01.03 Critical Incident Management

What is a critical incident. Well we have all seen them on the news, or been involved in one. Any unplanned or imminent event, and we will give some examples. The event is usually a threat to the health, safety and welfare of not only to us but to our patients and the community. A critical incident requires a significant and coordinated response. This isn't just a case of paging an attending. It's usually a large scale mobilization of people and resources. Unfortunately, in a true critical incident, there is the chance that our resources can be overwhelmed. This could be something as simple as running out of 4x4 gauze, or something as serious as not having an OR available to perform a life saving operation.

When we talk about critical incidents, there are alot of things that fall into the category. Natural disasters like fires, floods, earthquakes, hurricanes, or tornados. And by the way, we talked about unplanned or imminent events. Well a tornado or an earthquake would be considered unplanned but a hurricane is usually an imminent event. You also have unnatural acts, or is it non-natural. Neither of those sound right… How about man made disasters. Yea, that sounds better. Anyway, things like active shooters, bomb threats, ED overcrowding, violence, all these can reach the level of a critical incident.

The first thing we have to do is prepare. And we do this with training. Classroom sessions, read and sign sheets, or online modules are just a few ways to disseminate information to our nurses. Once the information is out there, we can conduct some small simulations. Individual departments, small groups, running through the basic flow of a critical incident. Once we have trained our team, we can get involved in large scale disaster drills. Usually these involve the entire department, nurses, doctors, ancillary staff, lab, radiology...everyone. They also include the community, this can be fire departments, EMS, police, Offices of Emergency Management. I have been involved in several of these type of exercises and they can get pretty large. The last one was run on a university campus and the undergraduate nursing students (120 of them) served as victims of the disaster. We had 17 fire and EMS agencies taking victims from the scene to the ED where the drill continued. We were able to discover a number of areas for improvement, which brings us to the trial and error concept. Until you run through your actual critical incident protocol, it's hard to know where the errors are going to occur. The best solutions are created when we make mistakes.

So what do we do in a critical incident. Well first thing is to know your chain of command. This may be different than the normal day to day. Usually we report to an assistant nurse manager, or nurse manager, then the director. During an event, this may change as there will be an incident commander and section chiefs who we will respond to. Make sure you know who is running the show and who you need to speak to. 

We always have to remember the basics. All hell is breaking loose and stress levels are high all over. We always want to make sure we are protecting ourselves first, then our patients. In a haz-mat event, we may want to rush in and help, but if we contaminate ourselves, aside from creating more work by putting yourself on the shelf till we are d-conned, we risk actually getting seriously injured.

In a critical incident, we typically bring out the START triage process which you can learn all about in our triage lesson here on NRSNG.

And of course, we need to work together. Aside from collaborating with all the parts of our department, we will need to work with the entire hospital as well as the community at large. 

After the threat is gone and the event is over, there is a period of time when stress levels still can run high. We find ourselves looking back over the experience and sometime reliving the worst parts. This can take a true toll on our mental states. It is recommended that everyone involved go through a Critical Incident Stress Debriefing. This is a 7 phase process that occurs 24-72 hours after the event is done. Small groups of the incident team get together and discuss the actual event. They go through the 7 phases of introduction, facts, thoughts, reactions, symptoms, teaching, and re-entry. The goal of the process is to reduce the pain or emotional trauma of the incident, facilitate the normal recovery of people who are normally psychologically healthy but have been affected by an unusually disturbing event, and to identify anyone who might need further support or professional care.

A few Key points: We need to know what a critical incident is. Anything that can stress our resources and cause increased stress can be considered critical.

We need to train. The only way to respond well is to be ready for whatever may come.

Know your chain of command during these events as it will change from the normal day-to-day.

Always protect yourself first, then your patients.

And make sure you participate in the debriefing after the incident. If not for yourself, then for your coworkers.

Once again guys, thanks so much for joining us for this lesson. Make sure to check out the rest of the Emergency medicine series here on NRSNG.com and as always…

HAPPY NURSING!