MCHC - University of Chicago Live Scenario Based Exercise

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MCHC - University of ChicagoLive Scenario Based
ExerciseTrain the Trainer

• Janis P. Tupesis, MD
• Mary Pat Olson, RN
• Susan Wood, RN

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Goals

• Overview
• MCHC
• Current Grant
• Incident Command
• NIMS
• HEICS
• Training
• Concept Train the trainers
• Clinical Scenario
• Review scenario and associated questions
• Integration with table top paperwork simulation
• Review and feedback

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ReviewCurrent Grant
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• Metropolitan Chicago Healthcare Council
• Service organization dedicated to improving the
  health of the public by enhancing access to
  health care and in assisting its members in
  improving the delivery of services in the greater
  Metropolitan Chicago Area
• Comprised of more than 140 hospitals and health
  care organizations
• Hospitals, physician groups, nursing homes,
  outpatient treatment centers, insurers, medical
  schools and other health care organizations

Source MCHC Web site, www.mchc.org
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• Federal Bioterrorism Grants
• Initial grant awarded in November, 2003
• 1.04 million
• Basic Bioterrorism curriculum focus on nurses,
  pharmacists and primary care physicians
• More than 2,000 health care workers have been
  trained by MCHC and its partners
• Illinois Poison Center
• John H. Stroger Hospital of Cook County
• Mount Sinai Hospital
• Rush University Medical Center
• University of Illinois at Chicago

Source MCHC Web site, www.mchc.org
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• Federal Bioterrorism Grants
• Second grant awarded in October, 2005
• Expand the initial grant to special patient
  populations
• Sponsor local and statewide drills involving
• pre-hospital first responders
• emergency room personnel
• local and state public health agencies
• multiple hospitals
• Purpose to provide the health care workforce in
  Illinois with the knowledge, skills, abilities
  and core competencies to recognize, notify, treat
  and participate in a multidisciplinary team
  response in the event of a terrorist threat of
  public health emergency

Source MCHC Web site, www.mchc.org
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Source MCHC Web site, www.mchc.org
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ReviewIncident Command
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The National Incident Management System (NIMS)
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Mandate for Change

• Post 9/11, perception of threats faced by U.S.
  has changed
• Increasing focus on terrorism threat while still
  addressing spectrum of contingencies from natural
  disasters to man-made hazards
• Department of Homeland Security created to reduce
  vulnerability of U.S. to terrorism
• HSPD-5 issued in February 2003 to enhance ability
  of the U.S. to manage domestic incidents. HSPD-5
  requires
• National Incident Management System (NIMS)
• National Response Plan (NRP)

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National Incident Management System

• NIMS guidance provides the national standard for
  incident management
• NIMS provides a framework for interoperability
  and compatibility by balancing flexibility and
  standardization
• MAJOR COMPONENTS
• Incident Command and Management
• Preparedness
• Resource Management
• Communications and Information Management
• Supporting Technologies
• Ongoing Management and Maintenance

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NIMS Components
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NIMS What It Is / What Its Not

• NIMS is
• Core set of
• Doctrine
• Concepts
• Principles
• Terminology
• Organizational processes
• Applicable to all hazards

• NIMS is not
• An operational incident management plan
• A resource allocation plan
• A terrorism or WMD-specific plan
• Designed to address international events

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Relationship NIMS and NRP
NIMS aligns command, control, organization
structure, terminology, communication protocols,
resources resource-typing to synchronize all
levels of response
National Incident Management System (NIMS)
Used for all events
NRP integrates applies Federal resources,
knowledge and abilities before, during, and
after an incident
Incident
Resources
Local Response
Local Response
Knowledge
State Response or Support
Abilities
Federal Response or Support
National Response Plan (NRP)
Activated only forIncidents of National
Significance
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NIMS Command Management

• Incident Command System A standard, on-scene,
  all-hazard incident management system designed to
  integrate resources from numerous organizations
  into a single structure using common terminology
  and processes
• Incident management activities organized under
  five functions

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NIMS Command Management
Unified Command is a variation in incident
management structure, typically used when there
is more than one agency with responsibility for
an incident, or when the incident crosses
political jurisdictions.
Unified Command (Fire,
Police, EMS, Public Works)
Operations
Finance/Admin.
Logistics
Planning
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NIMS Command Management
Multiagency Coordination Systems typically are
established in Emergency Operations Centers
(EOCs) at the local and State levels.
Other entities are established at the Federal
regional and national levels.
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NIMS Command Management

• Public Information Systems are essential for
  communicating timely and accurate information to
  the public during emergency situations
• Public Information Officer
• Joint Information System
• Joint Information Center

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NIMS Preparedness

• Preparedness
• Continuous cycle of planning, training,
  equipping, exercising, evaluating and taking
  corrective action, in advance of any potential
  incident
• Preparedness Planning
• Training Exercises
• Personnel Standards
• Equipment Standards
• Publications Management
• Mutual Aid Agreements

Components of NIMS
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NIMS Resource Management

• Resource Management
• Uniform methods of identifying,acquiring,
• allocating, and tracking resources
• Classifying kinds and types of resources
• Incorporating resources contributed by
• private sector and non-governmental
• organizations
• Using a credentialing system tied to
• uniform training and certification
• standards

Components of NIMS
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NIMS Communication

• Communications and Information Management
• Common operating picture
• Common communications and data standards

Components of NIMS

• Supporting Technologies
• Provide capabilities essential to incident
  management
• Operational scientific support
• Technical standards
• RD to solve operational
• problems

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NIMS Management/Maintenance

• Ongoing Management and Maintenance
• Strategic direction and oversight
• Continual review and refinement
• NIMS Integration Center

Components of NIMS
Download NIMS guidance document at NIMS web page
www.fema.gov/nims
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Supporting Organizations
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HEICSThe Hospital Emergency IncidentCommand
System

• HEICS is an emergency management system which
  employs a logical management structure, defined
  responsibilities, clear reporting channels, and a
  common nomenclature to help unify hospitals with
  other emergency responders.
• The Hospital Emergency Incident Command System
  is the standard by which the medical community
  has found success and common ground in the area
  of disaster management.

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HEICSThe Hospital Emergency IncidentCommand
System

• HEICS is fast becoming the standard for health
  care disaster response and offers the following
  features
• predictable chain of management
• flexible organizational chart allows
• flexible response to specific emergencies
• prioritized response checklists
• accountability of position function

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Because of the numbers and kinds of emergencies
that can impact a hospital, most begin planning
with a basic infrastructure...
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Incident CommandCommand CenterDefines the
mission and ensures its completion.
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Logistics
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LogisticsProvides for a working environment and
adequate materials to meet the overall medical
objective.
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Planning
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PlanningDetermines and provides for the
continuance of each medical objective. Prompts
and drives all HEICS officers to develop short-
and long-range action plans.
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Finance
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FinanceProvides funding for present medical
objective and stresses facility-wide
documentation to maximize financial recovery and
reduction of liability.
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Operations
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OperationsCarries out the medical objective to
the best of the hospitals ability.
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Review - Incident Command

• Strengths
• Organized and systematic chain of command
• Clear objectives for individual participants
• Uniform terminology for identifying resources and
  organizational functions
• Mutually recognized structures for all levels
• Institutional
• Local
• State
• National

• Weaknesses
• Lack of understanding of modular organizational
  structure (command structure and roles)
• Poor adherence to assigned roles
• Ineffective resource mobilization
• Inconsistency between various agencies
• Ineffectiveness in integrating non-governmental
  agencies (relief agencies and NGOs)

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Review - Incident Command

• Opportunities
• Promoting ICS as the standardized model of
  management
• Implement an ongoing systems evaluation process
• Promote multi-disciplinary drilling and
  preparation

• How do we do this?
• Review ICS structure
• Review hospital based ICS structure
• Educate pre-hospital personnel
• Educate hospital personnel
• Educate and train the trainers well!

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ReviewMethodology
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Review

• Concept Train the Trainers
• Used in
• Medicine
• Education
• Business
• Goal enabling teachers (you) to develop their
  ability to help students (providers) to learn

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Review - Training

• Strengths
• Ability for trainers to help their students to
  learn
• Pay it forward theory exponential growth - 1
  course teaches 5 instructors who implement it to
  100 students
• Well developed methodology in medicine, education
  and business

• Weaknesses
• Difficult to assure standardized quality
• Variability in downstream effects - teaching,
  transmitting info quickly, effectively and
  efficiently to target audience
• Difficult to evaluate - no test on teaching
• Rely on feedback from participants

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Review - Training

• Opportunities
• Training the trainers - courses like this one
• Giving the people who will be directly teaching
  scenarios the educational tools to succeed
• Potential to have hundreds trained from one
  course

• How do we do this?
• Train small group of people well
• Easily understandable and reproducible clinical
  scenario
• Organized, standardized table top type of
  exercise
• Effective teaching materials - written and
  multimedia
• Encourage Feedback

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ReviewClinical Scenario
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Clinical Scenario
Learning Objectives

• Identify some of your organizations current
  strengths and gaps
• Review and list the various roles, functions, and
  procedures involved in ICS activation
• Identify issues relevant to mass victim
  scenarios, e.g., policies, resources,
  communication, coordination, data management, and
  mental health needs

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Clinical Scenario
Purpose of Real Time Drills

• Emphasis on training and learning, not
  testinghelps prepare participants for a
  full-scale or functional exercise
• Evaluation of current systems, response plans
• Provides practice for integrating pre-hospital to
  hospital communications and operations

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Clinical Scenario
Exercise Logistics

• Suggested Schedule
• Introduction (5 minutes)
• Exercise (40 minutes)
• Debriefing (15 minutes)
• Roles
• Participants
• Facilitator
• Note taker
• (Observers)

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Clinical Scenario
Instructions to Remember

• Assume scenario is real make best decisions
  based on available information
• Play your department, agency, or community role
  throughout the exercise
• Consider policy issues as well as specific
  procedures
• Focus on identifying system gaps and strengths
  rather than individual knowledge
• Take notes for the debriefing discussion(e.g.,
  gaps/strengths in resource planning,
  communication, information management)

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Clinical Scenario
Day 1 Tuesday, August 17, 2004 The Setting

• Evergreen County
• Population 2 million residents
• Tourists approximately 8.5 millionovernight
  visitors per year
• Evergreen Square Mall
• 1.3 million sq. ft.
• Approximately 44,000visitors per day

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Clinical Scenario
Day 1 Tuesday, August 17, 2004 Suspicious
Behavior
Sarah Jones and her sister observe a
suspicious-looking man spraying some material in
the corridors and food court area at Evergreen
Square Mall.

• He is wearing a cap and sunglasses and using a
  hand-held aerosol dispersion device.

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Clinical Scenario
Day 1 Tuesday, August 17, 2004 Alerting
Authorities

• The women file a report with a mall security
  guard, noting the suspicious behavior, and
  promptly leave the premises.
• The suspect, having fled the scene, cannot be
  apprehended for questioning.
• The mall security guard initiates investigation
  and notifies law enforcement officials.

• Surveillance cameras verify the womens report of
  suspicious behavior.

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Clinical Scenario
Day 1 Tuesday, August 17, 2004 Initial Response

• The HAZMAT team and law enforcement officials
  arrive on the scene and secure the area.

• Handheld assays yield preliminary results within
  two hours, suggesting that an anthrax exposure
  has occurred.

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Clinical Scenario
Day 1 Tuesday, August 17, 2004 Situation
Develops

• Samples of the agent are collected for more
  sensitive and specific confirmatory testing at
  the state lab. Results will take1-2 days.
• Shoppers leave Evergreen Square Mall with their
  purchases, many eager to sharenews of the
  commotionwith friends and family.

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Clinical Scenario
Day 2 Wednesday, August 18, 2004 Confirmatory
Results

• The state lab confirms anthrax as agent in
  question.

• The local health officer (LHO)activates the
  Public HealthEmergency Operations Plan.
• Emergency Operations Center (EOC) activates.
• The LHO evaluates the need for mass dispensing
  operations and SNS resources.

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Clinical Scenario
Day 4 Friday, August 20, 2004 Initial Contact

• The family of Alisa Brown, a 33 year old clerk,
  calls 911 with a complaint of the patient having
  abdominal pain.
• Upon arrival, EMS providers find the patient
  feverish, with abdominal pain, vomiting and
  diarrhea.
• Mrs. Browns elderly mother-in-law and 2 year old
  daughter will accompany her to the hospital.

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Clinical Scenario
Day 4 Friday, August 20, 2004 Initial Response

• EMS RESPONSE
• Personal Protective Gear
• Universal Precautions
• Further patient history
• Initiate medical treatment and transport to the
  hospital
• Medical Control

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Clinical Scenario
Day 4 Friday, August 20, 2004 Hospital -
Arrival

• INITIAL ER RESPONSE
• Mrs. B and her 2 family members arrive at the
  hospital and are placed in a treatment room.
• Grandma Brown gives a history of being at the
  shopping mall a few days ago when all the
  commotion broke out.
• Grandmother and child appear to have localized
  raised rashes on hands arms and neck with severe
  itching.

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Clinical Scenario
Questions

• Would you notify the local health department?
• Would you notify the Public Health Emergency
  Operations Center?
• Is there a need to communicate any information to
  response partners, hospitals, the public?

Note Consider using HEICS Activity Log Sheet at
this time
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Clinical Scenario
Day 5 Saturday, August 21, 2004 Situation
Expanding

• The local EOC reports to your hospital that
  several surrounding EDs are seeing 10-12
  patients each with signs of cutaneous and
  gastrointestinal anthrax.
• A quick review patient charts in the waiting room
  reveals 6-7 more patients with suspicious
  presenting symptoms.

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Clinical Scenario
Assessment and Notifications
Questions

• What are priority actions for local EMS systems
  at this time?
• What are priority actions for hospitals at this
  time?

Note Consider using HEICS Activity Log Sheet at
this time
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Clinical Scenario
Day 5 Saturday, August 21, 2004 Recognition

• The hospital administrator decides to initiate
  the HEICS disaster plan
• The incident commander is notified of the
  increasing volume of patients in ED as well as in
  the surrounding hospitals
• The ED attending MD relays treatment plans for
  exposed patients according to systems affected

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Clinical Scenario
Questions

• Where is the best staging and patient care areas
  for potentially exposed /affected patients?
• What additional information should be relayed to
  the hospital incident commander?
• What types of security measures would you need to
  plan for in the pre-hospital arena?
• What types of security measures would you need to
  plan for at the hospital?

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Clinical Scenario
Day 6 Sunday, August 22, 2004 Day Six

• After 24 hours, 72 cases of affected or exposed
  patients have been reported to the Local Health
  Officer
• EOC reports an onslaught of 911 calls
• Worried well are showing up at EDs through the
  metro area in droves. Your ED daily census is
  double its usual
• The media is giving the story heavy media play

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Clinical Scenario
Day 6 Sunday, August 22, 2004 Panic

• One patient becomes very agitated when he is
  informed that he did not meet the criteria for
  credible exposure, but he is demanding that he
  receive the medication.
• Several other patients in the waiting area are
  becoming anxious just observing this individual.

Staff and patients exhibit signs and symptoms of
stress during this incident
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Clinical Scenario
Day 6 Sunday, August 22, 2004 Panic

• Ambulance personnel report being prohibited from
  leaving response scenes and of being swamped on
  the street by people demanding care

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Clinical Scenario
Questions - Patient Anxiety

• How would you handle these patient scenarios?
• What kinds of mental health problems would you
  need to plan for in the pre-hospital arena?
• What kinds of mental health problems would you
  need to plan for at the hospital?

Note Consider using HEICS Activity Log Sheet at
this time
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Clinical Scenario
Questions - Security

• What types of security measures would you need to
  plan for in the pre-hospital arena?
• What types of security measures would you need to
  plan for at the hospital?

Note Consider using HEICS Activity Log Sheet at
this time
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Clinical Scenario
Questions - Data Management

• What types of data should be collected for
  surveillance?
• Where can a health care provider go to get the
  latest information on anthrax?

Note Consider using HEICS Activity Log Sheet at
this time
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Clinical Scenario
Questions - Demobilization

• Who makes the decision to return to normal
  operations and to discontinue the NIMS/HEICS
  plans?
• Who should provide input into this decision?
• What criteria should be considered?

Note Consider using HEICS Activity Log Sheet at
this time
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Review - Clinical Scenario

• Strengths
• Modular organizational structure
• Defines common goals
• Able to examine the relationships in different
  stages of the care process
• Able to give real time feedback
• Able to evaluate using pre-post test questions.

• Weaknesses
• Variable quality in teaching
• Variable quality in assessment
• Difficult to evaluate communication between
  players

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Review - Clinical Scenario

• Opportunities
• Turning down time into clinical learning time
• Better learning assessment instruments for use in
  clinical settings
• Capitalize on information technology resources

• How do we do this?
• Routine scheduling of clinical scenario practices
• Regularly scheduled review and updating scenarios
• Develop training personnel for wide spread
  educational opportunities

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Wrap Up Slide!

• Special Thanks to
• You - participants!
• MCHC
• University of Chicago Hospitals
• Dr. Cai Glushak, MD
• Dr. Sonja Callejas, MD
• Dr. Jim Walter, MD
• Unique Washington, U of C
• Donna Jasutis, U of C

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References

• CDC,UpdateInvestigation of Bio-Terrorism related
  Anthrax and Interim Guidelines for Exposure
  Management and Anti-microbial Therapy, October
  2001. MMWR 2001 Vol.50909-919
• Cheah,J.Development and Implementation of a
  Clinical Pathway Programme in an Acute Care
  General Hospital in Singapore.International
  Journal for Quality in Health Care
  2000Vol.12,No.5403-412
• Cole,D. The incident command system a 25 year
  evaluation by California practitioners, February
  2000. An applied research project of the National
  Fire Academy Executive Fire Officer Program
• Friedewald,V. Medscape personal
  professorAnthrax.www.medscape.com, October 2003
  Millard, L. Teaching the teachers ways of
  improving teaching and identifying areas for
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• Gordon,J., Hazlett,C.,ten Cate,O., Mann,K.,
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• Inglesby,T.,Otoole,T., Henderson,D.,
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  Friedlander,A.,Gerberding,J., Hauer,J.,
  Hughes,J., McDade,J., Osterholm,M.,
  Parker,G.,Perl,T., Russell,P., Tonat,K. Anthrax
  as a Biological Weapon,2002. Update
  recommendations for Management. JAMA,May1,2002,
  Vol.287,No.172236-2252
• Walsh et al. National Incident Management
  System. Jones/Bartlett. 2005

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Acknowledgements

• Andy Stergachis, PhD, RPh, Northwest Center for
  Public Health Practice
• Jeff Duchin, MD, Chief, Communicable Disease
  Control, Public Health Seattle King County
• Michael Loehr, Section Manager, Public Health
  Seattle King County
• Dean Webb, RPh, Chief of Pharmacy, Public Health
  Seattle King County
• Yuzo Arima, MPH Candidate, University of
  Washington
• Kate Wetmore, MPH Candidate, University of
  Washington
• Dave Owens, State Strategic National Stockpile
  Coordinator, Department of Health, State of
  Washington
• UW and NWCPHP Faculty and Staff Randy Beaton,
  PhD, Bryant Karras, MD, Marcus Nemuth, MD, Judith
  Yarrow, MA, and Connie Curran, MA
• Online CDC.gov, NIMSONLINE.com, FEMA.gov