Public Health Emergency Preparedness: Planning and Practicing for a Disaster

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Public Health Emergency Preparedness Planning
and Practicing for a Disaster

• Monday, February 9th, 2009
• 100-230 pm EST

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Questions

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Agenda

• PART ONE
• Introduction, Karen Migdail
• Disaster Preparedness Tools Hospital Surge Model
  and Mass Evacuation Transportation Model, Tom
  Rich
• National Mass Patient and Evacuee Movement,
  Regulating, and Tracking System Initiative, F.
  Christy Music
• Moderated QA, Karen Migdail
• PART TWO
• Hospital Disaster Drills, Mollie Jenckes
• Users Perspective of Hospital Disaster Drills,
  Cindy Notobartolo
• Moderated QA and closing statements, Karen
  Migdail

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AHRQ Disaster Preparedness Tools Hospital
Surge Model and Mass Evacuation Transportation
Model

• Tom Rich
• Senior Associate
• Abt Associates Inc.

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Surge Model Partners

• Dr. Sally Phillips, AHRQ Project Officer
• Office of the Assistant Secretary for
  Preparedness and Response (ASPR)
• Gryphon Scientific (Rocco Casagrande, Principal
  Investigator)
• Weill Medical College, Cornell University
  (Nathaniel Hupert, Co-Principal Investigator)
• Project Steering Committee

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Surge Model Scenarios

• Biological
• Anthrax
• Smallpox
• Flu
• Food Contamination (under development)
• Plague (under development)
• Chemical
• Chlorine
• Mustard
• Sarin
• Nuclear / Radiological
• 1 Kiloton Yield (KT) or 10 KT nuclear device
• Radiological dispersion device (Dirty bomb)
• Radiological point source
• Conventional explosive (under development)

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Surge Model Outputs

• Based on
• The scenario
• The number and type of casualties requiring
  hospitalization
• The Hospital Surge Model estimates
• Number of patients in the hospital by day and
  hospital unit
• Resource requirements for patients, by resource,
  day, and hospital unit

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Hospital Resources

• Durable equipment
• Human resources
• Pharmacy
• Consumable supplies
• Personal protective equipment

• Psychological Support
• Housekeeping
• Lab / Radiology
• Mortuary
• Nutrition

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Key Assumptions and Considerations

• Time delay between incident and hospital arrivals
  (for biological and radiological scenarios, based
  on dispersion models)
• The patients assumed length of stay in the
  Emergency Department (ED), in the Intensive Care
  Unit (ICU), and on the floor varies by scenario
  and severity of condition
• Per patient per day resource consumption based on
  historical data to treat similar patients, and
  expert elicitation
• No capacity or resource limitations at the
  hospital

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Illustrative Output Hospitalized Patients by Day
and Unit
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For More Information

• To run the Hospital Surge Model, go to
  hospitalsurgemodel.ahrq.gov
• User Manual
• Model Description Document

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Mass Evacuation Transportation Model Partners

• Dr. Sally Phillips, AHRQ Project Officer
• ASPR1, HRSA2, FEMA3, DoD4
• Partners Healthcare (Drs. Paul Biddinger and
  Richard Zane)
• Project Steering Committee
• New York City Office of Emergency Management
• Los Angeles Emergency Preparedness Department

1 ASPR Office of the Assistant Secretary for
Preparedness and Response 2 HRSA Health
Resources and Services Administration 3 FEMA
Federal Emergency Management Agency 4 DoD
Department of Defense
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Model Outputs

• Based on
• Number of vehicles assigned to the evacuation --
  buses wheel chair vans Basic Life Support (BLS)
  and Advanced Life Support (ALS) ambulances
• Location of evacuating and receiving facilities
• Number and type of patients to be evacuated
• Surge capacity assumptions
• The Model estimates
• The time required to transport all patients to
  the receiving facilities

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Key Assumptions and Considerations

• A planning model not an operational tool to
  produce a vehicle schedule or patient transport
  roster
• Does not consider physical constraints within the
  hospitals (e.g., the number of elevators)
• Assumes appropriate staff are available in the
  vehicles
• Travel time estimates require latitude and
  longitude of evacuating and receiving facilities

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Web Implementation of the Model
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Illustrative Results Effect of Advanced Life
Support (ALS) Ambulance Availability
Data from Los Angeles pilot test
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For More Information

• To run the Mass Evacuation Transportation Model,
  go to massevacmodel.ahrq.gov
• User Manual
• Model Description Document

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Poll Question 1

• A short poll will appear on your screen. Please
  take a few seconds to answer the poll and provide
  valuable feedback!
• If you are unable to respond to the poll during
  this event, please e-mail your answer to
  emergencypreparedness_at_academyhealth.org.

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Questions

• To pose a question to the Panelists, please post
  it in the QA panel on the right hand side of
  your screen and press send.
• To expand or decrease the size of any panel on
  the right hand side of your screen, click the
  arrow shape in the upper-left corner of the
  panel.
• To pose a question to WebExs technical support,
  you can also post it in that QA panel and press
  send. Or you can dial
• 1-866-229-3239.

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National Mass Patient and Evacuee Movement,
Regulating, and Tracking Initiative

• F. Christy Music, MS, MT(ASCP)SBB
• Program Director, Health and Medical Support
• Office of the Assistant Secretary of Defense
  (Homeland Defense Americas Security Affairs),
  Department of Defense

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Create a National General Population Evacuee
Patient Movement, Regulating, Tracking System

• Issue Catastrophic incidents need for
  large-scale general population patient
  movement, regulating, and tracking
• Issue No interoperable, national (local, State,
  Federal, tribal) information system
• Tracking Locating and maintaining an audit
  trail of persons movement from initial entry
  through final location
• Regulating Matching transport needs to a
  receiving location
• Movement Availability, reservation, use, and
  release of transportation resources

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National Mass Patient and Evacuee Movement,
Regulating, and Tracking Initiative

• Purpose Build upon existing information systems
  and develop a National General Population Evacuee
  and Patient Movement, Regulating, and Tracking
  information system that is interoperable and
  shares data.
• Goal Federal Sector (DoD1, HHS2, DHS3, FEMA4)
  provide a national system for all jurisdictions
  use.
• Goal Use a central IT platform or other
  technology to share data among existing systems
  build and insert modules that are needed.

1 Department of Defense 2 Department of Health
and Human Services 3 Department of Homeland
Security 4 Federal Emergency Management Agency
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National Initiative Capabilities

• Near real-time location and tracking is needed
• Audit trail that tracks general population and
  patients
• Notice and tracking general population members ?
  patients
• Tracking from first entry through final location.
  
• Entry Point Fixed facility, collection point,
  point of injury, home, search and rescue,
  self-registration, etc.
• Incorporate regulating and movement information
  to perform operations during an event.

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Effects of the National Initiative

• Expand Nations capacity to transport, regulate,
  and track evacuees/patients.
• Support local, State, tribal, and Federal command
  control decision makers.
• Deconflict intended use of general
  population/patient movement resources and
  destinations.
• Coordinate general population/patient management
  at all vertical and horizontal levels of
  government.

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Effects of the National Initiative(continued)

• Locate general population evacuees /patients
  entry? intermediate locations? final
  destinations.
• Provide near real-time updates (e.g. medical
  status).
• Incorporate patients Electronic Medical Record.
• Track general population evacuees as they become
  patients during movement, requiring medical
  oversight en route.
• Use by all jurisdictions (authorized users) in a
  disaster available for routine use.

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National Mass Patient and Evacuee Movement,
Regulating, and Tracking Initiative History

• Proposed by DoD (2004) Noted as DHS Priority
  (2004) Secretary Ridges Homeland Security
  Interagency Security Planning Effort
• Included patient mobilization planning for
  catastrophic events as a long-term initiative and
  identifies this effort as a high-priority
  (Reference Secretary, Department of Homeland
  Security letter to Secretary, Department of
  Defense, September 22, 2004).
• Funded by FEMA (tracking recommendations)
• DoD asked AHRQ/HHS to apply these funds to the
  existing HAvBED contract
• HHS added funds (Mass Evacuation Transportation
  Model)
• Began Winter 2005, Draft Report 2008, Final
  Report 2009
• Supported by DoD Evacuee-Patient Tracking
  Initiative Interconnect DoDs ETAS1 and
  AHLTA-Mobile2 to HHS JPATS3

1 Emergency Tracking Accountability System 2
Armed Forces Health Longitudinal Technology
Application-Mobile 3 Joint Patient Assessment and
Tracking System
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National Initiative Advisory Board

• National Advisory Board HSC1, DoD, AHRQ, HHS,
  DHS, DOT2, VA3, other Federal agencies, State (NY
  and CA) and private industry representatives
• Developed recommendations for a system that could
  be used during a mass casualty evacuation to
• Locate and track general population
  evacuees/patients
• Improve decision making regarding
• General population evacuee and/or patient
  movement
• Resource allocation
• Incident management
• Built planning tool for use before a mass
  casualty/evacuation incident
• Estimate shortfalls in resources to transport
  patients and general population evacuees

1 Homeland Security Council 2 Department of
Transportation 3 Department of Veterans Affairs
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National Mass Patient and Evacuee Movement,
Regulating, and Tracking Initiative
Recommendations

• Build on existing systems incorporate data and
  architectural standards
• Activated system in major, multi-jurisdictional
  incidents optional routine use
• Begin with local, State, and tribal entry
  Federal entry last
• Track location health status/needs of any
  person encountering system
• Track at touch points (e.g. collection points,
  hospitals, etc.)
• Minimum data elements to enter patient/general
  population data

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National Mass Patient and Evacuee Movement,
Regulating, and Tracking Initiative
Recommendations (continued)

• Build system to accept more detailed
  demographic/medical information
• System accessible to emergency responders/planners
  
• Incorporate current or planned Feeder Tracking
  Systems
• Data from point of injury or first entry through
  final disposition
• Incorporate Feeder Institutional Records Systems
  (Check-In/Check Out)
• Facilities with mandatory reporting, common
  software platforms, within an agency (e.g. VA
  hospitals, DoD Military Treatment Facilities,
  Indian Health)
• Single facility (hospital with homegrown
  system)
• Eventually include public Web-based registration

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Supports Homeland Security Presidential
Directive 21

• Supports HSPD-21 Public Health and Medical
  Preparedness
• Integrate all vertical and horizontal levels of
  government and community components, achieving a
  much greater capability than we currently have. 
• Response deployed in a coordinated manner
  guided by a constant and timely flow of relevant
  information during an event and rapid public
  health and medical response that marshals all
  available national capabilities and capacities in
  a rapid and coordinated manner.
• Help ensure general population evacuee and
  patient movement is (1) rapid, (2) flexible, (3)
  scalable, (4) sustainable, (5) exhaustive
  (drawing upon all national resources), (6)
  comprehensive (e.g. addresses needs of mental
  health and special needs populations), (7)
  integrated and coordinated, and (8) appropriate
  (correct treatment in the most ethical manner
  with available capabilities).

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Initiative Recognized by Senior United States
Government (USG) Officials

• Initiative repeatedly recognized by White House
  and USG leaders as a national biodefense
  preparedness and response priority (Homeland
  Security Council / National Security Council
  Joint Biodefense Preparedness Deputies
  Committees (March and April 2008)
• Nations planning will ...include creation of a
  national system for the coordination and tracking
  of general population evacuee and patient
  movement from point of incident, fixed
  facilities, or collection points to their final
  destination.
• Supports HSC Mass Evacuation / Population
  Movement Policy Sub-Policy Coordinating
  Committee, December 17, 2008.
• Supports President Obamas Campaign Promise to
  create a National Family Locator System to help
  families locate loved ones after a disaster, and
  Prepare Effective Emergency Response Plans, to
  include medical surge.
• Next Step Develop the national system
• Proposal DoD, HHS, DHS/FEMA co-lead
• Participation American Red Cross, VA, DOJ1
  State, tribal, local representatives, commercial
  industry, professional association.

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1Department of Justice
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Poll Question 2

• A short poll will appear on your screen. Please
  take a few seconds to share your feedback with
  AHRQ.
• If you are unable to respond to the poll during
  this event, please e-mail your answer to
  emergencypreparedness_at_academyhealth.org.

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QA

• If you have a question for Tom Rich from Abt
  Associates and/or F. Christy Music from the
  Department of Defense, please type it into the
  QA panel to the right and press send.

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Part Two Agenda

• Hospital Disaster Drills , Mollie Jenckes
• Users Perspective of Hospital Disaster Drills ,
  Cindy Notobartolo
• Moderated QA and closing statements, Karen
  Migdail

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Mollie W. Jenckes, MHSc, BSNResearch
AssociateJohns Hopkins University
Johns Hopkins University Evidence-based Practice
Center

• Sara E. Cosgrove Christina L. Catlett
• Mollie W. Jenckes Karen A. Robinson
• Gary Green Carolyn J. Feuerstein
• Karen Kohri Eric B. Bass
• Edbert B. Hsu

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Training is Vital
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Background

• Hospitals are prepared for natural and manmade
  disasters
• Transportation accidents
• Structural collapse
• Earthquakes
• Why do hospitals hold disaster drills?
• To allow hands-on training in the hospital
  disaster plan
• To build knowledge and understanding of roles
• To identify strengths and weaknesses in response
• To build familiarity with infrequently used
  equipment
• To fulfill requirements of the Joint Commission
  for Accreditation of Healthcare Organizations
  (JCAHO)

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Continuous Quality Improvement (CQI)
ProcessApplied to Hospital Disaster Preparedness
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MethodsExpert Input/Feedback

• The JHU EPC1 assembled a multi-disciplinary team
  of experts for initial guidance and repeated
  feedback during development of modules
• Federal agencies (HRSA2, CDC3, FEMA4)
• State agencies (MEMA5, MD DHMH6)
• Hospitals (administrators, EM7 physicians)
• Disaster planning experts
• WMD8 experts

1Johns Hopkins University Evidence-based Practice
Center 2Health Resources and Services
Administration 3Center for Disease
Control 4Federal Emergency Management Agency
5Maryland Emergency Management Agency 6Maryland
Department of Health and Mental
Hygiene 7Emergency Medicine 8Weapons of Mass
Destruction
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ResultsDrill Evaluation Modules

• There are 7 modules
• Training module (use of product)
• Pre-drill planning module
• Command center zone
• Decontamination zone
• Triage zone
• Treatment zone
• De-briefing module..and 2 addenda

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Data Collected in Each Module

• Activity points documented within each
• zone module

• Time points
• Zone description
• Personnel
• Zone operations
• Communications
• Information flow
• Security

• Documentation and tracking
• Victim flow
• Personal protective
• equipment and safety
• Equipment and supplies
• Rotation of staff
• Zone disruption

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Addendums

• Biological Incident Addendum
• Assesses
• Awareness that a biological
• agent caused the event
• Appropriate and expert
• monitoring
• Reporting mechanisms
• Meeting of health and safety
• needs of patients and victims
• Availability of special supplies

• Radiation Incident Addendum
• Assesses
• Awareness that radiation
• exposure caused the illness
• Appropriate and expert
• monitoring
• Reporting to State and Federal
• agencies
• Meeting of health and safety
• needs of victims and staff
• Availability of special supplies

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Field Trial Results

• Trials indicated wide acceptance
• Hospitals were able to document activities
  occurring as they happened
• Modules allowed identification of areas that
  needed further training
• In follow up exercises,
• hospitals are requesting
• repeat use of the modules

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Products Available
Evaluation of Hospital Disaster Drills A
Module-Based Approach AHRQ Publication No.
04-0032 April 2004 Tool for Evaluating Core
Elements of Hospital Disaster Drills AHRQ
Publication No. 08-0019 June 2008
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Poll Question 3

• A short poll will appear on your screen. We
  appreciate your feedback!
• If you are unable to respond to the poll during
  this event, please e-mail your answer to
  emergencypreparedness_at_academyhealth.org.

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Users Perspective of Hospital Disaster Drills

• Cindy Notobartolo, RN, BSN
• Corporate Director of Emergency Department,
  Safety and Security Services
• Suburban Hospital, Bethesda, Maryland

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Drill Planning and Execution

• October 2008 designed, planned and participated
  in a regional large scale explosive event
  involving 40 military, research, national, State,
  county and private entities
• Historically the evaluation tool was created or
  adapted from existing templates
• Dissatisfaction with prior tools or the time
  needed to customize them for the event

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Discovery of AHRQ Evaluation Tool

• Logical framework
• Flow and sequence match actual event
• Pre-populated fields and circle answers
• Comment sections
• Prompting questions
• Diagram sections

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Modules

• Module based approach allows for individual
  selection
• Range from Red Zone to Incident Command Center to
  Group Debriefing Module
• We chose to integrate the AHRQ tool with specific
  targeted evaluation

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Suburban Hospital

• Founded in 1943
• Community based not for profit serving Montgomery
  County, Maryland
• Trauma center
• Distinguished self with affiliations with
  National Institutes of Health and Johns Hopkins
  Medicine
• Emergency Preparedness partnership with National
  Naval Medical Center, National Institutes of
  Health Clinical Center and the National Library
  of Medicine
• MOUs with all other Montgomery County Hospitals
  and Public Health Services

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Incident Command Center
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Incident Command Module

• Prompted important time parameters such as
  beginning and ending, response times of staff
• Allowed for picture of zone set-up
• External evaluator ease
• Able to target need for after action response
• Ease and efficiency of completion for post event
  documentation

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Future of the Tool

• The tool is being recommended to hospital
  Emergency Managers
• Receiving enthusiastic feedback
• Groups are sharing their use experiences
• This will lead to more widespread use

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QA

• If you have a question for Mollie Jenckes from
  Johns Hopkins University and/or Cindy Notobartolo
  from Suburban Hospital, please type it into the
  QA panel to the right and press send.

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For more information about.

• Todays event including a recording and
  transcript, go to http//www.ahrq.gov/prep/
• AHRQs suite of emergency preparedness tools, go
  to http//www.ahrq.gov/prep/
• If you have a question about utilizing AHRQ tools
  please e-mail us at emergencypreparedness_at_academy
  health.org.

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Thank you!

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  your browser. Please take a few moments to give
  us your feedback on todays event.
• Thank you!

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