Medical Disaster Planning and Response Process:Pre-event Disaster Planning

National Emergency Management SummitNew OrleansMarch 5, 2007

Barbara Bisset, PhD MPH MS RN EMTExecutive Director Emergency Services Institute

Raleigh, North Carolina

WakeMed Health & Hospitals

ObjectivesObjectives

Awareness of

• Key Considerations

• Disaster Phases

• Five Planning Tiers

• Contingency Business Plans

• Resources for Healthcare Planners

Key Considerations:Key Considerations:Defining EventsDefining Events

• Do NOT define events by the number of casualties

• Loss of mission critical systems is an event

Key Considerations:Key Considerations:Internal versus External EventsInternal versus External Events

Three potential scenarios

• Hospital only

• Community only

• Hospital and the community

Key Considerations:Key Considerations:Short term versus Long Term EventsShort term versus Long Term Events

Event may last from hours to months

Key Considerations:Key Considerations:Events Do Not Have BoundariesEvents Do Not Have Boundaries

Events can easily cross over county and/or state lines

Events may or may not be contained within one geographic location

Key Considerations: Key Considerations: Hospitals Are First ReceiversHospitals 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: Key Considerations: Capacity versus CapabilityCapacity versus Capability

Capacity (Volumes of Patients)

• Most hospitals are already at full capacity

• Rapid versus gradual influx of patients

• Expansion / surge spaces

Key Considerations: Key Considerations: Capacity versus CapabilityCapacity versus Capability

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:Key Considerations:Covert versus OvertCovert 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 ConsiderationsKey ConsiderationsWarning versus No Warning EventsWarning versus No Warning Events

Notification Systems

• Advisory

• Alert

• Activation

• Updates

Key Considerations:Key Considerations:Type of CasualtiesType of Casualties

For every one physical casualty, you can expect four to twenty mental health casualties

Key Considerations: Key Considerations: Special Needs PopulationsSpecial 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: Key Considerations: Ethical Considerations Ethical Considerations

• Limited resources• Level of care

– Sufficient versus “normal”

Key Considerations: CommunicationsKey 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: Key Considerations: CommunicationsCommunications

• Information may most likely be:

– Inaccurate and/or incomplete

– Delayed

• Rumors can run rampant

• Intelligent community

• Event may involve risk communications

Key Considerations: Campus SecurityKey Considerations: Campus Security• You cannot treat patients if you do not have a safe

environment

• The crowds will come

Key Considerations: StaffingKey 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:Key Considerations:Decision MakingDecision 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:Key Considerations:Availability of VendorsAvailability of Vendors

• Multiple agencies may have agreements with the same vendors

• Vendors contact may need to be 24/7

Key Considerations:Key Considerations:Financial CostFinancial Cost

• Cost of event can rapidly escalate

• Details and documentation are needed for insurance and other potential sources of reimbursement

Key Considerations: Key Considerations: Regulatory AgenciesRegulatory 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: DocumentationKey Considerations: Documentation

• Documentation of response to event is often uncoordinated and is generally the weakest link

• Many decisions may go undocumented

Disaster PhasesDisaster Phases

Mitigation PhaseMitigation Phase

• Critical systems on emergency power

• Redundant systems

• Construction and designs of space

Preparedness PhasePreparedness PhaseEmployee 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 PhasePreparedness Phase

Equipment and Supplies

• Just-in-time inventories versus preparedness for greater than 72 hours

• Specialty equipment for capability events

• Mobility of equipment

Preparedness PhasePreparedness Phase

Staff Assignments

• Active and Reserve Teams– All employees are essential

• Systems for rapid activation and deployment

• Task Forces

• Strike Teams

Response PhaseResponse Phase

• Incident Recognition

• Notification

• Mobilization

• Incident Operations

• Demobilization

• Transition to Recovery

Response PhaseResponse 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 PhaseRecovery 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 TiersPlanning in Five Tiers

• Personal

• Department

• Organizational

• Participate in regional planning

• Participate in state and other organizations planning efforts

Tier One:Tier One:Personal and Family PreparednessPersonal 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:Tier Two:Department PlansDepartment Plans

• Every department is essential

• Each department needs to understand their preassigned role

Tier Three:Tier Three:OrganizationOrganization’’s Plans Plan

Details how the hospital responds as a system

• Hospital Command Center• Policies, Procedures, Emergency

Operations Plans

Tier Three: Tier Three: OrganizationOrganization’’s Plans Plan

• 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

In addition to the standard planning

Tier Four:Tier Four:Community and Regional PlanningCommunity 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:Tier Five:Planning with the State and Planning with the State and OrganizationsOrganizations

• 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 PlanningBusiness Continuity Planning

• Continued access to services

• Record preservation

• Business relocation plans

Planning ResourcesPlanning Resources

National Incident Management National Incident Management System (NIMS)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:NIMS:Seventeen Implementation ActivitiesSeventeen Implementation Activities

# 1 Organizational Adoption

# 2 Command and 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:NIMS:Seventeen Implementation Activities 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:NIMS:Seventeen Implementation Activities 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:NIMS:Seventeen Implementation Activities Seventeen Implementation Activities

# 13 All Hazard Exercise Program

# 14 Corrective Actions Reports

NIMS:NIMS:Seventeen Implementation Activities 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 National Incident Management Structure versus Hospital Incident Structure versus Hospital Incident Command StructureCommand 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)Hospital Incident Command (HICS)(Version IV)(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)Hospital Incident Command (HICS)(Version IV)(Version IV)

• Seventeen internal and external events identified

– Incident Planning Guides

– Incident Response Guides

• Education Tools

• HICS Implementation Tools

The Joint Commission:The Joint Commission:Proposed Elements to Emergency Proposed Elements to Emergency Management StandardsManagement Standards

Need to think of critical capabilities beyond 72 hours

ResourcesResources

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

ResourcesResources

Hospital Incident Command (HICS IV)• www.emsa.ca.gov/hics

National Incident Management System• www.fema.gov/emergency/nims/index.shtm

SummarySummary

• Key challenges

• Phases of disaster

• Tier Planning

• Resources for Healthcare Planners

Raleigh, North Carolina

WakeMed Health & Hospitals