April 15 2013 Boston Marathon Bombings 2014 2015

April 15, 2013: Boston Marathon Bombings

2014 -2015

Leading Through Crisis: HOW MAY EMERGENCY PREPAREDNESS HELP US NAVIGATE AN INFECTIOUS DISEASE OUTBREAK ?

Agenda In the next 20 minutes we will discuss: • Definition of a Crisis • Incident Command System • Ebola Viral Disease Outbreak

The Definition Of A Crisis: Pearson and Clair • Psychological • Uncertain • Complex • Emotional • Socio-Political • Breakdown of socially constructed relationships • Technological/Structural • Interactive, tightly coupled technologies that interact with an organization in incomprehensible ways

The Definition Of an Organizational Crisis • Low Probability • High Impact • Threatening • Personally • Socially • Time Sensitive • Cognitive Limitations • High Stress

Categories of Crisis • Natural Disasters • Weather Events • Earthquakes • Pandemic/Epidemic • Human Conflict • War • Bombings • Mass Shootings • Technological • Information Systems Downtime • Power Outage

Navigating Crisis: The Reality “No battle plan ever survives contact with the enemy. ” Field Marshal Helmuth von Moltke

Incident Command System: Development • 1970 California Wildfires • Lacked Coordination of Large, Complex and Dynamic Situations • Inability to Expand or Contract • Nonstandard Communications and Procedures • Problematic Scene Protocols

Incident Command System: Development • Firefighting Resources of Southern California Organized for Potential Emergencies (FIRESCOPE) • Consultants from RAND and Aerospace

Our Healthcare System: Managing Complexity • Poor transitions • Health Care Associated Infections • Harmful Medication Errors • Wrong Site Surgical Infections • Operating Room Fires • Boarding and Crowding

High Reliability Organizations: Weick and Sutcliffe • Preoccupation With Failure • Reluctance to Simplify Interpretations: Ask Why? • Sensitivity to Operations • Commitment to Resilience • Deference to Expertise

Incident Command System: Principles • Defined Organizational Structure • Role Clarity • Consistent Nomenclature • Unity Of Command • Expandibility and Contractility • Span Of Control

Brigham Incident Command System

EVD Control Plan • Working EVD Control Plan on Pike. Notes Ø BWH Ø BWFH • Details include Ø Room monitors Ø Room entry logs Ø Cleaning procedures Ø Waste management Ø Clinical Laboratory Testing Ø Donning and doffing materials

Points of Access (POA): Patient Screening IDENTIFY: Ø IF history of travel to Ebola-affected areas within the past 21 days AND fever, then… ISOLATE: Ø Minimize direct patient contact Ø Give patient a surgical mask and place in a separate room CALL: Ø Ø Arrange for transfer to ED for further evaluation In ED, initiate isolation precautions in triage and move the patient to designated room as soon as available

Points of Access (POA): Communication • Mandatory 30 min semi-weekly conference call Ø Ambulatory administrative, medical and nursing leadership Ø Representation from all access points and each ambulatory area Ø Monday & Thursday 12 noon (commences 10/23) Ø To be added to the call please contact Lara Henshaw Archer • Ambulatory Leadership Community (10/21 9 am) Ø Operational impact of the screening process at initial presentation at all access points Ø Current PPE inventory and training requirements

Decision to Continue to Categorize Patients as Suspect EVD • Discussion Involving: Ø ED and Infectious Diseases Attendings • ED Flow Manager or NIC activates EVD group page Ø BWH leadership and Public Affairs Ø Department of Environmental Affairs Ø Infection Control Ø Environmental Services and Security Ø EVD Clinical Response team (includes EM/MICU MD and Nursing directors) Ø Clinical labs

ED: EVD Precautions • Place into a designated isolation room • EVD precautions: Ø Double gloves Ø Fluid resistant jumpsuit Ø Shoe covers or integrated feet Ø Powered air purifying respirator (PAPR) • Room monitor to observe and assist with donning and doffing of PPE

Inpatient: EVD Precautions • Admit to EVD Clinical Care Team, place into a negative pressure isolation room • Continue EVD precautions • Assign a room monitor • Keep a room entry log • Limit staff entering the room • Restrict visitors

Amory Isolation Unit – Donning Room

Amory Isolation Unit – Patient Room

Amory Isolation Unit – Patient Bathroom

Amory Isolation Unit – Doffing Room

Amory Isolation Unit – Environmental Services Room

Amory Isolation Unit – Patient Room / Patient Care

Amory Isolation Unit – Patient Room / EVD Site Lead Communication

Amory Isolation Unit – Patient Room / Communication

Amory Isolation Unit – Doffing Process

Clinical Laboratory - EVD Specimens • Isolated Satellite Laboratory • Teams trained in BL 3 practices • Simplified testing with point-of-care devices in biosafety cabinet • Limited menu of essential tests

Patient and Family Questions • Provide avenue for patient and family questions to be answered, through one centralized resource. Ø Ensure standardized messaging Ø Reducing anxiety and correcting mis-information regarding EVD • Contact Patient and Family Services at (617)732 -6636

Communication • Ensure transparent and up-to-date communication is available continuously • Provide ongoing email broadcast with frequent updates • Updated information available on: Ø Pike. Notes and Faulkner 411 Ø BWH Bulletin, BWFH Pulse Ø BWH and BWFH Infection Control sites: all resources and archived webcasts available

Additional Online Resources • Webcasts • BWH Ebola Virus Disease Control Plan • FAQs on Ebola (for BWHC patients); Ebola Virus FAQs • PHS Guideline Regarding Possible Ebola Deployment • BWH Clinician Guidance • MDPH and BPHC Guidance • CDC – Ebola Virus Disease Information for Clinicians • Ebola Lab FAQs • BWH Clinical Lab Test Menu and Requisition Forms • Donning and Doffing Personal Protective Equipment • …. and more

Employee Resources for Q&A • Employee questions and concerns about care, exposure, risk: Ø Initiate conversations with your managers – they are your first line of information. Ø Access Partners Employee Assistance Program for support, as needed. Ø Review Human Resources Policies specific to EVD (in process, with goal to be consistent across Partners). Ø Submit Questions to BWHCEbola. Response@partners. org, or call the Employee Emergency Announcement Line at 1 -800 -343 -7036. • For staff traveling to West Africa, to provide care or visit family, please make sure to follow pre-deployment/post-deployment policies. Ø Pre-Travel Screening - Contact Stephanie Kayden, MD or Ryan Wildes, MD Ø Post-Travel Screening - Contact Occupational Health

References • Kohn, Linda T. , Janet M. Corrigan, and Molla S. Donaldson, eds. To err is human: building a Safer Health System. Vol. 6. National Academies Press, 2000. • Chassin, Mark R. , and Jerod M. Loeb. "High‐reliability health care: Getting there from here. " Milbank Quarterly 91. 3 (2013): 459 -490. • Wolcott, Julie, J. Lyle Bootman, and Linda R. Cronenwett. Preventing medication errors. Washington: National Academies Press, 2007. • Klevans, R. M. , J. R. Edwards, C. L. Richards, T. C. Horan, R. P. Gaynes, D. A. Pollock, and D. M. Cardo. 2007. Estimating Health Care— Associated Infections and Deaths in U. S. Hospitals. Public Health Reports 122(2): 160– 66. • Bodenheimer, Thomas. "Coordinating care-a perilous journey through the health care system. " New England Journal of Medicine 358. 10 (2008): 1064. • Weick, Karl E. , and Kathleen M. Sutcliffe. Managing the unexpected: Resilient performance in an age of uncertainty. Vol. 8. John Wiley & Sons, 2011. • http: //www. jointcommission. org/highreliability. aspx • http: //www. cincinnatichildrens. org/service/j/anderson-center/safety/methodology/high-reliability/ • Chassin, Mark R. , and David W. Baker. "Aiming higher to enhance professionalism • Kelen, Gabor D. , et al. "Hospital-based shootings in the United States: 2000 to 2011. " Annals of emergency medicine 60. 6 (2012): 790 -798. • US Department of Justice; Federal Bureau of Investigation. A study of active shooter incidents in the United States between 2000 and 2013. http: //www. fbi. gov/news/stories/2014/september /fbi-releases-study-on-active-shooter-incidents /pdfs/a-study-of-active-shooter-incidents -in-the -u. s. -between-2000 -and-2013. Accessed March 10, 2015. • Brady, Patrick W. , et al. "Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events. " Pediatrics 131. 1 (2013): e 298 -e 308. • Resar, Roger, et al. "Using real-time demand capacity management to improve hospitalwide patient flow. " Joint Commission Journal on Quality and Patient Safety 37. 5 (2011): 217 -227. • Bigley, Gregory A. , and Karlene H. Roberts. "The incident command system: High-reliability organizing for complex and volatile task environments. " Academy of Management Journal 44. 6 (2001): 1281 -1299.

From the Frontlines to the Bedside: HOW MAY EMERGENCY PREPAREDNESS HELP US NAVIGATE AN INFECTIOUS DISEASE OUTBREAK ?