Biomedical Engineering Reference
In-Depth Information
well as purchased from well known medical soft-
ware retailers [6,7].
total authority over the functioning of the OR.
This author's bias is that the individual should
be a physician, probably a senior anesthesiol-
ogist, but other individuals could also assume
that role. Directly under this OR chief would be
representatives of nursing, surgery, and anesthe-
siology; each with authority to direct personnel
of their respective specialty. Additional positions
covering logistics and PACU should also be desig-
nated (Figure 13.2). In larger surgical suites,
specialty departments (e.g.: orthopedics, neuro-
surgery, cardiothoracic) already exist. Often, they
have entire wings dedicated to a single surgical
specialty. It makes sense to maintain this same
organization to the extent it facilitates patient care.
The key elements to any plan for mass-casualty
care involve transition to a contingency mode,
assessment of personnel and capacity, and main-
taining logistical support. Sustainment and tran-
sition back to routine operations must also be
considered. Upon alert that a mass-casualty inci-
dent is occurring, several actions must occur in
rapid succession (Figure 13.3). First, the Mass-
Casualty Plan should be reviewed by all leadership.
There should be a brief meeting between nursing,
anesthesiology, and surgery leaders to establish
that all services are in synchrony. Contact should
be made with the hospital EOC to determine the
exact nature of the situation, types and numbers
of casualties expected, and of course, the nature
of suspected agents. A message should be broad-
cast to all active operating rooms, passing along
what is known of the situation. Surgeons should
be informed that they should finish in the most
expeditious manner consistent with patient safety
and stand ready to receive acute surgical trauma.
13.3 Departmental Plan
The departmental plan serves as a top-down,
strategic approach to organization. It should be
a simple, living, practical document developed
jointly by the surgical service leadership. A unified
plan, encompassing nursing, anesthesiology, and
surgery is the best way to ensure synchronization
of all three specialties. The plan should address key
issues: who, what, where, when, and how. In other
words: the mission, chain of command, communi-
cations, and logistics (Figure 13.1).
Hospital operative services normally are an
amalgamation of several different groups who
interact to receive, treat, and transfer patients along
the “surgical axis” of the hospital. Patients usually
originate from the Emergency Department and are
transported to a holding area before being oper-
ated on in the surgical suite. They are then trans-
ported to a post anesthesia care unit (PACU) or to
an intensive care unit (ICU), ultimately returning
to a surgical ward. At least four diverse groups
of personnel are involved in patient care: surgical
nurses and technologists, ancillary staff (clerks,
secretaries, and transport aids), surgeons, and
anesthesia providers (anesthesiologists, anesthesia
assistants (AAs) and certified registered nurse
anesthetists (CRNAs)). During normal operations,
each of these groups functions semi-independently
to accomplish patient care. During a mass-casualty
event, they need to be much more closely coor-
dinated if they are to be successful. Although the
HEICS model does not continue below the level
of OR chief, it is logical that the same princi-
ples should apply. A single individual should have
The operating room is a major bottleneck in [mass
casualty scenarios]. Therefore, its immediate use
should be reserved for a few “absolute” indica-
tions such as compromised airway or the control
of active bleeding endangering life or limb. Other
surgeries are delayed to the second phase. Once
in surgery, the fundamental approach is “damage
control”. Holcomb et al. concluded their review on
“damage control philosophy” as follows: “This situa-
tion demand that surgeons, accustomed to expending
enormous resources and time on single patients,
Chain of Command
Priority Tasks
Patient Flow
Isolation
Logistics
Communications
Figure 13.1
Elements of operating room planning.
