Disaster Training Day A Systematic Approach Joan Rolland

Disaster Training Day: A Systematic Approach Joan Rolland, RN, MBA, MICN Sue Montierth, RN, MICN Steven Chin, MD, FACEP Presbyterian Intercommunity Hospital, Whittier, California 1

Disaster Training Day Presbyterian Intercommunity Hospital n 483 -bed, nonprofit, stand-alone, regional medical center serving nearly one million residents in Los Angeles and Orange counties. 2

Disaster Training Day What We Experience n 65, 000 ED Visits annually n Designated Disaster Resource Center with Los Angeles County n History of many disasters: FIRE, FLOOD, EARTHQUAKES, RIOTS AND LA TRAFFIC 3

Disaster Training Day Objectives: n Understand the deficits of classical disaster training n Describe a practical training model n Develop an effectiveness metric for disaster training n Identify future challenges to disaster training l l Physician training Just-in-time training Staff attrition and support Personal/family preparedness 4

Disaster Training Day History of Disaster Drills n Chaotic n Not taken seriously n Staff not well informed n Staff unsure what to do n Table top drills not effective n Poor participation of staff and MD’s n Lack of hospital wide participation 5

Disaster Training Day History of Disaster Drills n Just another thing that administration wants us to do n The physicians and staff are too busy taking care of real time patients n ED can take care of it n That’s not my job 6

Disaster Training Day History of Disaster Drills n I do not have to worry about it, I’m off that day n HEICS ? ? n HICS? ? n NIMS? ? 7

Disaster Training Day Disaster Drill November 2005 n Scenario Overview l A controversial speaker is to give a speech at Whittier College l As the speaker goes to the podium, an explosion occurs in the auditorium l Reports of multiple victims l A second bomb goes off in the triage area and a third bomb goes off in a local intersection 8

Disaster Training Day Disaster Drill November 2005 n Scenario Overview l It is reported that Anthrax contamination has occurred l Victims begin to arrive in the ED 9

Disaster Training Day What Happened Next… n Planned to push and stretch our EOP n 110 live victims were used n Victims were sent to in-patient nursing areas n This was a planned announced drill 10

Disaster Training Day Critique n HCC – too many people n Job Action Sheets n Patient Triage Tag n Patient Tracking n Patient Disaster Chart n Communications n Evacuation 11

Disaster Training Day Joint Commission Standard EC. 4. 20 n The hospital tests it emergency management plan n Planned exercises evaluate the effectiveness of improvements that were made in response to critiques of the previous exercise 12

Disaster Training Day Decision For Training Day n Training needed for Command Positions and Section Chiefs n Key staff needed to be pre-assigned and trained in role n House Supervisors needed focused training n Managers needed focused training n Charge Nurses needed focused training n Front line staff needed focused training 13

Disaster Training Day Decision For Training Day n Previous lecture-style training poorly attended n *Bartley, et. al. (Prehospital and Disaster Medicine, July 2006) has found: l combination of lecture and disaster simulation were suboptimal l Despite “exhaustive efforts” nearly half of the study group did not attend the lecture *Bartley, et. al. , What a Disaster? ! Assessing Utility of Simulated Disaster Exercise and Educational Process for Improving Hospital Preparedness 14

Disaster Training Day Decision For Training Day n Focused housewide training n Team approach n Multidisciplinary n Use a metric to grade the Nov and the next drill n Increase enthusiasm, interest n Food, Prizes, CEU’s and CME 15

Disaster Training Day Objectives of Training Day n Define hospital specific emergency codes n State what is HICS n Describe how job responsibilities are defined n Discuss patient flow through the hospital 16

Disaster Training Day Objectives of Training Day n Identify emergency communication process n Describe job role when assigned to the ED 17

Disaster Training Day Developing Competency In “Healthcare worker competencies for disaster training, ” by Hsu, et. al*. n Described the importance of competencies that cross job descriptions n Identified competencies include: l Recognize critical event and implementing initial action l Understanding institutional emergency operation plan l Effective emergency communications l Understanding the incident command system l Knowledge of your role in a critical incident n Describes the need for measurable terminal objectives. *BMC Medical Education, March 2006 18

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Disaster Training Day Training Stations n Code Definitions n HICS Structure n Job Action Sheets n Disaster box n Patient tracking/Flow tags n Receiving a patient n Communication n ED Triage n ED treatment areas n Code Decon 20

Disaster Training Day Code Definitions n HASC Universal “Emergency Codes” n Newly created “Code Triage Watch” process n Initial staff response expectations 21

Disaster Training Day HICS STRUCTURE n What HICS is designed to do n HICS and NIMS n Established one common language n Outlines vital command positions n Flexible, scalable, adaptable 22

Disaster Training Day Job Action Sheets n Step – by – Step Instructions n Developed Department Specific JAS n “One Stop Shopping” n Everything the staff will need in one location 23

Disaster Training Day Disaster Box n Locked Supply Box for each department n Emergency Supplies readily available n Disaster Envelope l Department Specific JAS l Operating/Bed Status l “Cheat Sheets” 24

Disaster Training Day Patient Tracking / Flow Tags n Developed Disaster Charts ready to go n Patient Flow Tag system n Criss-cross of victim information to be identified by l Name, l Triage tag # l Disaster victim chart # 25

Disaster Training Day Receiving a patient on your unit n What to do with flow tags n What the Disaster chart looks like n Role of in-house Registration n When to convert to usual operating procedures 26

Disaster Training Day Communication n Alternative Methods l Vocera l Analog phones l Two-way radios l Pay phones l Ham Radio l Reddinet n Pre-deployment of radios 27

Disaster Training Day ED Triage n Role of the Treatment Unit Leader n Establishing triage zones n Receiving patients from the field n Triage to appropriate treatment area 28

Disaster Training Day ED Treatment Areas n Where the Treatment Areas are located l Immediate l Delayed l Minor n What is their role if they are asked to report to the ED 29

Disaster Training Day Code Decon n Decontamination Procedures n Who is the Decon Team n What the Decon Team does n Recruit 30

Disaster Training Day PIH’s Decontamination Team 31

Disaster Training Day Disaster Training Light n Useful to the staff n Practical n LED light n Motivator n Status symbol among staff 32

Disaster Training Day Results n We hoped to train 200 - 300 n 950 staff trained n Measurable improvement shown at the next disaster drill n Recruited new Decon Team members n Staff asked to join Disaster Committee n Staff sent suggestions 33

Disaster Training Day Results n Staff has enthusiastically participated in drills and now takes it seriously n Executive Administration calls n 100% compliance with NIMS training in IS 100, and IS 700 n Asked to do Training Day annually 34

Disaster Training Day Effectiveness Metric for Disaster Training n Comments and critiques provide event specific and anecdotal measures n Need a consistent tool to measure progress over time n Helps to focus future training efforts n Metrics help meet Joint Commission standards n Metrics developed from the Elements of Performance 35

Disaster Training Day Measuring Effectiveness Score Weight Criteria 10 Administration notified or Incident Command System (ICS) invoked (event notification, staff notification, command structure, external notification: EP 8) 10 Hospital Command Center functional per system and job descriptions 10 Internal communication effective (EP 9) 10 External communication effective (EMS, OEM, Police, Fire, Public Health, Other Hospitals: EP 9) 10 Resource Mobilization and Allocation including; responders, equipment, supplies, PPE'S, transportation and security: (EP 10) 10 ED staff participated and able to meet the demands of the event and number of victims (Patient management clinical and support care activities, triage, patient ID and tracking: EP 11) 10 Code called and call-in list invoked, if applicable 10 Respiratory, EKG, Radiology, Dietary, EVS, Facilities and/or Materiels responded (EP 10) 10 Additional nursing and medical staff summoned (EP 10) 10 Hospital Lock-down was completed successfully-if applicable 10 Community involved: Power Company, Water Dept, EMS, Police or Hazmat 10 Entire hospital was taxed (surge capacity plan worked) 10 A post-incident critique and debrief was conducted (EP 12) 10 Participation by administration, clincal, physicians and support staff during critique: (EP 13) 10 A performance improvement plan/list was generated (EP 12) 10 Effectiveness of Improvements made in response to critiques of previous exercise (impact on this exercise): (EP 15) 160 [Note: 90% is passing or considered a successful EM exercise] 36

Score Weight Criteria 10 Administration notified or Incident Command System (ICS) invoked (event notification, staff notification, command structure, external notification: EP 8) 10 Hospital Command Center functional per system and job descriptions 10 Internal communication effective (EP 9) 10 External communication effective (EMS, OEM, Police, Fire, Public Health, Other Hospitals: EP 9) 10 Resource Mobilization and Allocation including; responders, equipment, supplies, PPE'S, transportation and security: (EP 10) 10 ED staff participated and able to meet the demands of the event and number of victims (Patient management clinical and support care activities, triage, patient ID and tracking: EP 11) 10 Code called and call-in list invoked, if applicable 10 Respiratory, EKG, Radiology, Dietary, EVS, Facilities and/or Materiels responded (EP 10) 10 Additional nursing and medical staff summoned (EP 10) 10 Hospital Lock-down was completed successfully-if applicable 10 Community involved: Power Company, Water Dept, EMS, Police or Hazmat 10 Entire hospital was taxed (surge capacity plan worked) 10 A post-incident critique and debrief was conducted (EP 12) 10 Participation by administration, clincal, physicians and support staff during critique: (EP 13) 10 A performance improvement plan/list was generated (EP 12) 10 Effectiveness of Improvements made in response to critiques of previous exercise (impact on this exercise): (EP 15) 160 [Note: 90% is passing or considered a successful EM exercise]

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Disaster Training Day Future Challenges to Disaster Training n Physician training n Just in time training n Staff attrition and support n Personal and family preparedness 39

Disaster Training Day Challenges to training physicians n Competing priorities n Multiple scheduling issues n Different specialties n Varying interest n Independent attending staff 40

Disaster Training Day Standard training solutions n “Mandatory” participation n Lectures and CME presentations n ED Section meetings n General Staff presentations 41

Disaster Training Day Alternative Training Solutions n Augmented self-study: l l Question and Answer format Email or “blast”-fax Reinforcement at time of drill Online training n Enforced repetition: l Visual reminders: small amount, frequently l Standing agenda item on medical staff clinical departments 42

Disaster Training Day Multimodal learning n Styles of Learning: l Visual l Auditory l Kinesthetic n Use all forms to reinforce 43

Disaster Training Day Just in Time Training n Tools l Question and Answer sheet l Clinical Guideline “Cheat” Sheet l Mentoring: pairing with experience n Drills l Announced and staffed drills l Assigned Shadows 44

Disaster Training Day Just in Time Training: “Evacuation” n ICU on 3 rd Floor n Seismically active area n Seismically susceptible structure n How do you get the patients down the stairs? 45

Disaster Training Day Just in Time Training: “Evacuation” n Drill at shift change so adequate staff to care for patients n During disaster drill, order to evacuate given. n Staff given printed instructions by proctor and 5 minute practicum using live victim on floor n Basic skill taught and tested 46

Disaster Training Day Post-Disaster Staff Attrition n May lose 30% or more of staff n Staff may have to leave the hospital n Staff may be unable to return to the hospital n Multiple factorial, but frequently involves concern for safety and welfare of their family and significant others n Would anyone return? 47

Disaster Training Day PIH Staff Disaster Survey n Do you have family care responsibilities that would prevent you from reporting to work? 56% 44% 48

Disaster Training Day PIH Staff Disaster Survey n If yes, would on-sit family care at the hospital allow you to report to work? 71% 29% 49

Disaster Training Day PIH Staff Disaster Survey n How many family members would you need to be able to provide care for here at the hospital? 68% 32% 50

Disaster Training Day PIH Staff Disaster Survey n Do you have pet care responsibilities that would prevent you from reporting to work? 65% 35% 51

Disaster Training Day PIH Staff Disaster Survey n If yes, would on-site pet care at the hospital allow you to report? 53% 47% 52

Disaster Training Day PIH Staff Disaster Survey n How many days of emergency food and water do you have on hand? 39% 17% 24% 16% 4% 53

Disaster Training Day PIH Staff Disaster Survey n How many miles do you commute to work? 41% 25% 14% 20% 54

Disaster Training Day PIH Staff Disaster Survey Results n Need to have a system of family support n Must include: l Communications plan l Home preparedness/readiness l On-site support l Transportation considerations 55

Disaster Training Day Disaster Personal Preparedness 1. Create an emergency communications plan: l Pre-determined out-of-state contact 2. Establish a meeting place, if you can’t go home 3. Assemble a disaster supply kit: l Food, water, first aid, clothing, etc. l Flashlight, battery powered radio, cell phone/battery l Cash, copies of important documents 4. Check on school’s or business’s emergency plans of your family 56

Disaster Training Day Personal Disaster Kits Considerations n n n Home Kit l Minimum of 3 day’s supplies…consider 14 days l Bulk water l Canned and freeze dried food l MRE’s: military Meals Ready to Eat Car Kit l Walking shoes, jacket, blanket l Baby wipes, hand sanitizer, Ziploc bags, tissues, first aid kit l “Lifeboat” water packets and rations Desk Kit l Light stick or flashlight l Dusk mask and space blanket l Triangular bandage with safety pins l Water packet and candy bar l Pry bar, especially if you don’t have any windows 57

Disaster Training Day Conclusions: n Use your prior drills to prioritize your training n Create a practical focused training model beyond the disaster drill n Use an effectiveness metric to assess your progress n Develop a staff preparedness and support program to minimize staff attrition 58

Disaster Training Day The True Measures n All of Administration coming in at 0400 for a drill n The staff wanting to be involved n Disaster management becoming part of daily operations! 59

Disaster Training Day QUESTIONS ? ? jrolland@pih. net schinmd@compuserve. com 60