medical screening
– If interior decon was done only AOD can turn on air handling equip.
– Salvage drums with haz mat water held under F-wing for DEP.
– Safety director inventory supplies and equip to repair, replace, replenish as soon as incident secured. Return to state of full operations ASAP.

Chief Resident Job Action Sheet
?Immediate Actions:
?1) Contact all residents w/ other chief residents to alert of incident & assess safety
2) Assess need to activate Resident Recall Plan in concert with ED Leadership
3) If Resident Recall Plan is activated, edit resident schedules for Sinai &
Elmhurst, to increase all shifts to 12 hrs, and provide adequate Department
coverage
4) If maintenance of communication is a concern in a city-wide event, the Chief
Residents may be expected to share alternating 24hr coverage from the ED
‘Headquarters’
5) As coordinators of resident coverage during mass casualty, the chief resident
may assist in assigning residents to new treatment areas including: Triage, Immediate Treatment Area, Delayed treatment Area, Minor Treatment Area, and Decontamination Area.
6) Send Home those residents who are working beyond their scheduled shifts, or who “just show up” at the ED site, as the goal is to provide adequate coverage for the full extent of the casualty situation
Intermediate Actions:
An ‘on duty’ Chief Resident, must continuously monitor fellow ‘on duty’ residents, Attendings, and support staff for:
a) Food Breaks
b) Water Breaks
c) Rest
d) Mental Health/ Stress related to the mass casualty
When the ED team takes breaks, and communication access is available, the members of the care team should also be encouraged to contact their families and loved ones outside of the hospital to re-assure them of our safety within the site of a mass casualty area

MSSM Emergency Resident Job Action Sheet[1][1]
KeyPointsduringadisaster
ExternalDisasterAssignments
Emergency Response Plan-MSSM Emergency Medicine Residency[1][1]

Written by reuben

September 21st, 2010 at 4:46 pm

Posted in Disaster,Elmhurst

Research Updates – InfoEd, COI, CITI program

The GCO has changed the submission process of their paperwork.  They are not accepting any more paper copies, instead you have to do it via infoed.  Infoed is located through the Sinai Central System. Log on to:  https://sinaicentral.mssm.edu/ ; go to GCO.

Before you begin go to the following link which will help you understand how to fill out the GCO forms and other GCO forms: http://sinaiknowledge.mssm.edu/sinai_central/conflict-of-interest/gco/?searchterm=GCO..

Anyone that has a project that is coming to an end must fill out the “continuation” or “final” paperwork to the GCO again, via infoed.  If you do not close out your project(s) the GCO will not allow you to submit any other projects until you close them out.

C.O.I- Conflict of Interest form must be updated every year.  So even if you have done this already you have to do it again.  Go into the Sinai Central System at: https://sinaicentral.mssm.edu/, sign in and go to the GCO link and go to “List Forms” on the upper left hand corner.  This is mandatory for everyone that works on any kind of research.  Anyone who is named on a project has to fill this form out also.  Staff must fill also fill out this form.

EVEN if you have completed a Human Research Subject Protection you MUST read the information below and apply for a new certificate.  You will not be allowed to submit any projects until this is done.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Human Research Subject Protection

Education Requirement

Effective August 18, 2010, the only Human Research Subject Protection training course available through the PPHS office will be the CITI program. All personnel will need to complete the CITI program course requirement.

HOW THIS AFFECTS YOU

If the PPHS office has your information on file for having previously completed the Human Subjects in Research requirement, you have until December 31, 2010 to complete the CITI training. Beginning January 1, 2011, the PPHS office will not process any further submissions until this training has been completed. Please make sure all research faculty and staff complete this requirement. No one will want to spend New Years Eve doing these modules to avoid having a project be suspended on January 1, 2011.

If the PPHS office does not have your information on file for having completed the Human Subjects in Research requirement, or you are new to the Institution, you must complete the CITI training curriculum before you can engage in any human subjects research. The PPHS office will not process any submissions until this training has been completed.

If you have previously completed CITI training for any other project or institution, please log in to CITI and add “Mount Sinai School of Medicine NYC” as an affiliate in order for any of your credits to transfer. You will be required to complete the course curriculum for your credits to transfer.

HOW LONG WILL IT TAKE TO COMPLETE THE COURSE

The Basic Human Subjects course is expected to take 4-6 hours to complete. The average user breaks this down over 5 sessions. All modules must be passed and completed in order for you to fulfill the education requirement.

WHAT TO DO WHEN THE COURSE HAS BEEN COMPLETED

Please retain your certificate. You do not have to send it to the PPHS. We will be notified by CITI when you have completed the course.

HOW LOW LONG THE COURSE WILL REMAIN VALID

Beginning in January 2011, ongoing education in human subjects research will be required every 3 years.

Refresher courses will be offered through the CITI program to meet this new requirement.

HOW TO BEGIN THE CERTIFICATION COURSE

1. Go to www.citiprogram.org

2.     Click on “New Users Register Here”

3.     Under “Select your institution or organization” , select “Mount Sinai School of Medicine NYC” in the  “Participating Institutions” drop down box.

4.     Create your own username and password and select the Learner group (Researcher)

5.     Make sure to keep a copy for your own file

Written by phil

September 17th, 2010 at 1:16 pm

Posted in Admin,Research

EAST ZONE WOUND CART

Written by phil

September 16th, 2010 at 5:30 pm

Posted in East Zone

Sux Shortage

EM Clinicians:

There is a manufacturer-side succinylcholine shortage and, for the indefinite future, when you call for succinylcholine, it may not be there.

The alternative agent for paralysis in RSI is rocuronium, which is dosed at 1.2 mg/kg. The onset is 45-60 seconds, and the duration is much longer than succinylcholine; at this dose generally 45-75 minutes. There are no contraindications (other than the contraindications to RSI itself). At Sinai, rocuronium is kept in the med room refrigerator in both the adult and pediatric zones.

Let me know if you have any questions.

reuben

Written by reuben

September 8th, 2010 at 1:51 am

Posted in Airway,Pharmacy