Medical Disaster Planning and Response Process Preevent Disaster

Medical Disaster Planning and Response Process: Pre-event Disaster Planning National Emergency Management Summit New Orleans March 5, 2007 Barbara Bisset, Ph. D MPH MS RN EMT Executive Director Emergency Services Institute Wake. Med Health & Hospitals Raleigh, North Carolina

Objectives Awareness of • Key Considerations • Disaster Phases • Five Planning Tiers • Contingency Business Plans • Resources for Healthcare Planners

Key Considerations: Defining Events • Do NOT define events by the number of casualties • Loss of mission critical systems is an event

Key Considerations: Internal versus External Events Three potential scenarios • Hospital only • Community only • Hospital and the community

Key Considerations: Short term versus Long Term Events Event may last from hours to months

Key Considerations: Events Do Not Have Boundaries Events may or may not be contained within one geographic location Events can easily cross over county and/or state lines

Key Considerations: Hospitals Are First Receivers Literature documents that greater than 85% of the population will likely bypass community emergency response systems and will report to the hospital that they normally go to for service

Key Considerations: Capacity versus Capability Capacity (Volumes of Patients) • Most hospitals are already at full capacity • Rapid versus gradual influx of patients • Expansion / surge spaces

Key Considerations: Capacity versus Capability (Types of Patients) • Specialized populations – – Burn victims Pediatric populations Need for isolation rooms Decontamination procedures required • Requires specialized equipment, supplies and staff

Key Considerations: Covert versus Overt • May or may not be an identifiable “scene” • Patients may already be in the hospital system before there is an identified event

Key Considerations Warning versus No Warning Events Notification Systems • Advisory • Alert • Activation • Updates

Key Considerations: Type of Casualties For every one physical casualty, you can expect four to twenty mental health casualties

Key Considerations: Special Needs Populations Special needs populations • Often are those who are “left behind” • Many times cannot afford the expense of taking personal actions • Medical needs will be accelerated in emergency events

Key Considerations: Ethical Considerations • Limited resources • Level of care – Sufficient versus “normal”

Key Considerations: Communications • All communication systems that you use on a daily basis will rapidly become overloaded and/or will fail • Hospitals can expect thousands of calls (if the normal communication systems are working)

Key Considerations: Communications • Information may most likely be: – Inaccurate and/or incomplete – Delayed • Rumors can run rampant • Intelligent community • Event may involve risk communications

Key Considerations: Campus Security • You cannot treat patients if you do not have a safe environment • The crowds will come

Key Considerations: Staffing • Employees and/or their families may be victims of the event • May have fear of responding • May need to alter duties • Staff may be needed from resources outside the facility

Key Considerations: Decision Making • If event requires a rapid activation, the steps taken in the first ten minutes will affect patient outcome and success of response • Normal “decision makers” may be unavailable

Key Considerations: Availability of Vendors • Multiple agencies may have agreements with the same vendors • Vendors contact may need to be 24/7

Key Considerations: Financial Cost • Cost of event can rapidly escalate • Details and documentation are needed for insurance and other potential sources of reimbursement

Key Considerations: Regulatory Agencies • Regulatory standards apply during emergency and disaster events. Recognize in catastrophic event life saving measures will be a priority. – Division of Facility Services – Occupational Safety and Health Administration (OSHA) – Emergency Medical Treatment and Active Labor Act (EMTALA) – Fire Marshall Having Jurisdiction – Environmental Protection Agency – Health Insurance Portability and Accountability Act (HIPAA) – Medical and Nursing and Allied Health Practice Boards

Key Considerations: Documentation • Documentation of response to event is often uncoordinated and is generally the weakest link • Many decisions may go undocumented

Disaster Phases

Mitigation Phase • Critical systems on emergency power • Redundant systems • Construction and designs of space

Preparedness Phase Employee Training 1. Awareness Level – Quick Response Guides 2. Active Participant Level – Quick Response Guides – Standing orders / Protocols – Other duties as assigned 3. Expert Level – – Knowledge of details of plans Job Action Sheets Key Assumptions Crisis Management

Preparedness Phase Equipment and Supplies • Just-in-time inventories versus preparedness for greater than 72 hours • Specialty equipment for capability events • Mobility of equipment

Preparedness Phase Staff Assignments • Active and Reserve Teams – All employees are essential • Systems for rapid activation and deployment • Task Forces • Strike Teams

Response Phase • Incident Recognition • Notification • Mobilization • Incident Operations • Demobilization • Transition to Recovery

Response Phase • Authority to activate emergency operations plans – Consider immediate threats – Time to respond – e. g. setting up decontamination operations • Implement incident command for all events • Develop focused action plan • Better to over commit than to under commit

Recovery Phase • Be prepared for extended operations • Incident command in place until operations return to “normal” • Opportunity for organizational learning • Develop After Action Report (AAR) – Follow identified actions through completion

Planning in Five Tiers • Personal • Department • Organizational • Participate in regional planning • Participate in state and other organizations planning efforts

Tier One: Personal and Family Preparedness • Every employee needs to have a plan • Includes: – Home inventories – Evacuation routes – Personal packs with self sustaining supplies, important papers – Work Pack – Emergency Car Kit – Pet Plan

Tier Two: Department Plans • Every department is essential • Each department needs to understand their preassigned role

Tier Three: Organization’s Plan Details how the hospital responds as a system • Hospital Command Center • Policies, Procedures, Emergency Operations Plans

Tier Three: Organization’s Plan In addition to the standard planning • Crowd Control – Restricted Access – Lockdown • Special Needs Populations • Management of Communications from the Public • Epidemiological Events • Management of Staff – Expectation of Employees – Emergency Credentialing • Capability Events – Burns – Mass decontamination – Pediatrics • Management of Donations • Management of Volunteers • Capacity Management

Tier Four: Community and Regional Planning • Hospitals must take a leadership role with community and regional partners • Cannot operate in a vacuum – Public Information • Joint Information Centers – Multiple agency plans need to be coordinated • Selection of Ambulatory Care Centers – Mutual Aid Agreements

Tier Five: Planning with the State and Organizations • Need to understand state plans and know individuals in key state and organizations agencies – – – Public Health Office of Emergency Medical Services Hospital Association Law Enforcement Emergency Management

Business Continuity Planning • Continued access to services • Record preservation • Business relocation plans

Planning Resources

National Incident Management System (NIMS) • Department of Health and Human Services in collaboration with the National Incident Management Systems (NIMS) Integration Center • Seventeen elements for hospitals • Compliance by August of 2008 if want to receive federal preparedness dollars

NIMS: Seventeen Implementation Activities # 1 Organizational Adoption # 2 Command Management (ICS) # 3 Multi-agency Coordination System # 4 Public Information Systems – Joint Information System (JIS) and Joint Information Center (JIC) # 5 Implementation Tracking – Annual Emergency Management report

NIMS: Seventeen Implementation Activities # 6 Preparedness Funding # 7 Revision and Updating of Response Plans annually # 8 Mutual Aid Agreements # 9 Training IS 700 NIMS – All personnel who have a leadership role in emergency preparedness, incident management or incident response need to take the course

NIMS: Seventeen Implementation Activities # 10 Training IS 800 National Response Plan – Must be completed by individuals whose primary responsibility in a hospital is emergency management # 11 Training ICS 100 and 200 – Must be completed by those who have a direct role in emergency preparedness, incident management or response # 12 Training and Exercises – Must include incident command structure

NIMS: Seventeen Implementation Activities # 13 All Hazard Exercise Program # 14 Corrective Actions Reports

NIMS: Seventeen Implementation Activities # 15 Response Inventory – NIMS Typing of resources # 16 Resource Acquisition – Relevant national standards and guidance are used to achieve equipment, communication and data interoperability. # 17 Standard and Consistent Terminology – Plain English communication standards across the public safety sector – Common language between Emergency Management, Law Enforcement, EMS, fire public health and hospitals

National Incident Management Structure versus Hospital Incident Command Structure • National committees collaborated • Reconciled discrepancies as HEICS (III) did not – Include multi-agency cooperation – Public information systems – Proper incident command system language

Hospital Incident Command (HICS) (Version IV) • Incident Command must be incorporated into the response to every events • HICS is NIMS compliant • HEICS III and HICS IV Position Crosswalk • Job Action Sheets

Hospital Incident Command (HICS) (Version IV) • Seventeen internal and external events identified – Incident Planning Guides – Incident Response Guides • Education Tools • HICS Implementation Tools

The Joint Commission: Proposed Elements to Emergency Management Standards Need to think of critical capabilities beyond 72 hours

Resources Agency for Healthcare Research and Quality • www. ahrq. gov Best Practices for the Protection of Hospital Based First Receivers • www. osha. gov/dts/osta/bestpractices/firstreceivers Emergency Management Principles and Practices for Healthcare Systems • www. va. gov/emshq/page. cfm? pg=122

Resources Hospital Incident Command (HICS IV) • www. emsa. ca. gov/hics National Incident Management System • www. fema. gov/emergency/nims/index. shtm

Summary • Key challenges • Phases of disaster • Tier Planning • Resources for Healthcare Planners

Wake. Med Health & Hospitals Raleigh, North Carolina