Disaster Management, Triage-based Wound Care, and Patient Safety: Reflections on Practice Following an Earthquake
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Triage is the process of prioritizing patient care based on need and available resources. Clinicians in wound clinics triage daily because time and resources never seem to be sufficient. The triage concept is taken to an extreme when a disaster strikes — the clinical goal of patient care transforms from the individual patient to providing the greatest good for the greatest number of patients. Situational awareness of system resources is of paramount importance in a disaster. Planning for surge capacity while simultaneously attending to patients who require immediate attention is a must. The recent earthquake in Haiti provided an opportunity to test those skill sets. Scores of clinicians volunteered their time and expertise, elevating wound care to the status of a clinical division. The experience of providing quality wound care despite a myriad of situational limitations suggests that busy wound clinics can learn valuable lessons from the realm of disaster management. The rate of under- and over-triage in wound clinics can be reduced by utilizing commonly collected outcomes and operational data. Patient safety improves when the hierarchy is flattened, communication is open, checklists are used, debriefings are held, and teamwork is encouraged. Reflecting on the working conditions in Haiti, it is clear that patients and clinicians benefit when success is measured by patient outcomes instead of individual accomplishments.
Key Words: disaster management, triage, patient safety, wound care
Index: Ostomy Wound Management 2010;56(11):61–69
Potential Conflicts of Interest: none disclosed
On January 12, 2010 at 4:53 p.m., an earthquake rated at 7.0 on the moment magnitude scale struck Haiti 16 miles east of the country’s capitol, Port-au-Prince. By January 20, at least 52 4.5-rated aftershocks had occurred. More than 230,000 people died, 300,000 were injured, and more than 1 million were made homeless.
Almost as quickly as the disaster struck, medical and relief teams began to mobilize to provide assistance. The first teams to arrive encountered total chaos, facing many wounded, few supplies, and nonexistent sanitary conditions. Reports began to emerge of numerous amputations performed out of necessity in nonsterile locations with minimal equipment. Military support was necessary for both security and logistical reasons. Through Project Medishare, the University of Miami (Miami, FL) organized a makeshift tent hospital on the grounds of the airport at Port-au-Prince. As supplies and volunteers arrived, the tent hospital expanded into a small medical compound with an emergency department, pharmacy, orthopedic unit, pediatric unit, central supply department, and outpatient wound clinic with a procedure area. Medical volunteers from all fields were organized for 1 week deployments. My team was deployed on February 7, 2010, a little more than 4 weeks after the quake. My years of medical, surgical, and leadership training did not adequately prepare me for the experience.
The medical teams were organized into a hierarchical system, not unlike at a university, with a chief medical officer (CMO) in charge of the division chiefs of five independent clinical units: orthopedics (surgery), pediatrics, internal medicine, anesthesia, and wound care. Our wound team treated up to 60 inpatients and 20 outpatients per day while providing emergency department consults. Clinical work began at 7 a.m. and frequently ended late in the evening. Food was limited, beds were uncomfortable cots, and the Fahrenheit temperature was in the 90s.