The ED Major Incident Center: A Perfect Refit

     Emergency departments are facing overwhelming challenges in delivering care to their daily patient volumes, much less patients from major incidents. Inpatient beds are in short supply in most metropolitan areas, backing patients up into EDs. Hospitals are under tremendous budget constraints and fiscal pressures such as malpractice liabilities and staffing costs. The public is concerned about its access to emergency care. Yet communities are seeking ways to invest in preparedness, and the public understands the importance of funding the rescue agencies that provide its safety-net services.

     How can we help our hospitals while answering the need for better preparedness? With a major investment in our emergency departments.

     There are currently around 3,900 EDs in the country; they serve about 110 million patients a year for all forms of illness and injury. Essentially every one of these EDs needs to be refitted for a new role in community surveillance and major incident medical care. This represents an opportunity for joint investment by federal, state and local governments-carried out in conjunction with the many businesses, charitable organizations and individuals who want new levels of emergency preparedness in their communities-to address two important and pressing problems at once. Our EDs can serve as major incident centers in times of outbreak, disaster or attack, while our hospitals are stabilized by a needed investment in their infrastructure and capabilities.

     Here's what such a system would look like.

Painting a Regional Picture
     Emergency departments across the country are required to have certain elements:

• Appropriate supplies, equipment and disposable patient-care items;
• Appropriate facilities for the management of major-incident casualties;
• A consistent manner of patient check-in, symptom evaluation, triage and processing.

     Under an enhanced system, area EMS providers should use a similar system, so that a regional picture of unscheduled patient presentations can be developed. This combined data would simultaneously feed a syndromic surveillance system and a regional coordination center, with experts watching incoming data for patterns of injury or illness that may require immediate management, such as public-safety or public-health activation. The utilities industry can provide models for regional surveillance, coordination and major-incident management.

Have-to Haves:
    Critical design components of ED major incident centers would include:

• A facility design friendly to communities and patients;
• Capabilities for safe management of patients contaminated or exposed to hazardous substances;
• Information systems linked with regional healthcare coordination centers;
• Links to the community's out-of-hospital emergency system;
• All other major incident preparedness elements.

Other Capabilities
     A consistent approach should be used for ED major incident centers. A center should "wrap around" its hospital's existing emergency department.

     It must provide a consistent approach to greeting incoming emergency patients, every day and in the event of a major incident. The greeting system should be designed to safely manage incoming EMS and ambulatory patients, and facilitate the systems that must survey for syndromes related to natural outbreaks of disease or heralding terrorist or criminal activity. The center will house the supplies needed for multiple-casualty incidents throughout the community, including the new wave of detection systems needed to identify hazardous chemical, biological and radioactive agents.

     Local government should contribute support for necessary roadway changes, zoning approvals and movement of public utilities that surround and feed the hospital (and upgrades of their durability) and facilitate the cooperation of local public-safety agencies in performing necessary community emergency medical preparedness planning.

     Hospitals will provide the space and customized design to incorporate the major incident center's preparedness function. The hospital will then be capable of expanding its existing ED for greater patient-care area and more room to buffer tight inpatient resources.

     National businesses, foundations and service organizations should contribute to, and be recognized for, the development of a uniform approach to community emergency medical preparedness. The elements needed to organize a system exist in other industries, and those industries should be incentivized to contribute expertise that will be disseminated nationwide in the field of emergency care. There is a need to develop a methodology to recognize those community organizations and corporations that contribute to this new model of community preparedness.

     This new model of emergency care for the community needs a friendly and effective technology base. For a large number of reasons, information technology has been slow to integrate in the healthcare system. Information solutions for community preparedness should be encouraged, and the federal government is the only agency with enough clout to facilitate doing so. Given the new constraints (and implementation costs) of HIPAA, a federally approved system of registering, collecting and reporting appropriate surveillance information would be a blessing.

Victim Reception:
     In each ED, the victim-reception area should:

• Facilitate containment of contamination, whatever the agent. No further spread into the hospital should take place from any hazard incident.
• Facilitate the work of law enforcement personnel in the event of a major incident.
• Maintain immediate contact with the regional coordination center, regional fire and EMS agencies, and media outlets. This contact system will allow victim-care personnel to be up to date with information coming from outside the hospital.

Designing the Wraparound
     The key elements of the ED design will facilitate both day-to-day and major incident preparedness functions in the community. This design begins in a dramatically altered approach to the reception area. The plan is to allow a smoother flow of patients into the ED, including large numbers of patients when a major incident occurs. The design must incorporate a new set of electronics for syndrome surveillance, and video monitoring by regional healthcare authorities.

     The area outside the ED should include elements to support field and hospital operations. It should have communications capabilities for EMS and ED staff. This area will feature good lighting, a communications board, a loudspeaker system and areas to be sheltered for patient decontamination.

     The ED entrance needs to be wide open, with a spot for a "greeter" or "guide" that juts out into the parking area. This should function like the bell area at a premium hotel. There should be another greeting area inside the ED. The security functions and rest rooms are the only features in the lobby area. The entrance into the ED then needs to be arranged with "pass through" lines, with a small work desk for the person doing a quick medical evaluation. This should be video-monitored and, in big EDs, linked to emergency physicians. There would be four or more "pathways" leading patients back to the ED.

     On either side of the "funnel" leading to the care areas would be collection points for specimens and an imaging area. Then the various care areas would be arranged in modules. Patient mix and service needs would determine the composition of the modules.

Outside the Ed
     A critical change will occur outside the walls of the ED major incident center. The design should facilitate large volumes of incoming EMS traffic, and the center should be recognizable immediately as a community emergency center. As such, the building design should feature a red neon stripe around the top of the structure, with a large visible E. This or another design should become the designating symbol of an ED major incident center.

     There should be a storage center outfitted for major incident supplies and equipment, available for hospital staff and EMS, fire and police agencies. This would become the community storehouse for crisis supplies. There should also be a large electronic message board on an outside wall to deliver information to incoming EMS units, ambulatory victims, emergency workers and the general public. The board can be used in major incidents to give timely instructions to victims and rescuers.

     Major incidents will always require that initial victim care take place outside the ED. If there are incidents involving contamination, that's where incoming victims will be cleaned. The entrance area needs to be configured to incorporate portico shelters, triage areas, ambulance unloading and washdown areas. It should have lighting, a sound system, drainage, warm fresh water outlets, phone cell repeaters and a supply center to support this mission.

     This washdown area needs to be connected to a multipurpose "dirty room" that leads to the main ED treatment area. This room would receive the most seriously contaminated patients, to prevent them from contaminating either the main ED reception area or the treatment area.

     The entire entrance area needs to be equipped for video monitoring. This will facilitate everyday operations and, in a major incident, allow the area to be monitored by federal officials. The ED's everyday entrance will need the same capability.

Small Town, Big Capabilities
     Seven years ago, Fort HealthCare's Fort Memorial Hospital launched the first hospital-based paramedic intercept program in Wisconsin. Now the Fort Atkinson-based institution boasts a state-of-the-art emergency department to better support its personnel in the field and the citizens of its community.

     Last December, the hospital unveiled a 96,000-square-foot addition that included an upgraded ED designed to enhance safety and efficiency for both patients and staff, both in times of disaster and in everyday operations. Features include decontamination areas that adjoin arrival locations; negative-airflow ED and positive-airflow trauma facilities; and automated medication vending that dispenses meds 24 hours a day. Among the hospital's other attributes are patient rooms that provide more space for teams of caregivers; in-room patient monitoring; bariatric, isolation and palliative-care rooms; and electronic medical records.

     For more on Fort HealthCare's operations and facilities, see our special report this month on www.emsresponder.com.

Inside the Major Incident Center
     Capable of managing victims who arrive by EMS vehicle or by ambulatory means, the oversized reception area would effectively collect all persons presenting for care. It would be easy to secure and allow easy establishment of one-way patient flow. It would have several potential pathways to the treatment area, so it cannot be obstructed by small groups of patients.

     This area must have a separate air handling system from the remainder of the ED and the hospital. Airborne contamination can then be isolated to this area. The entrance area should be capable of "sniffing" for any hazardous substances that instruments can detect. Victims can be processed through those detectors. We expect there will be a growing number of these for chemicals, radiation, biological agents, explosives and other weapons.

     Decontamination areas inside the building will allow continuation of the cleaning processes initiated outside, but must be situated so that care can simultaneously occur. A uniform greeting, triage and patient-tracking system is also necessary. Data collected here is fed live to the regional or federal coordination center, which includes the syndromic surveillance monitoring. This system would have to be based in a federal mandate to ensure consistent and immediate data feeds. A robust communications system is also necessary to coordinate the ED with regional sources of information and EMS providers.

     Finally, there should be counseling and coordination areas for families, law enforcement officials, public-health authorities and social-support agencies. This area needs to allow the provision of a broad range of support functions, regardless of the type of incident.

Conclusion
     The ED major incident center will be the new heart of the community preparedness plan. It will simultaneously serve as a community health management center, fully integrated with overall regional and state health systems, and the hub of the community's emergency response system.

James J. Augustine, MD, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operationsat Hartsfield-Jackson Atlanta International Airport. He served 25 years as a firefighter and EMT, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugust@emory.edu.