Hospital Emergency Preparedness

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Hospital Emergency PreparednessWhere we have
been and Where We are Going

• Greg Carter
• Director, Infection Control
• BT Coordinator,
• Reid Hospital Health Care Services

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OUTLINE

• I. Pre and Post 9/11 Hospital Emergency
  Preparedness and Command Structure.
• A. Pre 9/11
• B. Post 9/11
• Overview of Hospital Pandemic Preparedness

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OBJECTIVES

• Identify and evaluate hospital emergency
  preparedness, pre and post 9/11, and a need for a
  unified command structure.
• Identify need for a hospital Pandemic Influenza
  Plan.

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Internal/External Disasters
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The term hospital preparedness is a catch-all
phrase, covering a multitude of medical and
non-medical disaster management.Healthcare
Organizations such as (JCAHO), (HFAP), (Federal
state licensing agencies) mandates specific
standards for hospital preparedness.
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Hospitals now receive Federal Grant money
specifically for hospital emergency preparedness.
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While each institution is mandated to develop
their emergency plans, they have to develop these
plans using specific elements which are
universally applicable and accepted by multiple
agencies all using a common language.
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Prior to September 11, 2001, hospital
preparedness focused on either natural or
unintentional man-made mass accidents.Each
hospitals plan was very generalized and usually
not communicated and/or shared with other
healthcare institutions along with federal,
state, or local agencies.
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Most agencies were not free with sharing
information and did not work well together, even
within their own agency, much less with
others!Turf Wars
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Since 9/11, the reality of U.S. vulnerability
from terrorism has translated into an increased
sense of urgency to prepare for potential
attacks.
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A hospitals principal concern now focuses around
determination of adequate capabilities.
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Pre 9/11
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Pre 9/11

• Few Hospitals and other health related facilities
  had no comprehensive emergency management plan
  addressing terrorism, bioterrorism and pandemics.
  Mainly natural disasters.
• Little or no communications with outside agencies
  such as fire departments, law enforcement, FBI,
  etc.,
• Very few hospital employees trained on incident
  command and unified command structure and
  language.

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Pre 9/11

• Many of us thought things like terrorism,
  bioterrorism, and pandemics were things that
  happened over there, or we read about it in
  Sci-Fi books.
• Things the military, CDC, or WHO took care of.

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Pre 9/11

• Fire, ambulance and law enforcement always
  responded to incidents involving mass casualties,
  whether natural or man-made and we sat home
  watching it on TV.
• Most communities rarely experienced an incident
  that overwhelmed their resources or tested other
  aspects of their disaster response planning and
  training.

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9/11/01ChangedEverything !
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From the Manual of Afghan Jihad

• In every country, we should hit their
  organizations, institutions, clubs and
  hospitals, The targets must be
• identified, carefully chosen and include their
  largest gatherings so that any strike should
  cause thousands of deaths.
• From an Associated Press article Feb 2, 2002
  Author Hamza Hendawi

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Sarin Gasin Subways
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AnthraxinFlorida and NYC
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Post 9/11
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After the terrorist attacks of September 11,
2001, al-Qaeda (or al-Qa'ida, pronounced
al-KYE-da) surpassed the IRA, Hamas, and
Hezbollah as the world's most infamous terrorist
organization. Al-Qaeda"the base" in Arabicis
the network of extremists organized by Osama bin
Laden.
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Post 9/11

• The escalating threat of terrorism means that
  more than ever, all emergency services along with
  public health, hospitals, and emergency
  management officials must collaborate to develop,
  train, and rehearse emergency and mass casualty
  plans that address the possible use of chemical,
  biological, radiological, and/or explosive
  weapons of mass destruction.

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BIRDFLU
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Appendix 2. Hospital Preparedness
ChecklistPreparedness Subject Actions Needed1.
Structure for planning and decision making   An
internal, multidisciplinary planning committee
for influenza preparedness has been created.  
A person has been designated as the influenza
preparedness coordinator.(Insert name)  
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2. Development of a written pandemic influenza
plan  A written plan has been completed or is in
progress that includes the elements listed in 3
below.   The plan specifies the circumstances
under which the plan will be activated.   The
plan describes the organization structure that
will be used to operationalize the plan.  
Responsibilities of key personnel related to
executing the plan have been described.   A
simulation exercise has been developed to test
the effectiveness of the plan.   A simulation
exercise has been performed.(Date performed
_______________________)
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3. Elements of an influenza pandemic plan
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A surveillance plan has been developed.
Syndromic surveillance has been established in
the emergency room. Criteria for distinguishing
pandemic influenza is part of the syndromic
surveillance plan. Responsibility has been
assigned for reviewing global, national,
regional, and local influenza activity trends and
informing the pandemic influenza coordinator of
evidence of an emerging problem. (Name
___________________________) Thresholds for
heightened local surveillance for pandemic
influenza have been established. A system has
been created for internal review of pandemic
influenza activity in patients presenting to the
emergency department. A system for monitoring
for nosocomial transmission of pandemic has been
implemented and tested by monitoring for
non-pandemic influenza.  
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A communication plan has been developed.
Responsibility for external communication has
been assigned. Person responsible for updating
public health reporting __________________________
__ Clinical spokesperson for the facility
____________________________ Media spokesperson
for the facility ____________________________
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Key points of contact outside the facility have
been identified. State health department contact
   ___________________________________________
Local health department contact  
___________________________________________
Newspaper contact(s)                
___________________________________________
Radio contact(s)                         
___________________________________________
Public official(s)                          
___________________________________________
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A list of other healthcare facilities with whom
it will be necessary to maintain communication
has been established. A meeting with local
healthcare facilities has been held to discuss a
communication strategy. A plan for updating key
facility personnel on a daily basis has been
established. The person(s) responsible for
providing these updates are
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A system to track pandemic influenza admissions
and discharges has been developed and tested by
monitoring non-pandemic influenza admissions and
discharges in the community. A strategy for
regularly updating clinical, ED, and outpatient
staff on the status of pandemic influenza, once
detected, has been established. (Responsible
person ____________________) A plan for
informing patients and visitors about the level
of pandemic influenza activity has been
established.
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An education and training plan on pandemic
influenza has been developed. Language and
reading level-appropriate materials for educating
all personnel about pandemic influenza and the
facilitys pandemic influenza plan, have been
identified. Current and potential sites for
long-distance and local education of clinicians
on pandemic influenza have been identified.
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Means for accessing state and federal web-based
influenza training programs have been identified.
A system for tracking which personnel have
completed pandemic influenza training is in
place. A plan is in place for rapidly training
non-facility staff brought in to provide patient
care when the hospital reaches surge capacity.
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The following groups of healthcare personnel have
received training on the facilitys influenza
plan Attending physicians House staff Nursing
staff Laboratory staff Emergency Department
personnel
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Outpatient personnel Environmental Services
personnel Engineering and maintenance personnel
Security personnel Nutrition personnel
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A triage and admission plan has been developed.
A specific location has been identified for
triage of patients with possible pandemic
influenza. The plan includes use of signage to
direct and instruct patients with possible
pandemic influenza on the triage process.
Patients with possible pandemic influenza will
be physically separated from other patients
seeking medical attention.
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A system for phone triage of patients for
purposes of prioritizing patients who require a
medical evaluation has been developed. Criteria
for determining which patients need a medical
evaluation are in place. A method for tracking
the admission and discharge of patients with
pandemic influenza has been developed. The
tracking method has been tested with non-pandemic
influenza patients.
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A facility access plan has been developed.
Criteria and protocols for closing the facility
to new admissions are in place. Criteria and
protocols for limiting visitors have been
established. Hospital Security has had input
into procedures for enforcing facility access
controls.
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An occupational health plan has been developed.
A system for rapidly delivering vaccine or
antiviral prophylaxis to healthcare personnel has
been developed. The system has been tested
during a non-pandemic influenza season. A method
for prioritizing healthcare personnel for receipt
of vaccine or antiviral prophylaxis based on
level of patient contact and personal risk for
influenza complications has been established.
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A system for detecting symptomatic personnel
before they report for duty has been developed.
This system has been tested during a
non-pandemic influenza period. A policy for
managing healthcare personnel with symptoms of or
documented pandemic influenza has been
established. The policy considers When
personnel may return to work after having
pandemic influenza
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When personnel who are symptomatic but well
enough to work, will be permitted to continue
working A method for furloughing or altering the
work locations of personnel who are at high risk
for influenza complications (e.g., pregnant
women, immunocompromised healthcare workers) has
been developed. Mental health and faith-based
resources who will provide counseling to
personnel during a pandemic have been identified.
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A vaccine and antiviral use plan has been
developed. A contact for obtaining influenza
vaccine has been identified.(Name)
__________________________________________________
__ A contact for obtaining antiviral prophylaxis
has been identified.(Name) ______________________
______________________________
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A priority list (based on HHS guidance for use of
vaccines and antivirals in a pandemic when in
short supply) and estimated number of patients
and healthcare personnel who would be targeted
for influenza vaccination or antiviral
prophylaxis has been developed.
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Number of first priority personnel       
_____________ Number of second priority
personnel   _____________ Number of remaining
personnel           _____________ Number of
first priority patients           _____________
Number of second priority patients     
_____________ A system for rapidly distributing
vaccine and antivirals to patients has been
developed.
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Issues related to surge capacity have been
addressed. A plan is in place to address unmet
staffing needs in the hospital. The minimum
number and categories of personnel needed to care
for a group of patients with pandemic influenza
has been determined. Responsibility for
assessing day-to-day clinical staffing needs
during an influenza pandemic has been assigned.
Persons responsible are (names and/or titles)
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Legal counsel has reviewed emergency laws for
using healthcare personnel with out-of-state
licenses. Legal counsel has made sure that any
insurance and other liability concerns have been
resolved. Criteria for declaring a staffing
crisis that would enable the use of emergency
staffing alternatives have been defined.
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The plan includes linking to local and regional
planning and response groups to collaborate on
addressing widespread healthcare staffing
shortages during a crisis. A priority list for
reassignment and recruitment of personnel has
been developed. A method for rapidly
credentialing newly recruited personnel has been
developed.
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Mutual AID Agreements (MAAs) and Memoranda of
Understanding/Agreement (MOU/As) have been signed
with other facilities that have agreed to share
their staff, as needed.
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Strategies to increase bed capacity have been
identified A threshold has been established for
canceling elective admissions and surgeries MOAs
have been signed with facilities that would
accept non-influenza patients in order to free-up
bed space Areas of the facility that could be
utilized for expanded bed space have been
identified
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The estimated patient capacity for this facility
is ________ Plans for expanded bed capacity have
been discussed with local and regional planning
groups
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Anticipated durable and consumable resource needs
have been determined A primary plan and
contingency plan to address supply shortages has
been developed Plans for obtaining limited
resources have been discussed with local and
regional planning and response groups.
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A strategy for handling increased numbers of
deceased persons has been developed. Plans for
expanding morgue capacity have been discussed
with local and regional planning groups.
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Local morticians have been involved in planning
discussions. Mortality estimates have been used
to estimate the number of body bags and shrouds.
Supply sources for postmortem materials have
been identified.
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A strategy for housing healthcare personnel who
may be needed on-site for prolonged periods of
time is in place. A strategy for accommodating
and supporting personnel who have child or elder
care responsibilities has been developed.
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Pandemic Influenza is not a matter of if, but of
when!
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Post 9/11

• One of the challenges our hospitals face today is
  integrating a wide range of topics into our
  emergency plans which have gone from a Gee Whiz
  attitude to more of a Need to Know, Need to
  Plan, Need to Par-Up on supplies Need to
  Share, Need to Exercise mentality.
• Need to get our act together!

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Hospitals now have evidence-based tools to help
prepare and evaluate their disaster plans, and
training drills that we didnt have available
before.These tools help hospitals identify
strengths and weaknesses in their plans and
responses during a disaster drill and improve
their ability to fulfill required emergency
management plans.These tools help focus on what
works best under what circumstances for your
particular institution and geographic location.
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Key Lessons Learned

• Identify clear objectives
• Bring all players together
• Build professional and community relationships

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Identify Clear Objectives

• Readiness efforts
• Incident Command and unified command structure
  educated to administration and staff
• Staffing during different surge levels and during
  high absentee levels
• Cross training staff for emergency situations
• Treatment capacity
• Stockpiling of resources
• Communications
• Security
• Mass Prophylaxis vaccination
• Bed utilization
• Emergency department overcrowding
• Emergency Medical Services
• Administrative support is key to readiness

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Readiness Efforts

• Use assessment tools to evaluate your current
  state of readiness (Hazardous vulnerability
  assessment or HVA)
• Make sure assessment tools are nationally
  recognized tools
• Gather evidence that the current data you are
  using predicts your true preparedness structure
• Develop generally accepted scenarios to exercise
  your base of preparedness

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Readiness Efforts

• Establish Plans which measure Bioterrorism
  preparedness
• Establish Plans which measure Pandemic
  preparedness.
• Establish Plans which measure Dirty Bomb
  preparedness
• Establish Plans which measure Explosive devices
  (IED) preparedness
• Establish Plans which measure Radiological
  exposure preparedness

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Bring all Players Together, Professional and
Community

• JCAHO Emergency Preparedness standard 1.6
• Alternate roles and responsibilities of
  personnel during emergencies, including who they
  report to within a command structure that is
  consistent with that used by the local community

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Developing a solid unified command structure is a
must!
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Hospital Incident Command System (HICS)Hospital
Emergency Incident Command System(HEICS)
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Hospital Incident Command System (Structure)

• Hospital Incident Command System (HICS) Use to
  be known as Hospital Emergency Incident Command
  System (HEICS)
• Emergency management system unifies hospitals
  with other emergency responders like never before.

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Why HICS

• Unified Chain of Command
• Common Terminology
• Flexible
• Unifies hospitals with other emergency responders
• So hospitals can maintain their federal funding

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HICS Organizational Chart
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Emergency Operations Center

• Location
• Supplies
• Operating
  protocols
• Communications

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Purpose of HICS Structure

• Limits span of control
• Distributes work
• System of documentation and reporting
• Lessens liability
• Promotes financial recovery

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HICSis a POSITIONnot Persondriven system.
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Five Basic Disaster Management Functions

• Incident Command
• Finance
• Operations
• Logistics
• Planning

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Logistics Section

• Mission
• Provide an environment and materials for the
  overall medical objective or incident needs.

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Planning Section

• Mission
• Develops the action plan to accomplish the
  medical objectives, collects and evaluates
  information, maintains the status of resources

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Finance Section

• Mission
• Provide funding for present objectives, and
  stress facility wide documentation for later
  financial recovery.

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Operations Section

• Mission
• Conducts Medical Operations to carry out action
  plan. Directs all direct patient care resources.

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Job Action Sheets (JAS)

• One for each of 57 positions
• Focused objectives
• Concise mission statement
• Prioritized activities
• Intended to be customized

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Position Vests

• Valuable for Identification

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Tools - Functional

• Disaster Carts strategically located to include
• Vests for each position
• Color coded clips boards
• HEICS/HICS organizational charts
• Emergency Preparedness Manual located on Intranet
  and hard copy form.

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HEICS/HICS Forms

• Activity Log
• Section Personnel Time Sheet
• Procurement Summary Report
• Volunteer Staff Registration
• Facility Systems Status Report

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Supporting Forms

• Forms Help Drive Positions
• Aid in Documentation

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Activity log
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Action Plan
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HEICS/HICS Attributes

• Dependable chain of command
• Common language for communication
• for simple to complex
  incidents
• Prioritization of duties via Job Action Sheets
• Organized documentation for improved financial
  recovery

Flexibility
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Building the Relationship with Multi Agency
Partners

• Multi-agency Coordination System
• Coordinates and supports emergency incident and
  event management through the development and use
  of integrated multiagency coordination systems
  (MACs). That is, develop and coordinate
  connectivity capability with Hospital Command
  Center (HCC) and local Incident Command Posts
  (ICPs), local 911 centers, local Emergency
  Operations Centers (EOCs), the state EOC and
  others as applicable. (i.e., local EOC, public
  health, EMS, law enforcement, and others as
  appropriate).

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Not Partnering in your Planning Process May
Result in

• Failure to operate
• Failure to communicate
• Failure to handle surge
• Failure to sustain
• Failure to Recover

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Lessons Learned-Katrina
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SUMMARY of HICS/HEICS

• You have been introduced to the Hospital
  Incident Command System (HICS). It is time for
  you to look at how you will interface with this
  new command structure in your institution.

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Internet References to HICS

• http//www.emsa.ca.gov/hics/hics.asp
• http//mmrs.fema.gov/news/threats/2006/oct/nthr200
  6-10-20b.aspx
• http//www.fema.gov/txt/emergency/nims/imp_act_hos
  .txt
• http//www.fema.gov/pdf/emergency/nims/imp_act_hos
  .pdf
• http//www.fema.gov/kids/tch_ex1.htm
• http//www.pandemicflu.gov/

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THE END

• Any Questions?