Cover Slide Title

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KEEPING PEOPLE SAFE DECONTAMINATION PROGRAM
ACCESS MANAGEMENT

Keith Frost Mark St. Marie           
  Robert Porter            
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KEEPING PEOPLE SAFE

• Overview
• Planning for a Mass Causality Incident
• Decontamination Program Strategies
• Access Management Strategies
• OSLE / VACO Initiatives

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MCI Planning Response

• The Old Paradigm
• Clinically focused response
• Trauma patient focus
• Emergency Department involvement only

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MCI Planning Response

• The New Paradigm
• All-Hazards Hospital-Based Response
• Protect the Facility/Control Access
• Isolate, Decontaminate, Treat
• Anticipate large numbers of non-trauma cases
• Maximize use of all available resources

5
Disaster Planning Response

• Disaster planning is only as good as the
  assumptions on which it is based.
• Those who ignore history are
• doomed to repeat it.

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Evidence Based Disaster Planning

• Typical Assumptions
• VAMCs are low priority for local planners
• VAMCs will give Veterans priority
• Dispatchers will send correct units to scene
• Patients will be
• triaged stabilized by EMS
• decontaminated on scene if necessary
• distributed equally to receiving hospitals

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Evidence Based Disaster Planning

• Reality
• Atypical Dispatch
• Unsolicited responders
• Notified by news reports or scanners
• Poor communication
• Difficult to coordinate responders
• Initial care from bystanders
• Many pts not transported by EMS

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Evidence Based Disaster Planning

• Many pts not transported by EMS
• Initial arrival mode - 29 US Disasters

Quarantelli, EL Delivery of Emergency Services in
Disasters Assumptions and Realities
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Evidence Based Disaster Planning

• Many pts not transported by EMS
• Oklahoma City Bombing

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Evidence Based Disaster Planning

• Many pts not transported by EMS
• Sarin Gas Attack (St. Luke Hosp, Tokyo)

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Evidence Based Disaster Planning

• Casualty Maldistribution
• Study of 29 U.S. Disasters
• 75 of disasters, gt1/2 casualties taken to
  closest hospital
• 46 of disasters, gt3/4 casualties to closest
  hospital
• Unused hospitals average vacancy 20

Quarantelli, EL Delivery of Emergency Services in
Disasters Assumptions and Realities
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Disaster Casualty Severity

• Minor injuries arrive first
• Casualty flow begins within 30 minutes
• Sheer number of patients can
• overwhelm system
• impair identification of critical patients
• impair treatment of critical patients
• Most casualties at hospitals within 1½ hrs
• Second wave of more critical patients
• (i.e. Second wave phenomenon)

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Casualties Severity

• Oklahoma City Bombing (1995)

n587
Mallonee s et al. JAMA 1996276382-7
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Casualty Severity

• WTC Bombing (2001)
• n 790 Among 5 Hospitals closest to WTC

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Evidence Based Disaster Planning
Hospital Mass Causality Incident (MCI)
Resource Available
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Do I Really Need Decon?

• YES...
• The Care Imperative
• WMD, Common events (transportation, industrial,
  lab)
• The Regulatory Imperative
• JC, OSHA
• The Financial Imperative
• VACO, State and Federal grants
• The Publicity Imperative
• VAMC in the News

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The Care Imperative

• THREATS
• Weapons of mass destruction
• Transportation accidents
• Industrial accidents
• Internal spills (lab, chemo, radioactives)

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The Regulatory Imperative

• Joint Commission (JC)
• Health Care at the Crossroads, 2003
• Emergency preparedness as key goal
• Must have an appropriate decon capability
• 2008 Environment of Care Standards
• Protect employees, facility, patients
• OSHA
• First Receivers Best Practices

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The Financial Imperative

• Must Participate to Receive Funding
• VACO Funding
• Portable Decon Systems
• Fixed Decon Facilities
• PPE, Supplies
• Federal and State Funding
• HRSA
• CDC (Focus D) money

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The Publicity Imperative

• Public drills look good
• Working with the Community and other Hospitals
• Doing something to protect facility
• Visitors, Staff, Infrastructure
• Doing something to avoid bad publicity
• Public evasion looks bad

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How Do I Get It Done?
Relevant
Road Map to a Successful
Regulatory
Realistic

Decon Access Management Program
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VHA DECON PROGRAM

• RELEVANT
• Extension of the Medical Center
• Clinical presence on decon team is a must!
• Decon exists to protect visitors, staff and
  facility
• Designated Job Assignments
• Role Responsibilities well defined
• ICS and EM Committee representation
  
• All-Hazards Team Approach Incentive
• Patient Evacuation Team
• Alternate Care Surge Set-up

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VHA DECON PROGRAM

• REGULATORY
• Awareness Operations Level Training
• 1910.120 HAZWOPER
• First Receiver Capabilities
• OSHA First Receiver Best Practices
• 50 Core Competencies
• VHA Directive 0320
• Facilities must have an appropriate Decon
  capability
• Joint Commission
• Expansion of EM standards

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VHA DECON PROGRAM

• REALISTIC
• Hazard Vulnerability Analysis (HVA)
• HVA should drive level of Decon capability
• 24/7 Capability
• Local Community Coordination
• What are the expectations of VAMC?
• Familiarize Staff with MMRS language
• Exercise Frequency
• Minimum 2 full operational exercises annually
• More frequent focused drills strong team
• Involve ER and VA Police

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VHA DECON PROGRAM
One contaminated patient could close
your Emergency Department and/or Hospital
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Office of Security
Law Enforcement

• Perimeter Protection-Authorities
• Secretary responsible for protecting life and
  property within the jurisdiction of the
  Department (38 USC 901)
• Office of Security and Law Enforcement (OSLE) is
  the Department program office for VA Police
  activities
• VA Police officers in VHA are the response and
  operational forces

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Office of Security
Law Enforcement

• Perimeter Protection-Operations
• Law and regulation authorize Directors to close
  facilities to the public
• Lock down procedures are dependent on the layout
  of the facility (single building large campus
  store-front, etc.)
• VA Police policy is that VA needs take priority
  over the needs of the general public in an
  emergency
• In a decon event, VA police will staff entry
  control points and triage locations.
• Facility entry will generally be limited to VA
  staff and contractors.
• VA police officers are the first line of response
  and defense in the event of a major incident or
  emergency.
• However, the reality is that a panicked and upset
  population will seek care wherever they can,
  including VA and other Federal activities

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Office of Security
Law Enforcement

• Use of Force Issues
• VA doctrine mirrors the U.S. Department of
  Justice Use of Deadly Force policy
• VA Police officers may only use deadly force to
  protect themselves or others from imminent danger
  of death or serious bodily injury
• These rules apply in both routine and emergency
  situations
• VA officers are trained annually on use of force
  law and policy and rules.

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Office of Security
Law Enforcement

• Emergency and Decon Scenarios-Training and
  Preparation
• Specific response actions, based on the National
  Threat System (color codes) are promulgated from
  OSLE
• These actions are modified at field facilities to
  meet local needs
• Threat response for Code Yellow to Code Red
  include increasing levels of identification
  checks package and appurtenance searches
  limiting vehicle and pedestrian traffic
• VA police also participate in local facility
  emergency response planning and exercises

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Office of Security
Law Enforcement

• Emergency and Decon Scenarios-Training and
  Preparation
• VA Chiefs of Police participate in local planning
  bodies and Joint Terrorism Task Forces (JTTF)
• Facilities are required to maintain active
  sharing agreements and MOUs with state, local
  and Federal law enforcement.
• OSLE, working with and through DEMPS can augment
  VA police resources at impacted facilities

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Office of Security Law
Enforcement

• Vulnerability Assessments
• Required biennially
• Comprehensive, all hazards approach
• All Department-owned or operated facilities
• Use to develop mitigation plans

• Physical Security Surveys
• Focused on protecting specific key activities
• Used to develop and track mitigation plans
• Part of the overall vulnerability assessment
  approach

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OSLE Initiatives

• OSLE is continuing development of a quick
  response team (key goal in FY 09)
• 100 volunteer officers, arranged into 4
  25-officer teams with regional responsibilities
• Training to include small team defense tactics
  PPE use physical security anti-terrorism/force
  protection
• To be used for
• Security and stabilization of seriously impacted
  facility (e.g. VAMC New Orleans)
• Augment police forces with severe staffing issues
  or short term needs
• FMS protection
• ESF-13 assignments

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OSLE Initiatives

• Response time is 12-18 hours from initial
  deployment order
• Team management includes OSLE Inspectors

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VACO/LETC Initiatives

• Personal Protective Equipment for VA Police
• 3M Rapid Response Powered Air Purifying
  Respirators
• Begin Deploying April 09
• Vendor Training for VA Police
• Enrollment in RP Programs
• Reoccurring Officer Training

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QUESTIONS?
KEEPING PEOPLE SAFE VHA DECONTAMINATION PROGRAM
ACCESS MANAGEMENT

Keith Frost Mark St. Marie           
  Robert Porter