Disaster Managing Efforts Discussion Board Question

Image source: www.ucdenver.edu Emergency Management Update Team 2016- 1 © Copyright, The Joint Commission Emergency Management Debrief Lessons Learned Planning & Le

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adership Emergency Program Emergency Management Update Team 2016- 2 © Copyright, The Joint Commission EMERGENCY MANAGEMENT CHAPTER OUTLINE  Foundation for the Emergency Operations Plan [EM.01.01.01]  The Emergency Operations Plan (EOP) General Requirements [EM.02.01.01]  Specific Requirements  Six Critical Areas [EM.02.02.01-EM.02.02.11]  Disaster Volunteers [EM.02.02.13-EM.02.02.15]  Evaluation Evaluating the planning activities [EM.03.01.01]  Evaluating the Emergency Operations Plan through exercises [EM.03.03.03]  Emergency Management Update Team 2016- 3 © Copyright, The Joint Commission  1. Communication [EM.02.02.01] 2. Resources & Assets [EM.02.02.03] 3. Safety & Security [EM.02.02.05] 4. Staff responsibilities [EM.02.02.07] 5. Utilities Management [EM.02.02.09] 6. Patient, clinical & support activities [EM.02.02.11] Emergency Management Update Team 2016- 4 © Copyright, The Joint Commission SIX CRITICAL AREAS 2016 Emergency Management Update Team The Joint Commission © Copyright, The Joint Commission WHAT HAS THE JOINT COMMISSION BEEN UP TO? EMERGENCY MANAGEMENT TEAM  Cross-divisional team  Review of large-scale events  Improvement  Field and surveyor education  Survey process and standards Emergency Management Update Team 2016- 6 © Copyright, The Joint Commission  Debriefs  Lessons learned  Education and process improvement DEBRIEFS WITH HEALTH CARE ORGANIZATIONS  Hurricane Sandy  West Texas Fertilizer Explosion  West Virginia Water Contamination  Boston Marathon Bombing  Ebola Outbreak  Baltimore Civil Unrest  San Bernardino Terrorist Event  Ferguson Civil Unrest Emergency Management Update Team 2016- 7 © Copyright, The Joint Commission  South Carolina Flooding LESSONS LEARNED – PLANNING/PREPAREDNESS  Establish relationships w/law enforcement & back-up security agencies  Joint education, drills, etc.  Activate ICS early in incident to support situational awareness  Plan / drill for escalating events  Mass shooting plus bomb threat. Emergency Management Update Team 2016- 8 © Copyright, The Joint Commission  Communication. LESSONS LEARNED – PLANNING/PREPAREDNESS  Identify & reach out to staff living in hot  e.g., laundry service  Know actual usage of utilities on ‘normal’ day, in evening, on weekends. Emergency Management Update Team 2016- 9 © Copyright, The Joint Commission zones during unrest to identify support needs in advance.  Consider supply chain and alternate service providers during water contamination. LESSONS LEARNED – PLANNING/PREPAREDNESS  Plan for most emerging infectious diseases rather than new ‘outbreak of the week’ plan.  IC plan, surge plan, all hazards plan, decon plan, pan-flu plan  Don’t overlook common risks that could go on the HVA in community or region  CBRNE: Fertilizer storage facilities throughout the region that could pose risk of combustion/explosion. Emergency Management Update Team 2016- 10 © Copyright, The Joint Commission  Risks LESSONS LEARNED – PLANNING/PREPAREDNESS  Planning for civil unrest focused primarily on:  Communications (with staff, patients, community incident command, the public/media)  Security  Transit (to the facility for patients and staff) Emergency Management Update Team 2016- 11 © Copyright, The Joint Commission  Reviewing EOP annually  Policies addressing utility disruption, including approach to clinical interventions  Water LESSONS LEARNED – PLANNING/PREPAREDNESS  Don’t overlook home care, outpatient services and other ancillary providers home care providers were held back from entering certain communities where there were clients with chronic conditions – care arrangements can be addressed proactively. Emergency Management Update Team 2016- 12 © Copyright, The Joint Commission  During unrest LESSONS LEARNED – GENERAL RESPONSE hospital & campus to identify flood issues early.  Divert spontaneous volunteers (even clinical) from ED to avoid congestion during trauma response.  Community-based & mobile services (e.g., addiction services) need to choose their locations during unrest to preserve safety of staff/patients. Emergency Management Update Team 2016- 13 © Copyright, The Joint Commission  Conduct frequent tours (every 2 hours) of LESSONS LEARNED – COMMUNICATIONS command/control, staff, patients/families, media & the public.  Don’t presume that all staff have smart phones or use social media; use redundant methods of staff communication.  Manage staff stress and access to misinformation via proactive staff communication strategy. Emergency Management Update Team 2016- 14 © Copyright, The Joint Commission  Have separate lines of communication for LESSONS LEARNED – COMMUNICATIONS with cell phone during response and recovery.  Proactive media/social media outreach plan mitigates intrusions from reporters that consume leaders’ time during response.  Regular joint calls with local providers, city & state support situational awareness during unrest. Emergency Management Update Team 2016- 15 © Copyright, The Joint Commission  Carry extra batteries and/or chargers along  During unrest:  Monitor social media used/sponsored by protest groups to anticipate crowd movement and potential impact on transit or emergency/urgent care.  Reinforce with staff – verbally and in written messaging/scripts used as needed in patient/family interactions – values of diversity and role to care for all people to help mitigate safety concerns or racial tension impacting community. Emergency Management Update Team 2016- 16 © Copyright, The Joint Commission LESSONS LEARNED – COMMUNICATIONS LESSONS LEARNED – SECURITY  Definition of ‘lock-down’ with response partners  Security forces have one meaning, hospitals may vary  Civil unrest response from small community hospital & secured it’s perimeter – closed all off-site locations  Security to central site  Moved vehicles  Removed from public access items that could be removed/damaged Emergency Management Update Team 2016- 17 © Copyright, The Joint Commission  Reduced LESSONS LEARNED – SECURITY  Reinforced with staff use of de-escalation techniques during civil unrest.  Train/exercise with local law enforcement  During terrorist shooting over 40 officers were onsite in minutes Conducted bomb search and provided essential support. No need to arm hospital security.  Separate ED waiting area for injured police officers & their families during unrest Emergency Management Update Team 2016- 18 © Copyright, The Joint Commission  LESSONS LEARNED – STAFF  Senior leadership  Prioritize time and resources for staff training Emergency Management Update Team 2016- 19 © Copyright, The Joint Commission  Weather/natural disasters  Prepare for staff rotations & shift relief  Designated sleeping areas, adequate meals  Shuttle system to/from homes LESSONS LEARNED – STAFF  Monitor local/county/state agencies  Road closures, curfews, etc. that impact staff movement to & from work community conditions change  Place Critical Incident Stress management staff in EOC  Provide real-time support & guidance to chain of command during unrest Emergency Management Update Team 2016- 20 © Copyright, The Joint Commission  Adjust shifts, allow sheltering in place as LESSONS LEARNED – PATIENT CARE  Flooding  Review IC plan to assess patient risk for HAI. Emergency Management Update Team 2016- 21 © Copyright, The Joint Commission  Water contamination  Home health & DME partners proactively monitor at-risk patients  Facilitate patient education on O2 concentrators, CPAP machines, & water sourcing. LESSONS LEARNED – EXERCISES  Stress & test system, staff, leaders with escalating complications & patients with different functional needs.  Train & practice staff in active shooter response with in-house security & law enforcement. Emergency Management Update Team 2016- 22 © Copyright, The Joint Commission  Joint exercise LESSONS LEARNED – LEADERSHIP  Leaders met frequent w/staff to discuss quality of care and safety during flood response/recovery.  Leaders facilitated visible presence of security in and around building during unrest  Increased sense of security. managerial assistance; identified & addressed staff morale/support needs in process after terrorist attack. Emergency Management Update Team 2016- 23 © Copyright, The Joint Commission  Leaders rounded & provided hands-on LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING  Reinforced w/staff & community role of hospital as safe zone for all injured. Emergency Management Update Team 2016- 24 © Copyright, The Joint Commission  Civil unrest/recovery  Town hall meetings for information & support and to dispel myths/rumors  Made available EAP & pastoral care  Routed routine monthly prayer walk through vulnerable community.  During unrest response & recovery  Invited staff discussion (individual or small group) on racial tension  Sense of safety at home in impacted community  Need for safety tips or security/transit support (alter work hours, shelter at hospital, etc.). Emergency Management Update Team 2016- 25 © Copyright, The Joint Commission LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING LESSONS LEARNED – INFECTIOUS DISEASE  Plan, train, & exercise for infectious disease emergencies:  initial screening of PPE, including don and dof  safe patient flow (entry point to isolation)  iterative training of care teams  dedicated equipment  safe transfer of patients  disposal & transport of waste Emergency Management Update Team 2016- 26 © Copyright, The Joint Commission  use LESSONS LEARNED – UTILITIES  Water  Processes for cleaning water systems after loss of water  Supply for systems management  Potable vs. non-potable • Equipment use, i.e. sterile processing • Human consumption Emergency Management Update Team 2016- 27 © Copyright, The Joint Commission  Fuel  Increase run time through load-shedding LESSONS LEARNED – HEALTH CARE PARTNERS  Water contamination:  Ambulatory dialysis company deployed water tanker truck to supply hospital  Dialysis biochemist supported hospital in sampling & testing water Emergency Management Update Team 2016- 28 © Copyright, The Joint Commission  Nursing home destroyed in industrial blast:  Other homes contacted hospital to offer beds  Hospital worked with case manager, behavioral health staff and home care to place patients 2 weeks post-disaster LESSONS LEARNED – HEALTH CARE PARTNERS  Maintain access to care  Chronic care patients  Medications from pharmacies outside of impacted area of emergency • Civil unrest, weather emergencies, etc. Emergency Management Update Team 2016- 29 © Copyright, The Joint Commission  Reinforce IC preparedness  Affiliated clinics and physician offices where at-risk patients may be seen.  Screening, use of PPE and other precautions LESSONS LEARNED – EVACUATION  Practice evacuation drills using evacuation equipment: equipment is required?  Where will equipment be deployed (which units, floors, etc.)?  Who needs to be trained in its use? Emergency Management Update Team 2016- 30 © Copyright, The Joint Commission  How much LESSONS LEARNED – RECOVERY  Recovery  Ancillary / offsite / support departments that were impacted by event or that contribute to resiliency.  Business continuity  Timely engagement with FEMA and insurers Emergency Management Update Team 2016- 31 © Copyright, The Joint Commission  Leadership engagement  Avoid fatigue and silos  Accountability Link: http://www.jointcommission.org/emergency_management.aspx Emergency Management Update Team 2016- 32 © Copyright, The Joint Commission EMERGENCY MANAGEMENT PORTAL 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page i HEALTH CARE EMERGENCY MANAGEMENT PRINCIPLES AND PRACTICE Editors Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor, Public Health Practice New York Medical College School of Health Science and Practice Valhalla, New York and David Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com 5/21/10 1:36 AM Page ii Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Publisher: Michael Brown Editorial Assistant: Catie Heverling Editorial Assistant: Teresa Reilly Production Manager: Tracey Chapman Associate Production Editor: Kate Stein Senior Marketing Manager: Sophie Fleck Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Achorn International Art: diacriTech Associate Photo Researcher: Sarah Cebulski Cover Design: Kristin E. Parker Cover Image: Top left: Courtesy of Andrea Booher/FEMA; Top Right: Courtesy of Win Henderson/FEMA; Bottom left: Courtesy of Jocelyn Augustino/FEMA; Bottom right: Courtesy of Cynthia Hunter/FEMA Printing and Binding: Malloy, Inc. Cover Printing: John Pow Company Library of Congress Cataloging-in-Publication Data Health care emergency management : principles and practice / [edited by] Michael J. Reilly and David S. Markenson. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7637-5513-3 (pbk.) ISBN-10: 0-7637-5513-3 (pbk.) 1. Emergency medical services. 2. Emergency management—Planning. 3. Hospitals—Emergency services. I. Reilly, Michael J. II. Markenson, David S. [DNLM: 1. Disaster Planning—organization & administration. 2. Emergencies. 3. Emergency Service, Hospital—organization & administration. WX 185 H4336 2011] RA645.5.H38 2011 362.18068—dc22 2010001554 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iii Dedication MICHAEL REILLY I dedicate this text to my family and friends who have supported me throughout this project. I especially thank my parents, who have provided their unwavering advice and support throughout my life and career. I also dedicate this text to my professional mentors Dr. Linda Degutis and Dr. Robyn Gershon, who continue to give me invaluable guidance throughout my professional development. Finally, I dedicate this book to my coauthor David, who has provided me with the opportunity to pursue academic emergency and disaster medicine professionally, and who continues to encourage and support my development as a scientist and scholar in this evolving area of medicine and public health. DAVID MARKENSON This text is dedicated to my parents, who have always guided, supported, and encouraged me, and who, as physicians, have shown me through their work that providing care to others in a compassionate and knowledgeable way can be a rewarding endeavor. This text is also dedicated to my brothers, sister, and sisters-in-law, who are a constant source of advice, support, and energy; without their help and involvement in my life none of my efforts could have been accomplished. Most importantly this text is dedicated to my wife Heidi and my wonderful children, Emily, Rachel, and George, who not only support me but who were willing to give of their time with me to allow me to write this text. iii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iv iv | Dedication MICHAEL REILLY AND DAVID MARKENSON Lastly, this text is dedicated to all healthcare providers, emergency managers, and those in their care. Healthcare providers and emergency managers work each day in an environment that is unpredictable, often dangerous, and constantly challenging. They have become champions in changing the system to become better prepared. They dedicate their lives to aid the sick and the injured and prepare for any disaster, terrorism event, or public health emergency, driven only by their care for others and their devotion to this profession we call healthcare emergency management. We salute all of you in your professionalism and dedication. Also, we dedicate this to our patients who, in allowing us the privilege to provide them care, teach us each day about humanity. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page v Contents About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Chapter 1 Chapter 2 Principles of Emergency Management for Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction to Hospital and Healthcare Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Healthcare Incident Management Systems . . . . . . . . . . . . . 21 Arthur Cooper, MD, MS v 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vi vi | Contents Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 II Chapter 8 Section Chapter Chapter 9 10 Section III Chapter 11 Chapter 12 Improving Trauma System Preparedness for Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . 47 Michael J. Reilly, DrPH, MPH, NREMT-P Legal Issues and Regulatory Compliance . . . . . . . . . . . . . 67 Doris R. Varlese, JD Developing the Hospital Emergency Management Plan . . . 89 Nicholas V. Cagliuso, Sr., MPH; Nicole E. Leahy, RN, MPH; and Marcelo Sandoval, MD Introduction to Exercise Design and Evaluation . . . . . . . . 111 Garrett T. Doering, MS, EMT-P, CEM, MEP Integration with Local and Community Resources . . . . . . 143 Isaac B. Weisfuse, MD, MPH Hospital Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . 161 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Sean M. Kelly, MA, CCEMT-P and Lindsey P. Anthony, MPA, CEM, CHEC-III Functional Roles of Hospital Workers in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . 187 Tony Garcia, RN, CCEMT-P Credentialing and Management of Volunteer Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Deborah Viola, PhD, MBA and Peter Arno, PhD Hospital Operations During Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 221 Quantitative Planning for Epidemic and Disaster Response: Logistics and Supply Chain Considerations . . . . . . . . . . . 223 Nathaniel Hupert, MD, MPH; John A. Muckstadt, PhD; and Wei Xiong, PhD, MS Risk Communication and Media Relations . . . . . . . . . . . . 233 Linda C. Degutis, DrPH, MSN and Lauren Babcock-Dunning, MPH 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vii Contents | vii Chapter 13 Chapter 14 Chapter 15 Chapter 16 IV C h a p t e r 17 Section Chapter 18 V C h a p t e r 19 Section Chapter 20 Chapter 21 Chapter 22 Security and Physical Infrastructure Protections. . . . . . . . . 271 Robert Michael Schuler, BGS, NREMT-P and Veronica Senchak Snyder, MHS, MBA Hospital Decontamination and Worker Safety . . . . . . . . . . 299 Michael J. Reilly, DrPH, MPH, NREMT-P Pharmaceutical Systems Management in Disasters. . . . . . 317 David S. Markenson, MD, FAAP, FACEP, EMT-P Laboratory Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 331 Ramon Rosal, PhD Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Principles of Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . 341 E. Brooke Lerner, PhD and Richard B. Schwartz, MD Managing an Infectious Disease Disaster: A Guide for Hospital Administrators . . . . . . . . . . . . . . . . . 353 Ariadne Avellino, MD, MPH Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 Vulnerable Populations and Public Health Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Elizabeth A. Davis, JD, EdM; Rebecca Hansen, MSW; and Jennifer Mincin, PhD (ABD) Altered Standards of Care in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 401 John Rinard, BBA, MSCPI Mass Fatality Management . . . . . . . . . . . . . . . . . . . . . . . 423 Barbara A. Butcher, MPH and Frank DePaolo, RPA-C Research in Emergency and Disaster Medicine . . . . . . . . 447 Kobi Peleg, PhD, MPH and Michael Rozenfeld, MA Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page viii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page ix About the Authors MICHAEL J. REILLY, DRPH, MPH, NREMT-P Dr. Michael Reilly is currently the Assistant Director of the Center for Disaster Medicine at New York Medical College in Valhalla, New York. Additionally, he is an Assistant Professor of Public Health Practice and the Director of the Graduate Program in Emergency Preparedness at the School of Health Science and Practice. Dr. Reilly has over a decade of multidisciplinary experience in emergency preparedness, public safety, intergovernmental relations, public health, and emergency management. He has been published in the world’s leading disaster medicine and public health preparedness journals, and received international awards and recognition for his work on trauma systems and health systems in the context of disaster and public health preparedness. Dr. Reilly is an internationally recognized expert in the areas of emergency medical services, and health system preparedness and response, with direct experience in responding ix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page x x | About the Authors to mass casualty events and public health emergencies. Dr. Reilly is frequently called upon to provide expert consultation, subject matter expertise, and to evaluate healthcare systems preparedness, emergency planning, and drills and exercises. Dr. Reilly has designed numerous educational curricula and training programs for a variety of preparedness functional roles for public health, emergency management, and public safety audiences at the professional and graduate levels. He is a senior lecturer for multiple federal agencies including the Department of Justice, Department of Homeland Security, and the Occupational Safety and Health Administration. Additionally, he is an active member of several state and national committees on homeland security and emergency management programs. He received his undergraduate education at Northeastern University in paramedic technology and health science. He earned his Masters of Public Health from Yale University, and a doctorate in public health from New York Medical College. Dr. Reilly remains active as a paramedic in the Metro New York City region and maintains numerous specialty and technical certifications and instructor credentials in the areas of emergency medical services, worker safety, environmental health, hazardous materials emergency response, emergency management, counterterrorism, and weapons of mass destruction preparedness and response. DAVID SAMUEL MARKENSON, MD, FAAP, FACEP, EMT-P Dr. David Markenson is a board-certified pediatrician with Fellowship training in both pediatric emergency medicine and pediatric critical care. He is the Vice President and Medical Director of Disaster Medicine and Regional Emergency Services at the Westchester Medical Center and Maria Fareri Children’s Hospital. In addition, he is the Director of the Center for Disaster Medicine and the Interim Chair of Epidemiology and Community Health at the School of Health Sciences and Practice at New York Medical College. Dr. Markenson is also a Professor of Pediatrics and an Associate Professor of Public Health at the School of Health Sciences and Practice at New York Medical College in Valhalla, New York. He is an active member of, and has served in leadership positions within, multiple professional societies, including the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, the Society of Critical Care Medicine, the American College of Physician Executives, and the National Association of EMS Physicians. Dr. Markenson has been actively involved with the American Red Cross for over 20 years and currently serves as the National Chair of the Advisory Council which oversees disaster health, preparedness, and health and safety. In this role he directs the scientific and technical as- 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xi About the Authors | xi pects of all programs and products in these areas including their development, implementation, and research. Prior to coming to Westchester Medical Center and New York Medical College he was the Deputy Director of the National Center for Disaster Preparedness at the Mailman School of Public Health, Columbia University, and was also the Director of the Program for Pediatric Preparedness of the National Center, a program dedicated to improving the care children receive in times of disasters or acts of terrorism. His career has been dedicated to improving the approach to pediatric care, disaster medicine, EMS, and emergency medicine. He is the principal investigator on several federal grants related to pediatric disaster medicine, including Model Pediatric Component for State Disaster Plans and National Consensus Conference on the Needs of Children in Disasters. He has also addressed the needs of other special and vulnerable populations and directed a federal grant to develop the first and only national guidelines for emergency preparedness for persons with disabilities. In addition to this, he has conducted research on healthcare preparedness and healthcare provider and student education. In this area he was the principal investigator for a federal grant which developed the first competencies for all healthcare students in emergency preparedness and then piloted this set of competencies in a medical, dental, public health, and nursing school. Dr. Markenson has been recently appointed to the FEMA National Advisory Council as the In-Patient Medical Provider representative. The FEMA NAC is comprised of emergency management and law enforcement leaders from state, local, and tribal government and the private sector to advise the FEMA Administrator on all aspects of disaster preparedness and management to ensure close coordination with all partners across the country. He is a frequent presenter and lecturer at medical conferences across the country, serves in editorial roles for multiple professional scientific journals, and has authored numerous articles and books on pediatric care, disaster medicine, and prehospital medicine. His work in disaster medicine started during his college career when he worked in disaster services in upstate New York providing direct services and education to other disaster services workers on behalf of the local Red Cross and county office of emergency management. Dr. Markenson is a graduate of Albert Einstein College of Medicine in the Bronx, New York. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiii Contributors Lindsey P. Anthony, MPA, CEM, CHEC-III Operational Medicine Education Coordinator Center for Operational Medicine Medical College of Georgia Augusta, Georgia Peter Arno, PhD Professor Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York xiii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiv xiv | Contributors Ariadne Avellino, MD, MPH Research Associate Center for Disaster Medicine New York Medical College Valhalla, New York Lauren Babcock-Dunning, MPH Research Associate Center for Transportation Safety, Security and Risk Rutgers, The State University of New Jersey New Brunswick, New Jersey Barbara A. Butcher, MPH Chief of Staff Office of the Chief Medical Examiner City of New York New York, New York Nicholas V. Cagliuso, Sr., MPH Corporate Director Emergency Management Continuum Health Partners, Inc. New York, New York Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma and Pediatric Surgical Services Harlem Hospital New York, New York Elizabeth A. Davis, JD, EdM Principal EAD & Associates, LLC Brooklyn, New York Linda C. Degutis, DrPH, MSN Associate Professor of Surgery (Emergency Medicine) and Public Health Director, Center for Public Health Preparedness Yale University School of Medicine New Haven, Connecticut 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xv Contributors | xv Frank DePaolo, RPA-C Director Special Operations Division Office of the Chief Medical Examiner City of New York New York, New York Garrett T. Doering, MS, EMT-P, CEM, MEP Director of Emergency Management Westchester Medical Center Valhalla, New York Tony Garcia, RN, CCEMT-P Training Specialist Texas Engineering Extension Service Texas A&M University System College Station, Texas Rebecca Hansen, MSW Senior Project Manager EAD & Associates, LLC Brooklyn, New York Nathaniel Hupert, MD, MPH Associate Professor of Public Health and Medicine Weill Cornell Medical College New York, New York Sean M. Kelly, MA, CCEMT-P Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York Nicole E. Leahy, RN, MPH Manager Burn Outreach and Professional Education New York-Presbyterian Hospital / Weill Cornell Medical Center New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvi xvi | Contributors E. Brooke Learner, PhD Associate Professor Department of Emergency Medicine Department of Population Health Medical College of Wisconsin Milwaukee, Wisconsin David S. Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York Jennifer Mincin, PhD (ABD) Senior Project Manager/Director EAD & Associates, LLC Brooklyn, New York John A. Muckstadt, PhD Acheson/Laibe Professor Business Management and Leadership Studies School of Operations Research and Industrial Engineering Cornell University Ithaca, New York Kobi Peleg, PhD, MPH Director, Israel National Center for Trauma and Emergency Medicine Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Co-chair, The Multi-disciplinary Program for Emergency and Disaster Management School of Public Health Tel-Aviv University Tel-Aviv, Israel Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor of Public Health Practice New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvii Contributors | xvii John Rinard, BBA, MSCPI Milano, Texas Ramon Rosal, PhD Chemical Response Director Public Health Laboratory New York City Department of Health and Mental Hygiene New York, New York Michael Rozenfeld, MA Researcher National Center for Trauma & Emergency Medicine Research Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Tel Hashomer, Israel Marcelo Sandoval, MD Faculty, Department of Emergency Medicine Co-Chair, Emergency Management Committee Beth Israel Medical Center / Petrie Division New York, New York Robert Michael Schuler, BGS, NREMT-P Training Coordinator Texas Engineering Extension Service The Texas A&M University System College Station, Texas Richard B. Schwartz, MD Chair and Professor Department of Emergency Medicine Medical College of Georgia Augusta, Georgia Veronica Senchak Snyder, MHS, MBA Emergency Management Coordinator Emergency Management Services Geisinger Health System Geisinger Medical Center Danville, Pennsylvania Doris R. Varlese, JD Visiting Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xviii xviii | Contributors Deborah Viola, PhD, MBA Associate Professor of Public Health Practice Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York Isaac B. Weisfuse, MD, MPH Deputy Commissioner Division of Disease Control New York City Department of Health and Mental Hygiene New York, New York Wei Xiong, PhD, MS Instructor in Public Health Weill Cornell Medical College New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xix Acknowledgments he material contained in this text reflects the contributions of many authors, editors, emergency managers, healthcare providers, reviewers, and others who provided assistance and valuable suggestions. While here we acknowledge them, our sincere appreciation for all of their efforts is truly hard to express in this limited space. In addition, we could not possibly acknowledge all those who participated in this important endeavor, and so we would like to also extend our sincere appreciation to every person who helped with this project, whether listed by name or not. Many talented people at Jones & Bartlett Learning have been involved in developing and producing this new text. As authors and editors, we turned our manuscript to the exceptional editorial staff and publishers at Jones & Bartlett Learning to create this finished product. We are fortunate to have been able to work with this team of people, who have contributed so much and had such a tremendous impact on T xix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xx xx | Acknowledgments the quality of the textbook you now have in your hands. Specifically Michael Brown, Publisher, assisted by Catie Heverling and Kate Stein, has been our support at Jones & Bartlett Learning. As Publisher, Mike is committed to publishing quality books; his energy, intelligence, patience, and helpful efforts have enabled us to create an exceptional product. With the additional day-to-day support and guidance of both Catie Heverling and Kate Stein we were able to keep our project on track and ultimately produce this important text. A significant amount of coordinating and operational support in moving this project forward would not have been possible without the tireless work of our administrative assistant Patience Ameyaw. We thank her for her hard work and support of this project along with Geordana Roa, Nina Luppino, and our numerous disaster medicine interns over the past several years. Components of this text have been based on the exceptional work of the Center for Disaster Medicine at the New York Medical College, School of Health Sciences and Practice for which we serve as the Director and Assistant Director. Without the support of our Center, the prior research and models developed, and the strong and supportive academic environment of New York Medical College, this work would not have been possible. We would like to specifically thank Dean Robert Amler of the New York Medical College, School of Health Sciences and Practice, who in his own right is an internationally recognized expert in public health and healthcare preparedness, for providing his personal expertise and his leadership in creating an academic environment where work such as this text is not only encouraged but supported, and for his continued dedication to providing education to improve emergency preparedness. We would like to also acknowledge the Westchester Medical Center and its Maria Fareri Children’s Hospital, which serves as the regional center for healthcare emergency preparedness. The source and realworld testing of many of the theories and models in this text come from the preparedness efforts of this institution, which is recognized as not only a regional but as a national leader in emergency preparedness. We would like to thank the leadership of this institution for allowing us to use the wonderful preparedness work they have done as models for others to follow. While not being able to list all, we would like to acknowledge the members of the senior leadership who day in and day out support the preparedness activities: Mr. Michael Israel, Mr. Gary Brudnicki, Dr. Renee Garrick, Dr. Michael Gewitz, Ms. Marsha Casey, and Mr. Anthony Costello. Lastly, we would especially like to thank the institution’s Director of Emergency Management and chapter contributor Mr. Garrett Doering for sharing his professional insight and experience with us as we completed this project. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxi Acknowledgments | xxi Finally, we are extremely grateful to the numerous healthcare providers, emergency managers, educational consultants, and members of the preparedness academic community who carefully critiqued the manuscript to ensure that the information in this text would be both relevant and appropriate. Many more dedicated professionals than we could name here gave unstintingly of their own time and expertise. Their enthusiastic participation has been a motivating force behind this project, and they received no compensation beyond the knowledge that they were helping to create a greatly needed resource. We hope the final product lives up to their efforts, hopes, and expectations. Our warmest and kindest regards, Michael and David 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxii 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 1 Section I Principles of Emergency Management for Healthcare Facilities 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 2 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 3 Chapter 1 Introduction to Hospital and Healthcare Emergency Management Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Describe the need for and responsibilities of healthcare emergency management. ■ Describe the role of the hospital emergency manager. ■ Identify the activities performed by healthcare emergency management. Emergence and Growth of Healthcare Emergency Management The concept of healthcare emergency management is not entirely new, but may seem strange and foreign to those who have worked in healthcare or emergency management and, until recently, have not known anyone working in this profession. If one looks back more than 30 years, it would be almost impossible to find a hospital role called hospital 3 55133_CH01_Reilly:Achorn Int’l 4 | Chapter 1 5/13/10 12:08 PM Page 4 Introduction to Hospital and Healthcare Emergency Management emergency management or even a position for a healthcare emergency manager in a hospital or medical center.Yet healthcare emergency management responsibilities have always been addressed by hospitals, such as fire safety, backup power, and the ability to handle victims from a mass casualty event. A fundamental tenet of emergency management is that institutions must prepare for events that may rarely occur while taking protective actions to mitigate any likelihood that they will occur at all. Due to the low frequency of events testing the health system’s ability to respond to a disaster, an act of terrorism, or a public health emergency, the ability to evaluate the strengths and weaknesses of hospital emergency preparedness is limited. In addition, the public has strong expectations of the roles hospitals should play during times of disaster. Healthcare institutions are expected to provide both emergency care and continuance of the day-to-day healthcare responsibilities regardless of the volume and demand. Recently, they have also become sites of community refuge, bastions of safety in a threatening and dangerous environment. The public believes that hospitals will have light, heat, air conditioning, water, food, and communications capabilities, regardless of the fact that the institution may itself be affected by the calamity. During the terrorist attacks in the fall of 2001 and the Northeast Blackout of 2003, the public flocked to hospitals, even when they did not require medical care. Furthermore, with increased intelligence of the vulnerabilities of the healthcare infrastructure and the desire of terrorists to exploit this, institutions have been forced to focus limited resources on safety and security rather than on comprehensive emergency management efforts. A major change in the way hospitals plan for hazards and vulnerabilities includes less planning for specific single issues or threats but rather the adoption of an all–hazards comprehensive emergency management planning process. Additionally, hospitals need to look beyond their emergency department doors and engage community stakeholders to assist in this process, reaching out to local and regional emergency planners to assist in larger communitywide emergency preparedness planning. The interest of nonhospital entities in health system emergency preparedness can be seen through several examples, including emergency management and public health initiatives on mass vaccination, pandemic planning, increasing hospitals’ ability to perform decontamination of casualties contaminated with hazardous materials, etc. Recent reflection of the role of the hospital in emergency management and population health can been seen in revised laws, regulations, and even accreditation standards. An example of this is The Joint Commission on the Accreditation of Healthcare Organizations’ (JCAHO) change from placing emergency preparedness standards in the Environment 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 5 Emergence and Growth of Healthcare Emergency Management | 5 of Care section to placing the standards in a separate and distinct section with specific goals and requirements, as well as the release of the Occupational Safety and Health Administration (OSHA) document Best Practices for Hospital-Based First Receivers.1–3 Over the past eight years we have embarked on an interesting marriage of these two separate disciplines—health care and emergency management—whose common ground has historically been brought together in the street or on the disaster scene by emergency medical services workers, or sometimes brought into the emergency departments of hospitals and trauma centers across the country. Both disciplines have separate roles and responsibilities, but where the seemingly disparate goals of these fields come together is the reduction of morbidity and mortality following disasters, acts of terrorism, and public health emergencies. Emergency management agencies have traditionally been responsible for bringing first responders, government agencies, and community stakeholders together to assist with comprehensive emergency planning or disaster response and recovery. A common cornerstone of emergency management has been to protect life, then property, then the environment. As a result, when conducting emergency planning activities, the health and medical needs of the population are among the most significant and are considered with basic public health and human needs including sheltering, mass care, sanitation, environment health, food and water, and other essential services. In addition, as public health professionals, we also believe that population health activities include the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency. In healthcare delivery, we attempt to meet the health and medical needs of the community by providing a place for individuals to seek preventative medicine, care for chronic medical conditions, emergency medical treatment, and rehabilitation from injury or illness. While a healthcare institution serves the community, this responsibility occurs at the level of the individual. Each individual expects a thorough assessment and treatment if needed, regardless of the needs of others. This approach is different than that practiced by emergency managers, whose goal is to assist the largest number of people with the limited resources that are available. As such, emergency management principles are focused on the needs of the population rather than the individual. When either planning for a disaster or operating in a disaster response mode, the hospital should be prepared at some point to change its focus from the individual to the community it serves and to begin weighing the needs of any individual patient versus the most good for the most patients with scarce resources. Moving from the notion of doing the most for each individual to doing the best for the many is a critical shift in thinking 55133_CH01_Reilly:Achorn Int’l 6 | Chapter 1 5/13/10 12:08 PM Page 6 Introduction to Hospital and Healthcare Emergency Management for healthcare institutions considering a program of comprehensive emergency management. While the initial planning for emergencies by hospitals is focused on maintaining operations and handling the care needs of actual or potential increased numbers of patients and/or different presentations of illness or injury than is traditionally seen, there is also the need to recognize that at some point during a disaster, act of terrorism, or public health emergency there may be an imbalance of need versus available resources. At this point the approach to delivering healthcare will need to switch from a focus on the individual to a focus on the population. This paradigm shift is one of the core unique aspects of hospital emergency management that allows the hospital to prepare to maximize resources in disasters and then to know when to switch to a pure disaster mode of utilizing its limited and often scant resources to help the most people with the greatest chance of survival. The healthcare delivery system is vast and comprised of multiple entry points at primary care providers, clinics, urgent care centers, hospitals, rehabilitation facilities, and long-term care facilities. The point of entry for many individuals into the acute healthcare system is through the emergency department (ED). Since the late 1970s, the emergency medical services (EMS) system has allowed victims of acute illness and injury to receive initial stabilization of life-threatening medical conditions on the way to the emergency department. Among the many strengths of the ED is the ability to integrate two major components of the healthcare system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in this process by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate life-saving medical care until specialty resources become available.4–11 In this context, the healthcare system is an emergency response entity. Healthcare Emergency Management Activities Hospital emergency management activities vary and can be categorized in many ways, however some common areas of focus within healthcare emergency management include the following areas: ■ ■ ■ ■ ■ ■ ■ communication surge capacity volunteer management security issues hazmat/CBRNE preparedness collaboration and integration with public health education and training 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 7 Healthcare Emergency Management Activities | 7 ■ ■ ■ ■ ■ equipment and supplies worker safety drills and exercises emergency department disaster operations trauma centers COMMUNICATION Communication issues in disaster preparedness and response are cited throughout the literature as a major source of frustration and inadequacy for coordinating and executing disaster operation plans.4–5,8,11–16 By identifying the vulnerabilities in the existing system of healthcare communication systems, we can take steps to address these issues and further increase our health system preparedness. Addressing the vulnerabilities in communication systems and planning how to overcome them is an essential responsibility of a hospital emergency manager. Many of the criticisms of the current state of health systems’ communication systems center around the inability to communicate easily with external agencies and share critical information. Disaster after-action reports and exercise improvement plans almost universally cite poor communication as one of the problems associated with incident management and the event being reviewed. Infrastructure support is an important consideration when examining whether adequate safeguards are in place to support the systems we will rely upon during a disaster. On September 11, 2001, while one New York City hospital was preparing to treat a large number of (anticipated) casualties from the disaster, they experienced a loss of their computer and information systems.17 This unplanned event arose because the communication system line that supported their system’s infrastructure ran beneath the World Trade Center.17 Additionally, other reports have cited problems with battery failure and the lack of a prolonged power supply as limiting communication systems’ abilities during an event.14 This example illustrates a major point in emergency communication systems: hospitals need the ability to connect all significant parties during a disaster or other emergency and the system should be based on a redundant infrastructure.5 Clearly, from a planning perspective, this would be a desirable option. However, the reality remains that investing in communication systems is a significant financial burden on already underfunded hospitals and healthcare systems. Risk communication is often overlooked during the planning phase of an event, and this can lead to frustration and confusion during disaster operations. Risk communication is sometimes the only way for the public to gain an understanding of the scope and severity of an incident. Additionally, risk communication information provided by hospitals may be used to help families of disaster victims find information about 55133_CH01_Reilly:Achorn Int’l 8 | Chapter 1 5/13/10 12:08 PM Page 8 Introduction to Hospital and Healthcare Emergency Management their loved ones’ condition. Reviews of risk communication have shown that a predesignated public information officer (PIO), who will liaise with the media and the public and who has specific training and experience in giving briefings and fielding questions, should perform all risk communication tasks during disaster operations.13 Specific elements of risk communication that may be conveyed to the public may include information on evacuations, scope and breadth of the event, where and how to obtain assistance if needed, whom to call for specific information, location of postexposure prophylaxis or vaccination clinics, and what to expect over the next several hours and/or days of the event. This is discussed in more detail in Chapter 12. SURGE CAPACITY The General Accounting Office (GAO), which changed its name to the Government Accountability Office (GAO) in 2004, finalized reports during 2003 on the public health and hospital preparedness for bioterrorism and emerging infectious diseases.9,16 These reports found that most hospitals in the United States do not have the means to care for a surge of patients during a public health emergency.9,16 They stated that, based on the national emergency department diversion rates in urban and suburban areas, shortages in the healthcare workforce, and the general lack of available supplemental medical equipment and supplies in hospitals, the medical community is not prepared to handle a patient surge caused by an infectious disease outbreak or bioterrorism related event.9,16 Emergency departments are being utilized more often as urgent care centers because the growing population utilizes the ED as their point of primary care. This increasing phenomenon is contributing to ED overcrowding and diversionary status (hospital EDs asking that ambulances refrain from bringing patients to their facility for a period of time) in virtually every healthcare and trauma system in the country. The current state of affairs in the nation’s EDs makes it very difficult to prepare for surge capacity when many hospitals cannot effectively handle their daily patient volume.18 Referral patterns of patients presented to medical facilities will vary in terms of how they arrive at the facility (EMS or self-transport) as well as which facilities they access (hospital ED or physician’s office), depending on the type of disaster or public health emergency. In cases of natural disasters, explosions, and acute catastrophic events where there is a clear and defined “scene,” many patients will be triaged, treated, and perhaps transported to hospitals or trauma centers by EMS personnel. In cases of bioterrorism or infectious disease outbreaks, patients would normally exhibit minor signs and/or symptoms of an illness (e.g., fever, rash, flu-like symptoms, etc.). These patients may be 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 9 Healthcare Emergency Management Activities | 9 presented to their primary care physician or an urgent care center to receive initial diagnosis and treatment. The patients that can be expected to arrive at the ED in these cases would be those who could not access a private physician, those too acutely ill to seek care in an office setting, those referred to the ED by their physicians, and those patients who called EMS for assistance. This latter group would yield the least number of ED arrivals.19–20 Incidents of chemical and biological terrorism as well as pandemic or epidemic incidents of infectious diseases may arguably produce the most significant burden on the healthcare system.9,13,16,18,21 A main reason for this is the unpredictable referral patterns of patients who fall victim to a chemical or biological hazard. Although some disaster after-action reports do suggest that even victims of conventional disasters will self-refer to medical facilities, the issues of delayed onset of symptoms, cross-contamination, and person-to-person disease transmission that are associated with a chemical, biologic, or radiologic incident call for more detailed contingency plans. An example of hospital referral patterns after a chemical agent event can be seen in the post-event summary of the sarin attack in the Tokyo subways in March of 1995.22 In this incident 12 people were killed, but more than 5000 people sought medical attention, and only 688 of them were medically transported to area hospitals.22 At some point during the evolution of a disaster or other public health emergency, patients will converge on acute care hospitals. Studies have consistently shown that despite rigorous planning initiatives, hospitals and emergency departments are not prepared to handle the mass influx of patients that a bioterrorism event or infectious disease outbreak would produce.9,16,19–20 During the sarin attack on the Tokyo subway in 1995, the nearest hospital had 500 patients in the first hour after the incident and more than 20% of its staff was secondarily contaminated.22 It is important that planners additionally recognize that in certain catastrophic disasters involving bombings, building collapse, etc., mass injuries and a patient surge may not occur as anticipated because of the high rate of mortality.17,23 The hospital emergency manager and all those involved in hospital emergency management must ensure that their hospital has adequate plans for the surge of patients that will arrive during a disaster, terrorism event, or public health emergency. VOLUNTEER MANAGEMENT The use of volunteers in disasters and public health emergencies presents a unique set of considerations for the hospital emergency manager. Volunteers can be utilized in several ways to assist in disaster relief services. However, the problems of volunteer management, credentialing, 55133_CH01_Reilly:Achorn Int’l 10 | Chapter 1 5/13/10 12:08 PM Page 10 Introduction to Hospital and Healthcare Emergency Management safety, and security often preclude their utility in the acute disaster environment unless significant pre-planning for their use has occurred and their arrival is through a pre-defined system. Cone et al. describe “convergent volunteerism” (the influx of citizens and/or health providers to a major incident) as a “critical problem” in disaster management.24 Intuitively, you may think that the outpouring of community support to assist in rendering aid during a disaster or other public health emergency is a welcome show of support for disaster victims. However, the reality is that convergent volunteerism brings with it security, resource, and worker safety problems that require personnel and critical resources to manage. In their discussion of convergent volunteerism in the September 11 terrorist attacks in NYC, Cone and colleagues discuss the myriad of additional challenges and problems that the unsolicited and often intrusive behavior of “Good Samaritans” imposed on the NYC responders. Issues included the unsupervised practice of medicine and paramedicine; credential verification of certified and/or licensed personnel; the performance of search and rescue operations by lay responders; the need to feed, shelter, and provide sanitary facilities for volunteers; potential injury and illness to volunteers who were unsupervised and lacked proper personal protective equipment; and personal vehicle congestion on scene access and egress.24 Many of these concerns may seem trivial to some who view a community response to a disaster as being the quintessential demonstration of altruism and support for fellow citizens. However, as mentioned by Cone and colleagues, untrained and unauthorized volunteers can ultimately put themselves and others in danger, and deplete emergency response resources by attempting to provide assistance at disaster scenes. This was most poignantly illustrated during the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, when an untrained and unprotected volunteer nurse was crushed by falling debris while trying to assist with urban search and rescue operations.24 SECURITY ISSUES Hospitals frequently overlook the need to maintain adequate security of the healthcare facility and overall medical operations as part of both daily operations and emergency planning. The concept of “locking down” or restricting access to a healthcare facility is often contradictory to the typical hospital design and approach of open access to both patients and their families and other visitors. But during a disaster this type of control is essential for many reasons, which include but are not limited to: control of the flow of patients to the areas where care will be provided; access to the facility only by authorized staff; accounting for staff and patients 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 11 Healthcare Emergency Management Activities | 11 in time of evacuation; prevention of potentially contaminated patients entering the hospital from contaminating staff, other patients, and facilities; and prevention of acts of terrorism. Security resources generally vary among hospitals. Some hospitals and trauma centers have sworn police officers present in their facilities 24 hours a day, and others may hire a private security firm to maintain safety or simply serve a concierge or customer service role. Security concerns during disasters and public health emergencies can become significant when considering the potential vulnerabilities associated with the chaotic response environment.15,17,24–25 Specifically cited issues with security during the response to a disaster or public health emergency include access control to medical facilities; credentialing of employees, responders, and volunteers; crime scene and evidence preservation; infrastructure and resource protection; and crowd control.15,17,24–25 HAZMAT/CBRNE PREPAREDNESS There is no question that in the current state of health system and public health preparedness the medical community is ill-prepared to deal with an incident that involves the management and treatment of multiple potentially contaminated victims, including those from chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Multiple recent reports of hospital preparedness cite decontamination capabilities as a serious weakness of disaster readiness plans.4–5,8–9,11,15–16,26–27 One study cites as few as 6% of Level I trauma centers as having the necessary equipment on hand to safely decontaminate a single patient.26 Planning for these events has traditionally centered around the fallacy that patients will be decontaminated at the scene by first responders and then be triaged, treated, and transported to the ED. The decontamination process serves a dual purpose. First, it removes the potential agent that is causing harm to the patient, and second, it prevents the spread of secondary contamination to other patients and hospital staff. We have come to realize from recent incidents involving victim contamination that many ambulatory victims will leave the scene and bypass EMS decontamination and triage, seeking medical care on their own.11,15,19–20 The reality of dealing with an intentional release of chemical, biological, or radiological agent is that by the time acute care facilities can be made aware that an event has taken place, they may have already been contaminated themselves.22 The specifics of hospital decontamination and worker safety are discussed in Chapter 14. Throughout the nation, trauma systems, acute care hospitals, and first responders are unprepared for handling an event involving the release of a nuclear, biological, or chemical (NBC) agent.8,15,26 Largely, this is due to ineffective planning and relying on resources that may not be available 55133_CH01_Reilly:Achorn Int’l 12 | Chapter 1 5/13/10 12:08 PM Page 12 Introduction to Hospital and Healthcare Emergency Management during a disaster or public health emergency.15 The most often cited weaknesses are an overall lack of training, lack of personal protective equipment (PPE), lack of resources and equipment to rapidly and reliably perform preliminary agent detection, and lack of appropriate medical facilities, equipment and supplies to effectively isolate infectious patients and manage them through the course of their illnesses.8,15,21–22,26 COLLABORATION AND INTEGRATION WITH PUBLIC HEALTH In order for disaster preparedness and response to be successful, it must involve interagency resources and consider the 3C’s of emergency response planning: Collaboration, Cooperation, and Coordination. Response plans cannot be designed and implemented in a vacuum. Disaster response and recovery operations will certainly consist of a multiagency response at the local, state, and federal levels. In order to ensure that the response plan is valid, and will operationally integrate with other key responding agencies, the planner must collaborate with fellow agencies and develop plans that involve aspects of interagency response. Interagency planning groups, such as the Local Emergency Planning Committee (LEPC), operate under the assumption that if a hazardous event occurs, all key public safety and health agencies will respond in a unified approach with common goals to protect the welfare and safety of the community. These principles of collaboration, cooperation, and coordination among the agencies that will likely respond to a disaster or other public health emergency will minimize unnecessary redundancy in response plans and create partnerships with agencies that can provide expertise and resources during the public health emergency response. In a large-scale disaster or act of terrorism, such as the World Trade Center attacks in 1993 and 2001, the Oklahoma City bombing in 1995, and the 1994 and 1995 sarin attacks in Tokyo, continuous medical monitoring and follow-up of the survivors, responders, and participants in these events is needed to detect the associated long-term health effects. With the exception of large academic medical institutions that may perform epidemiologic analysis on specific cohorts of individuals, the public health community must recruit and maintain a database of affected individuals so they can study the long-term impact of these events on the health of the population. It is important to note that although the imminent threat of danger may no longer be present, the need for medical care, disease surveillance, and follow-up studies is essential to the completion of the public health role in a disaster or other public health emergency. Additionally, public health agencies at the federal, state, and local levels have the responsibility under the National Response Framework (NRF) to coordinate and serve as the lead agency for disasters involv- 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 13 Healthcare Emergency Management Activities | 13 ing mass care. This may include assisting both hospitals and communities to establish alternate care sites (ACS) where patients can be directed to receive medical treatment during a public health emergency, which will allow a hospital to use its resources to treat higher acuity patients and remain open to handle routine emergencies during a pandemic or other public health emergency. EDUCATION AND TRAINING Reports have suggested that healthcare workers lack the knowledge to detect and manage a patient who has been exposed to a chemical or biological agent.6,27–28 The Health Resources and Services Administration (HRSA) survey helped to illustrate the lack of training and education among trauma center and hospital staff by reporting that only eight states required employees to be trained in disaster-related topics, two states required training in biological agent topics, and two states required training for chemical-related topics.8 Additionally, training for EMS personnel was equally poor because only six states required prehospital providers to have education on disaster-related topics, only one state required biological agent training, and three states required education on chemical agents.8 EQUIPMENT AND SUPPLIES In the GAO’s report of hospital preparedness in August 2003, they reported several findings on hospital equipment and supply resources. The survey showed that for every 100 beds, 50% of hospitals had fewer than 6 ventilators, fewer than 3 PPE suits, fewer than 4 isolation beds, and could only handle fewer than 6 patients per hour through a 5-minute decontamination shower, given their current state of preparedness.9 Additionally, the GAO reports that most first responders lack a reliable means to detect chemical and/or biological agents in the field, and do not typically have the proper PPE to protect themselves from agent exposure.9 The HRSA evaluation of state trauma systems showed that the availability of PPE for healthcare workers was significantly lacking among states because only one state (Ohio) had enough PPE resources immediately available for its EMS personnel, and only one state (New Jersey) had enough PPE resources immediately available for its hospital personnel if a chemical or biological agent release occurred.8 In addition to PPE issues, hospitals and trauma centers often lack the inventory of equipment and supplies necessary to effectively treat an influx of potentially affected patients.8–9,14–16,26 Many hospitals, in a strategy to reduce overall costs, replenish their central supply on a “just-in-time” basis, clearly ineffective in preparing to treat a mass 55133_CH01_Reilly:Achorn Int’l 14 | Chapter 1 5/13/10 12:08 PM Page 14 Introduction to Hospital and Healthcare Emergency Management influx of patients.18 Pharmaceutical access is another concern among healthcare facilities. As demonstrated in the fall 2001 anthrax scare, hundreds of postal and healthcare workers required postexposure prophylaxis after potential exposure to the agent. Maintaining an adequate pharmaceutical stock of essential antibiotics, antidotes, and specialty medications in case of a disaster is often viewed as cost prohibitive due to the shelf life and daily usefulness of certain drugs.18 Although this has improved slightly over the past 6 years, hospitals around the country still struggle to build the internal capacity necessary to perform emergency decontamination of patients from hazardous substance incidents and properly protect their staff, patients, and visitors from secondary contamination. WORKER SAFETY A report released by HRSA on the national state of the trauma system and EMS preparedness for disasters and mass causality events showed that only one state in the country thought that its hospital workers would be adequately protected in the event of a biological (but not chemical) agent attack.8 Additionally, only one state reported that its EMS system would have access to PPE in the event of a bioterrorism event.8 Similar research has underscored a general lack of protection for the public health workforce against any type of chemical, biological, or radiological contamination in the event of a disaster.8 A major role for the public health community during an event is to ensure the health and safety of all disaster workers.13,15 DRILLS AND EXERCISES Criticisms regarding drills and exercises are notable throughout the preparedness literature.6,9,11,15,21,26 Comments include statements that exercises are not realistic, drills tend to be conducted with advanced warning on shifts with favorable staffing levels, and with equipment and resource levels at their best, etc. Therefore, the drills bias any useful results from the exercise.15 The purpose of conducting drills and exercises (besides remaining in compliance with accrediting bodies) is to assess whether or not a facility is adequately prepared to handle an incident with relatively low probability, but with extremely significant impact on the health system, and to identify areas that need improvement on an operational and planning level.15 Exercises that simply go through the motions or are conducted with limited realism, under optimal conditions, or are simply haphazardly conducted to meet regulatory or legal requirements are futile and worthless assessment tools that will only perpetuate a hospital’s state of unpreparedness.15 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 15 The Role of the Hospital/Healthcare Emergency Manager | 15 EMERGENCY DEPARTMENT DISASTER OPERATIONS The importance of the ED’s role in disaster and emergency preparedness is discussed in several sources.4–12 The American College of Surgeons mentions that the ED is a major strength of a trauma center.12 They refer to the ED staff as “highly competent” and often “experts” in the medical management of chemical, biological, and radiological casualties.12 Among the many strengths of the ED is the ability to integrate two major components of the trauma system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in the chain of survival by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate lifesaving medical care until specialty resources become available.4–11 TRAUMA CENTERS The roles of trauma centers during a disaster or public health emergency are consistent with their daily activities in the treatment of injured patients. Triage and treatment of injured victims after a disaster is frequently discussed as a central role of the trauma center in the aftermath of a disaster.6,8–11,13,15–16,18,23,25–29 It is well documented that trauma centers are adept at the care of the injured victim, and are viewed as the best choice for the triage and treatment of disasterrelated injured victims.4–10,12,14,17,23,25–31 Trauma care is identified most frequently as the major strength of the trauma center and the trauma system. Another expectation is that trauma centers and acute care hospitals will be able to treat mass numbers of affected patients as well, including the rapid triage and treatment of all casualties (including those from CBRNE events), decontamination and/or isolation, and quarantine of contaminated or potentially infectious patients. Trauma centers are also expected to have access to essential equipment, supplies, and pharmaceutical agents.4–6,8,14–15,17,23,27–29,32 The Role of the Hospital/Healthcare Emergency Manager What then, is a hospital or healthcare emergency manager? A hospital or healthcare emergency manager is an individual employed by a healthcare organization whose job is to coordinate the emergency management functions of the hospital. This may include many responsibilities 55133_CH01_Reilly:Achorn Int’l 16 | Chapter 1 5/13/10 12:08 PM Page 16 Introduction to Hospital and Healthcare Emergency Management depending on the hospital or healthcare system, the location of the facility, the size and type of facility or organization, and specific local issues or threats and activities. While there may be variation in the role, almost universally the hospital/healthcare emergency manager will perform hazard vulnerability analysis, planning activities, coordination of the hospital’s disaster and other emergency management planning groups or committees, design and conduct training programs, perform drills and exercises, interact with other agencies and organizations involved in healthcare emergency management (e.g., local public health department, local office of emergency management, EMS, local law enforcement, and state agencies), and maintain compliance with regulatory agencies and accreditation organizations such as the JCAHO. Many hospital or healthcare emergency managers are individuals who have these duties in addition to their normal occupational roles in the healthcare organization. Typical positions within healthcare organizations that also perform emergency preparedness activities include nursing managers, educators, administrators, security managers, environmental health and safety administrators, facilities or physical plant directors, or emergency medical services coordinators. Few hospitals have taken the initiative to hire a full-time emergency preparedness coordinator for several reasons. First, there is no direct revenue return on investment in hospital preparedness. Emergency management is rather a fixed but necessary operating cost. In the United States, hospitals and healthcare organizations need to generate a profit. Even in not-for-profit hospitals, CEOs need to be able to show that profit increased in order to justify growth and add services for their patients. Activities that cannot improve the profitability of the organization often remain unfunded. Second, there is a shortage of qualified individuals to fill these positions. As mentioned before, most hospitals have added the duties and responsibilities of preparedness onto an existing full-time employee and this individual had to teach themselves how to perform these added duties. Most individuals who serve in full-time hospital emergency manager positions have a public safety background or a clinical background and have had to learn the discipline of emergency management. Until recently there have been few higher educational opportunities for people who wish to learn the discipline of healthcare emergency management. In 2010, the Federal Emergency Management Agency’s (FEMA) Higher Education Program listed only 10 undergraduate and graduate programs combined that focus on both healthcare and emergency management. Many of these are new programs that have only been in existence for a few years. There have been degree programs in general emergency management, but only a few that apply this discipline to the public health or hospital environment. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 17 References | 17 If you don’t seek out a formal degree, how do you become knowledgeable in hospital emergency planning? Initially, it begins with your current role. If you are a healthcare worker who needs to learn the finer points of emergency planning, drills and exercises, and incident management, then you could benefit from FEMA’s independent study program or professional development series. On the other hand, if you are an emergency management professional with little knowledge of the healthcare environment, you may benefit from continuing education in health and medical issues such as the strategic national stockpile, emerging infectious diseases and pandemics, the health and medical impact of terrorism and weapons of mass destruction, and the health impact on populations displaced as the result of disasters. This text is designed specifically for individuals who wish to learn the applied discipline of healthcare emergency management, and for all other personnel in a hospital or from other disciplines who will work with either a hospital or any other aspect of a healthcare system in planning for and responding to disasters, terrorism, and public health emergencies. Whether you are a college or graduate student learning the fundamentals of public health or healthcare emergency management, or a current healthcare professional looking to increase your current knowledge in order to apply emergency management principles to your trade, this book is designed to meet your needs. There is a lot to learn, and this text is just the beginning. This emerging field is exciting, challenging, and rewarding. We wish you luck on your journey! References 1. 2. 3. 4. 5. 6. U.S. Department of Labor, Occupational Safety and Health Administration. Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. Washington, DC: OSHA; 2005. OSHA publication 3249–08N. Joint Commission Resources. Emergency management standards. Environ Care News. 2007;10(12):2–8. Joint Commission Resources. Preparing for catastrophes and escalating emergencies. Environ Care News. 2008;11(1):1–3, 11. American College of Surgeons. Resources for Optimal Care of the Injured Patient: 1999. Chicago: American College of Surgeons; 1999. American Trauma Society and U.S. Department of Transportation, National Highway Traffic Safety Administration. Trauma System Agenda for the Future. National Highway Traffic Safety Administration; October 2002. Report #3P0138. American College of Surgeons. [ST-42] Statement on disaster and mass casualty management [by the American College of Surgeons]. American College of Surgeons Web site. http://www.facs.org/fellows_info/statements/st-42.html. Published 2003. Accessed December 28, 2009. 55133_CH01_Reilly:Achorn Int’l 18 | Chapter 1 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 5/13/10 12:08 PM Page 18 Introduction to Hospital and Healthcare Emergency Management Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Upper Saddle River, New Jersey: Brady/Prentice Hall Health; 2003. U.S. Department of Health and Human Services, Health Resources and Services Administration. A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events. Washington, DC: Health Resources and Services Administration; 2002. U.S. General Accounting Office. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. Washington, DC: U.S. General Accounting Office; August, 2003. Report GAO-03-924. Frykberg ER. Disaster and mass casualty management: a comment on the ACS position statement. Bulletin of the American College of Surgeons. 2003;88(8):12–13. White SR. Hospital and emergency department preparedness for biological, chemical, and nuclear terrorism. Clin Occup Environ Med. 2002;2(2):405–425. Trunkey DD. Trauma centers and trauma systems. JAMA. 2003;289:1566–1567. Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001. May AK, McGwin G Jr, Lancaster LJ, et al. The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries. J Trauma. 2000; 48(4):666–672. Rubin, JN. Recurring pitfalls in hospital preparedness and response. J Homeland Security. January, 2004. http://www.homelanddefense.org/journal/Articles/ rubin.html. Accessed August 18, 2009. U.S. General Accounting Office. SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases. Washington, DC: U.S. General Accounting Office; May 7, 2003. Publication GAO-03-769T. Feeney J, Parekh N, Blumenthal J, Wallack MK. September 11, 2001: a test of preparedness and spirit. Bulletin of the American College of Surgeons. 2002;87(5). Barbera JA, Macintyre AG, DeAtley CA. Ambulances to nowhere: America’s critical shortfall in medical preparedness for catastrophic terrorism. In: Howitt AM, Pangi RL, eds. Countering Terrorism: Dimensions of Preparedness. Cambridge, MA: MIT Press; 2003:283–297. Reilly MJ, Markenson D. Hospital emergency department referral patterns in a disaster. Prehosp Disast Med. 2009;24(2):s29–s30. Reilly MJ. Referral patterns of patients in disasters—who is coming through your emergency department doors? Prehosp Disast Med. 2007;22(2):s114–s115. Kellerman A. A hole in the homeland defense. Modern Healthcare. 2003;33(16):23. U.S. Department of Defense, Army, SBCCOM, Federal Domestic Preparedness Program. NBC Domestic Preparedness Senior Officials’ Workshop (SOW) [CD-ROM]. SBCCOM; 1999. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003;54:147–155. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41(4):457–462. Feliciano DV, Anderson GV Jr, Rozycki GS, et al. Management of casualties from the bombing at the Centennial Olympics. Am J Surg. 1998;176(6):538–543. Ghilarducci DP, Pirallo RG, Hegmann KT. Hazardous materials readiness of United States Level 1 trauma centers. J Occup Environ Med. 2000;42(7):683–692. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 19 References | 19 27. 28. 29. 30. 31. 32. American College of Surgeons. Disasters from biological and chemical terrorism—what should the individual surgeon do?: a report from the Committee on Trauma. American College of Surgeons Web site. http://www.facs.org/ civiliandisasters/trauma.html. Accessed December 30, 2009. American College of Surgeons. Statement on unconventional acts of civilian terrorism: a report from the Board of Governors. American College of Surgeons Web site. http://www.facs.org/civiliandisasters/statement.html. Accessed December 30, 2009. Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health threat with a trauma system response. J Trauma. 2003;55(6):1014–1021. MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA. 2003;289:1515–1522. Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published evidence regarding trauma system effectiveness. J Trauma. 1999; 47(3);S25–S33. Peterson TD, Vaca F. Commentary: Trauma systems: a key factor in homeland preparedness. Ann Emerg Med. 2003;41(6):799–801. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 20 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 21 Chapter 2 Healthcare Incident Management Systems Arthur Cooper, MD, MS Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Discuss the fundamental principles of healthcare incident management systems. ■ Describe the incident command system structure and its application to the healthcare environment. ■ Discuss the importance of interagency cooperation and collaboration when managing disasters and public health emergencies that impact the healthcare system. Overview Making method out of madness The aim of this chapter is to arm the busy healthcare staff, clinician, or emergency manger with a basic understanding of incident management 21 55133_CH02_Reilly:Achorn Int’l 22 | Chapter 2 5/13/10 1:15 PM Page 22 Healthcare Incident Management Systems systems as applied to the healthcare and hospital environment, including the Hospital Incident Command System (HICS), not as a substitute, but as a rationale for incident management training and the need to understand the application to a hospital or healthcare system. This chapter will cover the fundamental principles of healthcare incident management systems, including one system modified specifically for the hospital, the Hospital Incident Command System. Such systems are vital to the management of disasters, acts of terrorism, and public health emergencies involving healthcare organizations because, without the effective coordination of resources achieved through use of a healthcare incident management system, chaos, rather than order, will prevail. After a concise introduction to set the stage, the chapter will consider the historical background, foundational principles, incident leadership, command structures, HICS organization, training systems, HICS implementation, logistic concerns, practical concerns, and interagency relationships essential to successful healthcare incident management, before delivering its conclusions. Case Study A Cloud in the Midnight Sky You are the administrator on duty (AOD) when you are called by the physician in charge of the emergency department, who reports that numerous arriving patients are exhibiting spasms of severe coughing triggered by “something in the air.” While you consider your next steps, your spouse calls to tell you there has been a large explosion at a nearby tank farm adjacent to a large industrial facility. Television reports document widespread panic at the scene and in the immediate vicinity of your hospital, which is located about two miles (three kilometers) east of the site. It is past midnight; only caretaker staff are on duty (except in your critical and acute care units) and hospital staff await your orders. The following questions race through your mind. How would you begin to answer them? ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Does a bona fide disaster exist? Should I declare a disaster now? Should I seek additional information before declaring a disaster? Should I implement the hospital’s emergency operations plan? Should I activate the hospital’s command center? How will I ensure the safety of staff and patients? Should I mobilize additional hospital staff? Should I lock down the facility? Should all emergency patients be decontaminated? Should public health agencies be notified? 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 23 Historical Background | 23 ■ ■ ■ Who should I ask for necessary additional resources? Are there potential threats to the hospital itself? How will I coordinate and supervise all the staff? The decisions are yours to make. The answers may be found in this chapter. Introduction “Who’s in charge? They’re all in charge!”1 Understanding the Incident Command System (ICS) applied during disasters may prove a daunting task, even for healthcare executives experienced in interpreting complex tables of organization that baffle other managers, clinicians accustomed to solving and treating complex medical problems, and staff prepared to work in the complex healthcare environment. However, as recently stated so eloquently by Lieutenant Thomas Martin of the Virginia State Police in the illuminating video, The Many Hats Of Highway Incident Command (http://cts .virginia.edu/incident_mgnt_training.htm), the principles of incident command are fundamentally no different from the everyday manners children learn as youngsters, as elegantly and clearly described in the poignant work by author Robert Fulghum, All I Really Need To Know I Learned In Kindergarten.1,2 Within this simple framework, the responsible healthcare emergency manager can readily answer the question, “Who’s in charge?” The answer, of course, is that they’re all in charge, of what they’re in charge of—because all those involved in the disaster response are responsible for their immediate tasks, their communication with others, and first and foremost, their own and others’ safety. Historical Background “The best way to predict the future is to create it.”3 Modern incident command grew from the experience of firefighters in combating the California wildfires of the mid 1970s. Inadequate communication and ineffective collaboration between the numerous agencies battling these natural disasters led to the deaths of many firefighters whose lives need not have been lost. The subsequent after-action reports identified numerous critical weaknesses in the organization and delivery of many responders’ agencies and efforts, including lack of accountability, barriers to communication, poor planning processes, 55133_CH02_Reilly:Achorn Int’l 24 | Chapter 2 5/13/10 1:15 PM Page 24 Healthcare Incident Management Systems overloaded incident commanders, and absent response integration. The dawning realization that deficient and defective command and control were mostly responsible for these tragic fatalities led California fire chiefs to develop an “interoperable” system for emergency response, whereby all the involved agencies could communicate with one another and collaborate in the field, based upon a common organizational structure that all such agencies could understand and apply. This new system, called FIRESCOPE (Firefighting Resources of California Organized for Potential Emergencies), was based upon principles gleaned from military experience and management theory, especially the management by objectives concepts introduced in 1954 by Peter F. Drucker in his classic work, The Practice of Management.4 Its core purpose was to provide a standardized, on-scene, all-hazard incident management dogma that allowed its users to quickly implement an integrated organizational structure that was not impeded by jurisdiction boundaries, and was flexible and scalable enough to match the needs and resources for single, expanding, multiple, and complex incidents, despite their special circumstances and unique demands. It rapidly evolved into the Incident Command System (ICS) that has gradually been adopted by most fire and emergency services nationwide, the purposes of which are to ensure the (1) safety of responders and others, (2) achievement of tactical objectives, and (3) efficient use of resources. As a result, ICS was subsequently designated for use throughout the United States by the federal Superfund Amendments and Reauthorization Act (SARA) of 1986 (PL 99-499), Occupational Health and Safety Administration (OSHA) rule 1910.120, and, most recently, Homeland Security Presidential Directive 5 (HSPD 5),5 in addition to numerous other state and local regulations. Its early success also led the California Emergency Medical Services Authority to adapt and periodically revise it for use in all disasters involving hospitals, such that it now serves as the basis of the Hospital Incident Command System (HICS) used by most hospitals in the Americas and, increasingly, worldwide. Specific instruction in HICS is available through both the California Emergency Medical Services Authority HICS Web site (http://www.emsa.ca.gov/HICS/default.asp), and the Emergency Management Institute’s Web site (http://training .fema.gov), within the independent study ICS courses IS-100.HC and IS-200.HC revised in 2007 for healthcare providers.6 Foundational Principles “Management by objectives”4 The three key strategies of the disaster response, in order, are to (1) protect and preserve life, (2) stabilize the disaster scene, and (3) protect and preserve property. Healthcare providers intuitively understand the first 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 25 Incident Leadership | 25 purpose, and intellectually understand that the third purpose is essential to the first because healthcare providers cannot perform their lifesaving tasks without the appropriate facilities, equipment, and resources. The second purpose, however, may be less obvious. This is because an organized disaster response can occur only within the context of a stable work environment—an environment that is difficult to achieve in the first minutes after disaster strikes, when chaos is the rule, even in greatly complex work environments, such as hospitals, that are highly self-regulated. Thus, an incident management system is needed to bring order to the chaos, the sine qua non of which is an incident command structure characterized by the three key tactics that must underlie all of incident command—unity of command, span of control, and clarity of text. Unity of command refers to the principle that sharing of information among all personnel involved in a disaster response is vital, but such individuals receive formal orders from, and make formal reports to, a single supervisor in order to preserve the viability of the chain of command. Span of control refers to the principle that in a high stress environment, no line supervisor can effectively coordinate the efforts of more than three to seven, and ideally no more than five, subordinate personnel. Clarity of text refers to the principle that all communications, written and spoken, must be transmitted in the simplest, most generic language possible, avoiding the use of words or jargon likely beyond the understanding of many emergency responders, so as to ensure that all personnel involved in the disaster response understand both the general strategy of the Emergency Operations Plan (EOP) and the special tactics being applied to combat the disaster. Incident Leadership “Coordination, Communication, Cooperation”1 Healthcare incident management systems achieve their goals by ensuring what have been termed the “3 Cs” of incident command: coordination, communication, and cooperation, of which the most important is cooperation, because it makes coordination and communication feasible. However, effective incident management requires not only universal education in disaster management appropriate to the functional job description of the individual healthcare employee—awareness, technical, and professional—but also frequent drilling in the implementation of the hospital disaster plan, especially its incident command structure. Most texts and training rightly emphasize that the individuals designated to fulfill specific functional job descriptions must be appropriately trained to do so; therefore, hospital executives who perform similar tasks during routine hospital business must step aside and yield these responsibilities to those who have been trained 55133_CH02_Reilly:Achorn Int’l 26 | Chapter 2 5/13/10 1:15 PM Page 26 Healthcare Incident Management Systems to do so. However, this notion ignores long-established realities of human behavior—the boss is still the boss, even if untrained in disaster management—so every effort should be made by senior executives to ensure that all hospital executives receive training in disaster management and incident command that will enable supervisors to function in their assigned roles even when disaster strikes. Physicians commonly presume that because the first key purpose of incident management is to protect and preserve life, they should be in charge of emergency operations. However, physicians often overlook the fact that while they must clearly be in charge of all aspects of medical care, they generally comprise no more than approximately 10% of the total number of hospital personnel. Typically, the healthcare needs of the hospitalized patient require an average of 10 other personnel to support the treatments prescribed and the operations performed by a single physician or surgeon. Moreover, the physician’s expertise—and most valuable contribution to the hospital disaster response—lies in the medical care of the hospitalized patient, rather than its operational, logistical, or planning support. Command Structure “[ICS is] the system to achieve the coordination necessary to carry out an effective and efficient response.”7 Two basic command structures, and variations thereof, are utilized worldwide: (1) the Hospital Incident Command System (HICS), developed by the California Emergency Medical Services Authority and promulgated both by its originator (http://www.ems…
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Disaster Managing Efforts Discussion Board Question

Image source: www.ucdenver.edu Emergency Management Update Team 2016- 1 © Copyright, The Joint Commission Emergency Management Debrief Lessons Learned Planning & Leadership Emergency Program Emergency Management Update Team 2016- 2 © Copyright, The Joint Commission EMERGENCY MANAGEMENT CHAPTER OUTLINE  Foundation for the Emergency Operations Plan [EM.01.01.01]  The Emergency Operations Plan (EOP) General Requirements [EM.02.01.01]  Specific Requirements  Six Critical Areas [EM.02.02.01-EM.02.02.11]  Disaster Volunteers [EM.02.02.13-EM.02.02.15]  Evaluation Evaluating the planning activities [EM.03.01.01]  Evaluating the Emergency Operations Plan through exercises [EM.03.03.03]  Emergency Management Update Team 2016- 3 © Copyright, The Joint Commission  1. Communication [EM.02.02.01] 2. Resources & Assets [EM.02.02.03] 3. Safety & Security [EM.02.02.05] 4. Staff responsibilities [EM.02.02.07] 5. Utilities Management [EM.02.02.09] 6. Patient, clinical & support activities [EM.02.02.11] Emergency Management Update Team 2016- 4 © Copyright, The Joint Commission SIX CRITICAL AREAS 2016 Emergency Management Update Team The Joint Commission © Copyright, The Joint Commission WHAT HAS THE JOINT COMMISSION BEEN UP TO? EMERGENCY MANAGEMENT TEAM  Cross-divisional team  Review of large-scale events  Improvement  Field and surveyor education  Survey process and standards Emergency Management Update Team 2016- 6 © Copyright, The Joint Commission  Debriefs  Lessons learned  Education and process improvement DEBRIEFS WITH HEALTH CARE ORGANIZATIONS  Hurricane Sandy  West Texas Fertilizer Explosion  West Virginia Water Contamination  Boston Marathon Bombing  Ebola Outbreak  Baltimore Civil Unrest  San Bernardino Terrorist Event  Ferguson Civil Unrest Emergency Management Update Team 2016- 7 © Copyright, The Joint Commission  South Carolina Flooding LESSONS LEARNED – PLANNING/PREPAREDNESS  Establish relationships w/law enforcement & back-up security agencies  Joint education, drills, etc.  Activate ICS early in incident to support situational awareness  Plan / drill for escalating events  Mass shooting plus bomb threat. Emergency Management Update Team 2016- 8 © Copyright, The Joint Commission  Communication. LESSONS LEARNED – PLANNING/PREPAREDNESS  Identify & reach out to staff living in hot  e.g., laundry service  Know actual usage of utilities on ‘normal’ day, in evening, on weekends. Emergency Management Update Team 2016- 9 © Copyright, The Joint Commission zones during unrest to identify support needs in advance.  Consider supply chain and alternate service providers during water contamination. LESSONS LEARNED – PLANNING/PREPAREDNESS  Plan for most emerging infectious diseases rather than new ‘outbreak of the week’ plan.  IC plan, surge plan, all hazards plan, decon plan, pan-flu plan  Don’t overlook common risks that could go on the HVA in community or region  CBRNE: Fertilizer storage facilities throughout the region that could pose risk of combustion/explosion. Emergency Management Update Team 2016- 10 © Copyright, The Joint Commission  Risks LESSONS LEARNED – PLANNING/PREPAREDNESS  Planning for civil unrest focused primarily on:  Communications (with staff, patients, community incident command, the public/media)  Security  Transit (to the facility for patients and staff) Emergency Management Update Team 2016- 11 © Copyright, The Joint Commission  Reviewing EOP annually  Policies addressing utility disruption, including approach to clinical interventions  Water LESSONS LEARNED – PLANNING/PREPAREDNESS  Don’t overlook home care, outpatient services and other ancillary providers home care providers were held back from entering certain communities where there were clients with chronic conditions – care arrangements can be addressed proactively. Emergency Management Update Team 2016- 12 © Copyright, The Joint Commission  During unrest LESSONS LEARNED – GENERAL RESPONSE hospital & campus to identify flood issues early.  Divert spontaneous volunteers (even clinical) from ED to avoid congestion during trauma response.  Community-based & mobile services (e.g., addiction services) need to choose their locations during unrest to preserve safety of staff/patients. Emergency Management Update Team 2016- 13 © Copyright, The Joint Commission  Conduct frequent tours (every 2 hours) of LESSONS LEARNED – COMMUNICATIONS command/control, staff, patients/families, media & the public.  Don’t presume that all staff have smart phones or use social media; use redundant methods of staff communication.  Manage staff stress and access to misinformation via proactive staff communication strategy. Emergency Management Update Team 2016- 14 © Copyright, The Joint Commission  Have separate lines of communication for LESSONS LEARNED – COMMUNICATIONS with cell phone during response and recovery.  Proactive media/social media outreach plan mitigates intrusions from reporters that consume leaders’ time during response.  Regular joint calls with local providers, city & state support situational awareness during unrest. Emergency Management Update Team 2016- 15 © Copyright, The Joint Commission  Carry extra batteries and/or chargers along  During unrest:  Monitor social media used/sponsored by protest groups to anticipate crowd movement and potential impact on transit or emergency/urgent care.  Reinforce with staff – verbally and in written messaging/scripts used as needed in patient/family interactions – values of diversity and role to care for all people to help mitigate safety concerns or racial tension impacting community. Emergency Management Update Team 2016- 16 © Copyright, The Joint Commission LESSONS LEARNED – COMMUNICATIONS LESSONS LEARNED – SECURITY  Definition of ‘lock-down’ with response partners  Security forces have one meaning, hospitals may vary  Civil unrest response from small community hospital & secured it’s perimeter – closed all off-site locations  Security to central site  Moved vehicles  Removed from public access items that could be removed/damaged Emergency Management Update Team 2016- 17 © Copyright, The Joint Commission  Reduced LESSONS LEARNED – SECURITY  Reinforced with staff use of de-escalation techniques during civil unrest.  Train/exercise with local law enforcement  During terrorist shooting over 40 officers were onsite in minutes Conducted bomb search and provided essential support. No need to arm hospital security.  Separate ED waiting area for injured police officers & their families during unrest Emergency Management Update Team 2016- 18 © Copyright, The Joint Commission  LESSONS LEARNED – STAFF  Senior leadership  Prioritize time and resources for staff training Emergency Management Update Team 2016- 19 © Copyright, The Joint Commission  Weather/natural disasters  Prepare for staff rotations & shift relief  Designated sleeping areas, adequate meals  Shuttle system to/from homes LESSONS LEARNED – STAFF  Monitor local/county/state agencies  Road closures, curfews, etc. that impact staff movement to & from work community conditions change  Place Critical Incident Stress management staff in EOC  Provide real-time support & guidance to chain of command during unrest Emergency Management Update Team 2016- 20 © Copyright, The Joint Commission  Adjust shifts, allow sheltering in place as LESSONS LEARNED – PATIENT CARE  Flooding  Review IC plan to assess patient risk for HAI. Emergency Management Update Team 2016- 21 © Copyright, The Joint Commission  Water contamination  Home health & DME partners proactively monitor at-risk patients  Facilitate patient education on O2 concentrators, CPAP machines, & water sourcing. LESSONS LEARNED – EXERCISES  Stress & test system, staff, leaders with escalating complications & patients with different functional needs.  Train & practice staff in active shooter response with in-house security & law enforcement. Emergency Management Update Team 2016- 22 © Copyright, The Joint Commission  Joint exercise LESSONS LEARNED – LEADERSHIP  Leaders met frequent w/staff to discuss quality of care and safety during flood response/recovery.  Leaders facilitated visible presence of security in and around building during unrest  Increased sense of security. managerial assistance; identified & addressed staff morale/support needs in process after terrorist attack. Emergency Management Update Team 2016- 23 © Copyright, The Joint Commission  Leaders rounded & provided hands-on LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING  Reinforced w/staff & community role of hospital as safe zone for all injured. Emergency Management Update Team 2016- 24 © Copyright, The Joint Commission  Civil unrest/recovery  Town hall meetings for information & support and to dispel myths/rumors  Made available EAP & pastoral care  Routed routine monthly prayer walk through vulnerable community.  During unrest response & recovery  Invited staff discussion (individual or small group) on racial tension  Sense of safety at home in impacted community  Need for safety tips or security/transit support (alter work hours, shelter at hospital, etc.). Emergency Management Update Team 2016- 25 © Copyright, The Joint Commission LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING LESSONS LEARNED – INFECTIOUS DISEASE  Plan, train, & exercise for infectious disease emergencies:  initial screening of PPE, including don and dof  safe patient flow (entry point to isolation)  iterative training of care teams  dedicated equipment  safe transfer of patients  disposal & transport of waste Emergency Management Update Team 2016- 26 © Copyright, The Joint Commission  use LESSONS LEARNED – UTILITIES  Water  Processes for cleaning water systems after loss of water  Supply for systems management  Potable vs. non-potable • Equipment use, i.e. sterile processing • Human consumption Emergency Management Update Team 2016- 27 © Copyright, The Joint Commission  Fuel  Increase run time through load-shedding LESSONS LEARNED – HEALTH CARE PARTNERS  Water contamination:  Ambulatory dialysis company deployed water tanker truck to supply hospital  Dialysis biochemist supported hospital in sampling & testing water Emergency Management Update Team 2016- 28 © Copyright, The Joint Commission  Nursing home destroyed in industrial blast:  Other homes contacted hospital to offer beds  Hospital worked with case manager, behavioral health staff and home care to place patients 2 weeks post-disaster LESSONS LEARNED – HEALTH CARE PARTNERS  Maintain access to care  Chronic care patients  Medications from pharmacies outside of impacted area of emergency • Civil unrest, weather emergencies, etc. Emergency Management Update Team 2016- 29 © Copyright, The Joint Commission  Reinforce IC preparedness  Affiliated clinics and physician offices where at-risk patients may be seen.  Screening, use of PPE and other precautions LESSONS LEARNED – EVACUATION  Practice evacuation drills using evacuation equipment: equipment is required?  Where will equipment be deployed (which units, floors, etc.)?  Who needs to be trained in its use? Emergency Management Update Team 2016- 30 © Copyright, The Joint Commission  How much LESSONS LEARNED – RECOVERY  Recovery  Ancillary / offsite / support departments that were impacted by event or that contribute to resiliency.  Business continuity  Timely engagement with FEMA and insurers Emergency Management Update Team 2016- 31 © Copyright, The Joint Commission  Leadership engagement  Avoid fatigue and silos  Accountability Link: http://www.jointcommission.org/emergency_management.aspx Emergency Management Update Team 2016- 32 © Copyright, The Joint Commission EMERGENCY MANAGEMENT PORTAL 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page i HEALTH CARE EMERGENCY MANAGEMENT PRINCIPLES AND PRACTICE Editors Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor, Public Health Practice New York Medical College School of Health Science and Practice Valhalla, New York and David Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com 5/21/10 1:36 AM Page ii Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Publisher: Michael Brown Editorial Assistant: Catie Heverling Editorial Assistant: Teresa Reilly Production Manager: Tracey Chapman Associate Production Editor: Kate Stein Senior Marketing Manager: Sophie Fleck Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Achorn International Art: diacriTech Associate Photo Researcher: Sarah Cebulski Cover Design: Kristin E. Parker Cover Image: Top left: Courtesy of Andrea Booher/FEMA; Top Right: Courtesy of Win Henderson/FEMA; Bottom left: Courtesy of Jocelyn Augustino/FEMA; Bottom right: Courtesy of Cynthia Hunter/FEMA Printing and Binding: Malloy, Inc. Cover Printing: John Pow Company Library of Congress Cataloging-in-Publication Data Health care emergency management : principles and practice / [edited by] Michael J. Reilly and David S. Markenson. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7637-5513-3 (pbk.) ISBN-10: 0-7637-5513-3 (pbk.) 1. Emergency medical services. 2. Emergency management—Planning. 3. Hospitals—Emergency services. I. Reilly, Michael J. II. Markenson, David S. [DNLM: 1. Disaster Planning—organization & administration. 2. Emergencies. 3. Emergency Service, Hospital—organization & administration. WX 185 H4336 2011] RA645.5.H38 2011 362.18068—dc22 2010001554 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iii Dedication MICHAEL REILLY I dedicate this text to my family and friends who have supported me throughout this project. I especially thank my parents, who have provided their unwavering advice and support throughout my life and career. I also dedicate this text to my professional mentors Dr. Linda Degutis and Dr. Robyn Gershon, who continue to give me invaluable guidance throughout my professional development. Finally, I dedicate this book to my coauthor David, who has provided me with the opportunity to pursue academic emergency and disaster medicine professionally, and who continues to encourage and support my development as a scientist and scholar in this evolving area of medicine and public health. DAVID MARKENSON This text is dedicated to my parents, who have always guided, supported, and encouraged me, and who, as physicians, have shown me through their work that providing care to others in a compassionate and knowledgeable way can be a rewarding endeavor. This text is also dedicated to my brothers, sister, and sisters-in-law, who are a constant source of advice, support, and energy; without their help and involvement in my life none of my efforts could have been accomplished. Most importantly this text is dedicated to my wife Heidi and my wonderful children, Emily, Rachel, and George, who not only support me but who were willing to give of their time with me to allow me to write this text. iii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iv iv | Dedication MICHAEL REILLY AND DAVID MARKENSON Lastly, this text is dedicated to all healthcare providers, emergency managers, and those in their care. Healthcare providers and emergency managers work each day in an environment that is unpredictable, often dangerous, and constantly challenging. They have become champions in changing the system to become better prepared. They dedicate their lives to aid the sick and the injured and prepare for any disaster, terrorism event, or public health emergency, driven only by their care for others and their devotion to this profession we call healthcare emergency management. We salute all of you in your professionalism and dedication. Also, we dedicate this to our patients who, in allowing us the privilege to provide them care, teach us each day about humanity. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page v Contents About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Chapter 1 Chapter 2 Principles of Emergency Management for Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction to Hospital and Healthcare Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Healthcare Incident Management Systems . . . . . . . . . . . . . 21 Arthur Cooper, MD, MS v 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vi vi | Contents Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 II Chapter 8 Section Chapter Chapter 9 10 Section III Chapter 11 Chapter 12 Improving Trauma System Preparedness for Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . 47 Michael J. Reilly, DrPH, MPH, NREMT-P Legal Issues and Regulatory Compliance . . . . . . . . . . . . . 67 Doris R. Varlese, JD Developing the Hospital Emergency Management Plan . . . 89 Nicholas V. Cagliuso, Sr., MPH; Nicole E. Leahy, RN, MPH; and Marcelo Sandoval, MD Introduction to Exercise Design and Evaluation . . . . . . . . 111 Garrett T. Doering, MS, EMT-P, CEM, MEP Integration with Local and Community Resources . . . . . . 143 Isaac B. Weisfuse, MD, MPH Hospital Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . 161 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Sean M. Kelly, MA, CCEMT-P and Lindsey P. Anthony, MPA, CEM, CHEC-III Functional Roles of Hospital Workers in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . 187 Tony Garcia, RN, CCEMT-P Credentialing and Management of Volunteer Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Deborah Viola, PhD, MBA and Peter Arno, PhD Hospital Operations During Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 221 Quantitative Planning for Epidemic and Disaster Response: Logistics and Supply Chain Considerations . . . . . . . . . . . 223 Nathaniel Hupert, MD, MPH; John A. Muckstadt, PhD; and Wei Xiong, PhD, MS Risk Communication and Media Relations . . . . . . . . . . . . 233 Linda C. Degutis, DrPH, MSN and Lauren Babcock-Dunning, MPH 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vii Contents | vii Chapter 13 Chapter 14 Chapter 15 Chapter 16 IV C h a p t e r 17 Section Chapter 18 V C h a p t e r 19 Section Chapter 20 Chapter 21 Chapter 22 Security and Physical Infrastructure Protections. . . . . . . . . 271 Robert Michael Schuler, BGS, NREMT-P and Veronica Senchak Snyder, MHS, MBA Hospital Decontamination and Worker Safety . . . . . . . . . . 299 Michael J. Reilly, DrPH, MPH, NREMT-P Pharmaceutical Systems Management in Disasters. . . . . . 317 David S. Markenson, MD, FAAP, FACEP, EMT-P Laboratory Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 331 Ramon Rosal, PhD Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Principles of Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . 341 E. Brooke Lerner, PhD and Richard B. Schwartz, MD Managing an Infectious Disease Disaster: A Guide for Hospital Administrators . . . . . . . . . . . . . . . . . 353 Ariadne Avellino, MD, MPH Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 Vulnerable Populations and Public Health Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Elizabeth A. Davis, JD, EdM; Rebecca Hansen, MSW; and Jennifer Mincin, PhD (ABD) Altered Standards of Care in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 401 John Rinard, BBA, MSCPI Mass Fatality Management . . . . . . . . . . . . . . . . . . . . . . . 423 Barbara A. Butcher, MPH and Frank DePaolo, RPA-C Research in Emergency and Disaster Medicine . . . . . . . . 447 Kobi Peleg, PhD, MPH and Michael Rozenfeld, MA Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page viii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page ix About the Authors MICHAEL J. REILLY, DRPH, MPH, NREMT-P Dr. Michael Reilly is currently the Assistant Director of the Center for Disaster Medicine at New York Medical College in Valhalla, New York. Additionally, he is an Assistant Professor of Public Health Practice and the Director of the Graduate Program in Emergency Preparedness at the School of Health Science and Practice. Dr. Reilly has over a decade of multidisciplinary experience in emergency preparedness, public safety, intergovernmental relations, public health, and emergency management. He has been published in the world’s leading disaster medicine and public health preparedness journals, and received international awards and recognition for his work on trauma systems and health systems in the context of disaster and public health preparedness. Dr. Reilly is an internationally recognized expert in the areas of emergency medical services, and health system preparedness and response, with direct experience in responding ix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page x x | About the Authors to mass casualty events and public health emergencies. Dr. Reilly is frequently called upon to provide expert consultation, subject matter expertise, and to evaluate healthcare systems preparedness, emergency planning, and drills and exercises. Dr. Reilly has designed numerous educational curricula and training programs for a variety of preparedness functional roles for public health, emergency management, and public safety audiences at the professional and graduate levels. He is a senior lecturer for multiple federal agencies including the Department of Justice, Department of Homeland Security, and the Occupational Safety and Health Administration. Additionally, he is an active member of several state and national committees on homeland security and emergency management programs. He received his undergraduate education at Northeastern University in paramedic technology and health science. He earned his Masters of Public Health from Yale University, and a doctorate in public health from New York Medical College. Dr. Reilly remains active as a paramedic in the Metro New York City region and maintains numerous specialty and technical certifications and instructor credentials in the areas of emergency medical services, worker safety, environmental health, hazardous materials emergency response, emergency management, counterterrorism, and weapons of mass destruction preparedness and response. DAVID SAMUEL MARKENSON, MD, FAAP, FACEP, EMT-P Dr. David Markenson is a board-certified pediatrician with Fellowship training in both pediatric emergency medicine and pediatric critical care. He is the Vice President and Medical Director of Disaster Medicine and Regional Emergency Services at the Westchester Medical Center and Maria Fareri Children’s Hospital. In addition, he is the Director of the Center for Disaster Medicine and the Interim Chair of Epidemiology and Community Health at the School of Health Sciences and Practice at New York Medical College. Dr. Markenson is also a Professor of Pediatrics and an Associate Professor of Public Health at the School of Health Sciences and Practice at New York Medical College in Valhalla, New York. He is an active member of, and has served in leadership positions within, multiple professional societies, including the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, the Society of Critical Care Medicine, the American College of Physician Executives, and the National Association of EMS Physicians. Dr. Markenson has been actively involved with the American Red Cross for over 20 years and currently serves as the National Chair of the Advisory Council which oversees disaster health, preparedness, and health and safety. In this role he directs the scientific and technical as- 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xi About the Authors | xi pects of all programs and products in these areas including their development, implementation, and research. Prior to coming to Westchester Medical Center and New York Medical College he was the Deputy Director of the National Center for Disaster Preparedness at the Mailman School of Public Health, Columbia University, and was also the Director of the Program for Pediatric Preparedness of the National Center, a program dedicated to improving the care children receive in times of disasters or acts of terrorism. His career has been dedicated to improving the approach to pediatric care, disaster medicine, EMS, and emergency medicine. He is the principal investigator on several federal grants related to pediatric disaster medicine, including Model Pediatric Component for State Disaster Plans and National Consensus Conference on the Needs of Children in Disasters. He has also addressed the needs of other special and vulnerable populations and directed a federal grant to develop the first and only national guidelines for emergency preparedness for persons with disabilities. In addition to this, he has conducted research on healthcare preparedness and healthcare provider and student education. In this area he was the principal investigator for a federal grant which developed the first competencies for all healthcare students in emergency preparedness and then piloted this set of competencies in a medical, dental, public health, and nursing school. Dr. Markenson has been recently appointed to the FEMA National Advisory Council as the In-Patient Medical Provider representative. The FEMA NAC is comprised of emergency management and law enforcement leaders from state, local, and tribal government and the private sector to advise the FEMA Administrator on all aspects of disaster preparedness and management to ensure close coordination with all partners across the country. He is a frequent presenter and lecturer at medical conferences across the country, serves in editorial roles for multiple professional scientific journals, and has authored numerous articles and books on pediatric care, disaster medicine, and prehospital medicine. His work in disaster medicine started during his college career when he worked in disaster services in upstate New York providing direct services and education to other disaster services workers on behalf of the local Red Cross and county office of emergency management. Dr. Markenson is a graduate of Albert Einstein College of Medicine in the Bronx, New York. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiii Contributors Lindsey P. Anthony, MPA, CEM, CHEC-III Operational Medicine Education Coordinator Center for Operational Medicine Medical College of Georgia Augusta, Georgia Peter Arno, PhD Professor Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York xiii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiv xiv | Contributors Ariadne Avellino, MD, MPH Research Associate Center for Disaster Medicine New York Medical College Valhalla, New York Lauren Babcock-Dunning, MPH Research Associate Center for Transportation Safety, Security and Risk Rutgers, The State University of New Jersey New Brunswick, New Jersey Barbara A. Butcher, MPH Chief of Staff Office of the Chief Medical Examiner City of New York New York, New York Nicholas V. Cagliuso, Sr., MPH Corporate Director Emergency Management Continuum Health Partners, Inc. New York, New York Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma and Pediatric Surgical Services Harlem Hospital New York, New York Elizabeth A. Davis, JD, EdM Principal EAD & Associates, LLC Brooklyn, New York Linda C. Degutis, DrPH, MSN Associate Professor of Surgery (Emergency Medicine) and Public Health Director, Center for Public Health Preparedness Yale University School of Medicine New Haven, Connecticut 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xv Contributors | xv Frank DePaolo, RPA-C Director Special Operations Division Office of the Chief Medical Examiner City of New York New York, New York Garrett T. Doering, MS, EMT-P, CEM, MEP Director of Emergency Management Westchester Medical Center Valhalla, New York Tony Garcia, RN, CCEMT-P Training Specialist Texas Engineering Extension Service Texas A&M University System College Station, Texas Rebecca Hansen, MSW Senior Project Manager EAD & Associates, LLC Brooklyn, New York Nathaniel Hupert, MD, MPH Associate Professor of Public Health and Medicine Weill Cornell Medical College New York, New York Sean M. Kelly, MA, CCEMT-P Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York Nicole E. Leahy, RN, MPH Manager Burn Outreach and Professional Education New York-Presbyterian Hospital / Weill Cornell Medical Center New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvi xvi | Contributors E. Brooke Learner, PhD Associate Professor Department of Emergency Medicine Department of Population Health Medical College of Wisconsin Milwaukee, Wisconsin David S. Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York Jennifer Mincin, PhD (ABD) Senior Project Manager/Director EAD & Associates, LLC Brooklyn, New York John A. Muckstadt, PhD Acheson/Laibe Professor Business Management and Leadership Studies School of Operations Research and Industrial Engineering Cornell University Ithaca, New York Kobi Peleg, PhD, MPH Director, Israel National Center for Trauma and Emergency Medicine Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Co-chair, The Multi-disciplinary Program for Emergency and Disaster Management School of Public Health Tel-Aviv University Tel-Aviv, Israel Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor of Public Health Practice New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvii Contributors | xvii John Rinard, BBA, MSCPI Milano, Texas Ramon Rosal, PhD Chemical Response Director Public Health Laboratory New York City Department of Health and Mental Hygiene New York, New York Michael Rozenfeld, MA Researcher National Center for Trauma & Emergency Medicine Research Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Tel Hashomer, Israel Marcelo Sandoval, MD Faculty, Department of Emergency Medicine Co-Chair, Emergency Management Committee Beth Israel Medical Center / Petrie Division New York, New York Robert Michael Schuler, BGS, NREMT-P Training Coordinator Texas Engineering Extension Service The Texas A&M University System College Station, Texas Richard B. Schwartz, MD Chair and Professor Department of Emergency Medicine Medical College of Georgia Augusta, Georgia Veronica Senchak Snyder, MHS, MBA Emergency Management Coordinator Emergency Management Services Geisinger Health System Geisinger Medical Center Danville, Pennsylvania Doris R. Varlese, JD Visiting Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xviii xviii | Contributors Deborah Viola, PhD, MBA Associate Professor of Public Health Practice Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York Isaac B. Weisfuse, MD, MPH Deputy Commissioner Division of Disease Control New York City Department of Health and Mental Hygiene New York, New York Wei Xiong, PhD, MS Instructor in Public Health Weill Cornell Medical College New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xix Acknowledgments he material contained in this text reflects the contributions of many authors, editors, emergency managers, healthcare providers, reviewers, and others who provided assistance and valuable suggestions. While here we acknowledge them, our sincere appreciation for all of their efforts is truly hard to express in this limited space. In addition, we could not possibly acknowledge all those who participated in this important endeavor, and so we would like to also extend our sincere appreciation to every person who helped with this project, whether listed by name or not. Many talented people at Jones & Bartlett Learning have been involved in developing and producing this new text. As authors and editors, we turned our manuscript to the exceptional editorial staff and publishers at Jones & Bartlett Learning to create this finished product. We are fortunate to have been able to work with this team of people, who have contributed so much and had such a tremendous impact on T xix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xx xx | Acknowledgments the quality of the textbook you now have in your hands. Specifically Michael Brown, Publisher, assisted by Catie Heverling and Kate Stein, has been our support at Jones & Bartlett Learning. As Publisher, Mike is committed to publishing quality books; his energy, intelligence, patience, and helpful efforts have enabled us to create an exceptional product. With the additional day-to-day support and guidance of both Catie Heverling and Kate Stein we were able to keep our project on track and ultimately produce this important text. A significant amount of coordinating and operational support in moving this project forward would not have been possible without the tireless work of our administrative assistant Patience Ameyaw. We thank her for her hard work and support of this project along with Geordana Roa, Nina Luppino, and our numerous disaster medicine interns over the past several years. Components of this text have been based on the exceptional work of the Center for Disaster Medicine at the New York Medical College, School of Health Sciences and Practice for which we serve as the Director and Assistant Director. Without the support of our Center, the prior research and models developed, and the strong and supportive academic environment of New York Medical College, this work would not have been possible. We would like to specifically thank Dean Robert Amler of the New York Medical College, School of Health Sciences and Practice, who in his own right is an internationally recognized expert in public health and healthcare preparedness, for providing his personal expertise and his leadership in creating an academic environment where work such as this text is not only encouraged but supported, and for his continued dedication to providing education to improve emergency preparedness. We would like to also acknowledge the Westchester Medical Center and its Maria Fareri Children’s Hospital, which serves as the regional center for healthcare emergency preparedness. The source and realworld testing of many of the theories and models in this text come from the preparedness efforts of this institution, which is recognized as not only a regional but as a national leader in emergency preparedness. We would like to thank the leadership of this institution for allowing us to use the wonderful preparedness work they have done as models for others to follow. While not being able to list all, we would like to acknowledge the members of the senior leadership who day in and day out support the preparedness activities: Mr. Michael Israel, Mr. Gary Brudnicki, Dr. Renee Garrick, Dr. Michael Gewitz, Ms. Marsha Casey, and Mr. Anthony Costello. Lastly, we would especially like to thank the institution’s Director of Emergency Management and chapter contributor Mr. Garrett Doering for sharing his professional insight and experience with us as we completed this project. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxi Acknowledgments | xxi Finally, we are extremely grateful to the numerous healthcare providers, emergency managers, educational consultants, and members of the preparedness academic community who carefully critiqued the manuscript to ensure that the information in this text would be both relevant and appropriate. Many more dedicated professionals than we could name here gave unstintingly of their own time and expertise. Their enthusiastic participation has been a motivating force behind this project, and they received no compensation beyond the knowledge that they were helping to create a greatly needed resource. We hope the final product lives up to their efforts, hopes, and expectations. Our warmest and kindest regards, Michael and David 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxii 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 1 Section I Principles of Emergency Management for Healthcare Facilities 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 2 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 3 Chapter 1 Introduction to Hospital and Healthcare Emergency Management Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Describe the need for and responsibilities of healthcare emergency management. ■ Describe the role of the hospital emergency manager. ■ Identify the activities performed by healthcare emergency management. Emergence and Growth of Healthcare Emergency Management The concept of healthcare emergency management is not entirely new, but may seem strange and foreign to those who have worked in healthcare or emergency management and, until recently, have not known anyone working in this profession. If one looks back more than 30 years, it would be almost impossible to find a hospital role called hospital 3 55133_CH01_Reilly:Achorn Int’l 4 | Chapter 1 5/13/10 12:08 PM Page 4 Introduction to Hospital and Healthcare Emergency Management emergency management or even a position for a healthcare emergency manager in a hospital or medical center.Yet healthcare emergency management responsibilities have always been addressed by hospitals, such as fire safety, backup power, and the ability to handle victims from a mass casualty event. A fundamental tenet of emergency management is that institutions must prepare for events that may rarely occur while taking protective actions to mitigate any likelihood that they will occur at all. Due to the low frequency of events testing the health system’s ability to respond to a disaster, an act of terrorism, or a public health emergency, the ability to evaluate the strengths and weaknesses of hospital emergency preparedness is limited. In addition, the public has strong expectations of the roles hospitals should play during times of disaster. Healthcare institutions are expected to provide both emergency care and continuance of the day-to-day healthcare responsibilities regardless of the volume and demand. Recently, they have also become sites of community refuge, bastions of safety in a threatening and dangerous environment. The public believes that hospitals will have light, heat, air conditioning, water, food, and communications capabilities, regardless of the fact that the institution may itself be affected by the calamity. During the terrorist attacks in the fall of 2001 and the Northeast Blackout of 2003, the public flocked to hospitals, even when they did not require medical care. Furthermore, with increased intelligence of the vulnerabilities of the healthcare infrastructure and the desire of terrorists to exploit this, institutions have been forced to focus limited resources on safety and security rather than on comprehensive emergency management efforts. A major change in the way hospitals plan for hazards and vulnerabilities includes less planning for specific single issues or threats but rather the adoption of an all–hazards comprehensive emergency management planning process. Additionally, hospitals need to look beyond their emergency department doors and engage community stakeholders to assist in this process, reaching out to local and regional emergency planners to assist in larger communitywide emergency preparedness planning. The interest of nonhospital entities in health system emergency preparedness can be seen through several examples, including emergency management and public health initiatives on mass vaccination, pandemic planning, increasing hospitals’ ability to perform decontamination of casualties contaminated with hazardous materials, etc. Recent reflection of the role of the hospital in emergency management and population health can been seen in revised laws, regulations, and even accreditation standards. An example of this is The Joint Commission on the Accreditation of Healthcare Organizations’ (JCAHO) change from placing emergency preparedness standards in the Environment 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 5 Emergence and Growth of Healthcare Emergency Management | 5 of Care section to placing the standards in a separate and distinct section with specific goals and requirements, as well as the release of the Occupational Safety and Health Administration (OSHA) document Best Practices for Hospital-Based First Receivers.1–3 Over the past eight years we have embarked on an interesting marriage of these two separate disciplines—health care and emergency management—whose common ground has historically been brought together in the street or on the disaster scene by emergency medical services workers, or sometimes brought into the emergency departments of hospitals and trauma centers across the country. Both disciplines have separate roles and responsibilities, but where the seemingly disparate goals of these fields come together is the reduction of morbidity and mortality following disasters, acts of terrorism, and public health emergencies. Emergency management agencies have traditionally been responsible for bringing first responders, government agencies, and community stakeholders together to assist with comprehensive emergency planning or disaster response and recovery. A common cornerstone of emergency management has been to protect life, then property, then the environment. As a result, when conducting emergency planning activities, the health and medical needs of the population are among the most significant and are considered with basic public health and human needs including sheltering, mass care, sanitation, environment health, food and water, and other essential services. In addition, as public health professionals, we also believe that population health activities include the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency. In healthcare delivery, we attempt to meet the health and medical needs of the community by providing a place for individuals to seek preventative medicine, care for chronic medical conditions, emergency medical treatment, and rehabilitation from injury or illness. While a healthcare institution serves the community, this responsibility occurs at the level of the individual. Each individual expects a thorough assessment and treatment if needed, regardless of the needs of others. This approach is different than that practiced by emergency managers, whose goal is to assist the largest number of people with the limited resources that are available. As such, emergency management principles are focused on the needs of the population rather than the individual. When either planning for a disaster or operating in a disaster response mode, the hospital should be prepared at some point to change its focus from the individual to the community it serves and to begin weighing the needs of any individual patient versus the most good for the most patients with scarce resources. Moving from the notion of doing the most for each individual to doing the best for the many is a critical shift in thinking 55133_CH01_Reilly:Achorn Int’l 6 | Chapter 1 5/13/10 12:08 PM Page 6 Introduction to Hospital and Healthcare Emergency Management for healthcare institutions considering a program of comprehensive emergency management. While the initial planning for emergencies by hospitals is focused on maintaining operations and handling the care needs of actual or potential increased numbers of patients and/or different presentations of illness or injury than is traditionally seen, there is also the need to recognize that at some point during a disaster, act of terrorism, or public health emergency there may be an imbalance of need versus available resources. At this point the approach to delivering healthcare will need to switch from a focus on the individual to a focus on the population. This paradigm shift is one of the core unique aspects of hospital emergency management that allows the hospital to prepare to maximize resources in disasters and then to know when to switch to a pure disaster mode of utilizing its limited and often scant resources to help the most people with the greatest chance of survival. The healthcare delivery system is vast and comprised of multiple entry points at primary care providers, clinics, urgent care centers, hospitals, rehabilitation facilities, and long-term care facilities. The point of entry for many individuals into the acute healthcare system is through the emergency department (ED). Since the late 1970s, the emergency medical services (EMS) system has allowed victims of acute illness and injury to receive initial stabilization of life-threatening medical conditions on the way to the emergency department. Among the many strengths of the ED is the ability to integrate two major components of the healthcare system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in this process by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate life-saving medical care until specialty resources become available.4–11 In this context, the healthcare system is an emergency response entity. Healthcare Emergency Management Activities Hospital emergency management activities vary and can be categorized in many ways, however some common areas of focus within healthcare emergency management include the following areas: ■ ■ ■ ■ ■ ■ ■ communication surge capacity volunteer management security issues hazmat/CBRNE preparedness collaboration and integration with public health education and training 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 7 Healthcare Emergency Management Activities | 7 ■ ■ ■ ■ ■ equipment and supplies worker safety drills and exercises emergency department disaster operations trauma centers COMMUNICATION Communication issues in disaster preparedness and response are cited throughout the literature as a major source of frustration and inadequacy for coordinating and executing disaster operation plans.4–5,8,11–16 By identifying the vulnerabilities in the existing system of healthcare communication systems, we can take steps to address these issues and further increase our health system preparedness. Addressing the vulnerabilities in communication systems and planning how to overcome them is an essential responsibility of a hospital emergency manager. Many of the criticisms of the current state of health systems’ communication systems center around the inability to communicate easily with external agencies and share critical information. Disaster after-action reports and exercise improvement plans almost universally cite poor communication as one of the problems associated with incident management and the event being reviewed. Infrastructure support is an important consideration when examining whether adequate safeguards are in place to support the systems we will rely upon during a disaster. On September 11, 2001, while one New York City hospital was preparing to treat a large number of (anticipated) casualties from the disaster, they experienced a loss of their computer and information systems.17 This unplanned event arose because the communication system line that supported their system’s infrastructure ran beneath the World Trade Center.17 Additionally, other reports have cited problems with battery failure and the lack of a prolonged power supply as limiting communication systems’ abilities during an event.14 This example illustrates a major point in emergency communication systems: hospitals need the ability to connect all significant parties during a disaster or other emergency and the system should be based on a redundant infrastructure.5 Clearly, from a planning perspective, this would be a desirable option. However, the reality remains that investing in communication systems is a significant financial burden on already underfunded hospitals and healthcare systems. Risk communication is often overlooked during the planning phase of an event, and this can lead to frustration and confusion during disaster operations. Risk communication is sometimes the only way for the public to gain an understanding of the scope and severity of an incident. Additionally, risk communication information provided by hospitals may be used to help families of disaster victims find information about 55133_CH01_Reilly:Achorn Int’l 8 | Chapter 1 5/13/10 12:08 PM Page 8 Introduction to Hospital and Healthcare Emergency Management their loved ones’ condition. Reviews of risk communication have shown that a predesignated public information officer (PIO), who will liaise with the media and the public and who has specific training and experience in giving briefings and fielding questions, should perform all risk communication tasks during disaster operations.13 Specific elements of risk communication that may be conveyed to the public may include information on evacuations, scope and breadth of the event, where and how to obtain assistance if needed, whom to call for specific information, location of postexposure prophylaxis or vaccination clinics, and what to expect over the next several hours and/or days of the event. This is discussed in more detail in Chapter 12. SURGE CAPACITY The General Accounting Office (GAO), which changed its name to the Government Accountability Office (GAO) in 2004, finalized reports during 2003 on the public health and hospital preparedness for bioterrorism and emerging infectious diseases.9,16 These reports found that most hospitals in the United States do not have the means to care for a surge of patients during a public health emergency.9,16 They stated that, based on the national emergency department diversion rates in urban and suburban areas, shortages in the healthcare workforce, and the general lack of available supplemental medical equipment and supplies in hospitals, the medical community is not prepared to handle a patient surge caused by an infectious disease outbreak or bioterrorism related event.9,16 Emergency departments are being utilized more often as urgent care centers because the growing population utilizes the ED as their point of primary care. This increasing phenomenon is contributing to ED overcrowding and diversionary status (hospital EDs asking that ambulances refrain from bringing patients to their facility for a period of time) in virtually every healthcare and trauma system in the country. The current state of affairs in the nation’s EDs makes it very difficult to prepare for surge capacity when many hospitals cannot effectively handle their daily patient volume.18 Referral patterns of patients presented to medical facilities will vary in terms of how they arrive at the facility (EMS or self-transport) as well as which facilities they access (hospital ED or physician’s office), depending on the type of disaster or public health emergency. In cases of natural disasters, explosions, and acute catastrophic events where there is a clear and defined “scene,” many patients will be triaged, treated, and perhaps transported to hospitals or trauma centers by EMS personnel. In cases of bioterrorism or infectious disease outbreaks, patients would normally exhibit minor signs and/or symptoms of an illness (e.g., fever, rash, flu-like symptoms, etc.). These patients may be 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 9 Healthcare Emergency Management Activities | 9 presented to their primary care physician or an urgent care center to receive initial diagnosis and treatment. The patients that can be expected to arrive at the ED in these cases would be those who could not access a private physician, those too acutely ill to seek care in an office setting, those referred to the ED by their physicians, and those patients who called EMS for assistance. This latter group would yield the least number of ED arrivals.19–20 Incidents of chemical and biological terrorism as well as pandemic or epidemic incidents of infectious diseases may arguably produce the most significant burden on the healthcare system.9,13,16,18,21 A main reason for this is the unpredictable referral patterns of patients who fall victim to a chemical or biological hazard. Although some disaster after-action reports do suggest that even victims of conventional disasters will self-refer to medical facilities, the issues of delayed onset of symptoms, cross-contamination, and person-to-person disease transmission that are associated with a chemical, biologic, or radiologic incident call for more detailed contingency plans. An example of hospital referral patterns after a chemical agent event can be seen in the post-event summary of the sarin attack in the Tokyo subways in March of 1995.22 In this incident 12 people were killed, but more than 5000 people sought medical attention, and only 688 of them were medically transported to area hospitals.22 At some point during the evolution of a disaster or other public health emergency, patients will converge on acute care hospitals. Studies have consistently shown that despite rigorous planning initiatives, hospitals and emergency departments are not prepared to handle the mass influx of patients that a bioterrorism event or infectious disease outbreak would produce.9,16,19–20 During the sarin attack on the Tokyo subway in 1995, the nearest hospital had 500 patients in the first hour after the incident and more than 20% of its staff was secondarily contaminated.22 It is important that planners additionally recognize that in certain catastrophic disasters involving bombings, building collapse, etc., mass injuries and a patient surge may not occur as anticipated because of the high rate of mortality.17,23 The hospital emergency manager and all those involved in hospital emergency management must ensure that their hospital has adequate plans for the surge of patients that will arrive during a disaster, terrorism event, or public health emergency. VOLUNTEER MANAGEMENT The use of volunteers in disasters and public health emergencies presents a unique set of considerations for the hospital emergency manager. Volunteers can be utilized in several ways to assist in disaster relief services. However, the problems of volunteer management, credentialing, 55133_CH01_Reilly:Achorn Int’l 10 | Chapter 1 5/13/10 12:08 PM Page 10 Introduction to Hospital and Healthcare Emergency Management safety, and security often preclude their utility in the acute disaster environment unless significant pre-planning for their use has occurred and their arrival is through a pre-defined system. Cone et al. describe “convergent volunteerism” (the influx of citizens and/or health providers to a major incident) as a “critical problem” in disaster management.24 Intuitively, you may think that the outpouring of community support to assist in rendering aid during a disaster or other public health emergency is a welcome show of support for disaster victims. However, the reality is that convergent volunteerism brings with it security, resource, and worker safety problems that require personnel and critical resources to manage. In their discussion of convergent volunteerism in the September 11 terrorist attacks in NYC, Cone and colleagues discuss the myriad of additional challenges and problems that the unsolicited and often intrusive behavior of “Good Samaritans” imposed on the NYC responders. Issues included the unsupervised practice of medicine and paramedicine; credential verification of certified and/or licensed personnel; the performance of search and rescue operations by lay responders; the need to feed, shelter, and provide sanitary facilities for volunteers; potential injury and illness to volunteers who were unsupervised and lacked proper personal protective equipment; and personal vehicle congestion on scene access and egress.24 Many of these concerns may seem trivial to some who view a community response to a disaster as being the quintessential demonstration of altruism and support for fellow citizens. However, as mentioned by Cone and colleagues, untrained and unauthorized volunteers can ultimately put themselves and others in danger, and deplete emergency response resources by attempting to provide assistance at disaster scenes. This was most poignantly illustrated during the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, when an untrained and unprotected volunteer nurse was crushed by falling debris while trying to assist with urban search and rescue operations.24 SECURITY ISSUES Hospitals frequently overlook the need to maintain adequate security of the healthcare facility and overall medical operations as part of both daily operations and emergency planning. The concept of “locking down” or restricting access to a healthcare facility is often contradictory to the typical hospital design and approach of open access to both patients and their families and other visitors. But during a disaster this type of control is essential for many reasons, which include but are not limited to: control of the flow of patients to the areas where care will be provided; access to the facility only by authorized staff; accounting for staff and patients 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 11 Healthcare Emergency Management Activities | 11 in time of evacuation; prevention of potentially contaminated patients entering the hospital from contaminating staff, other patients, and facilities; and prevention of acts of terrorism. Security resources generally vary among hospitals. Some hospitals and trauma centers have sworn police officers present in their facilities 24 hours a day, and others may hire a private security firm to maintain safety or simply serve a concierge or customer service role. Security concerns during disasters and public health emergencies can become significant when considering the potential vulnerabilities associated with the chaotic response environment.15,17,24–25 Specifically cited issues with security during the response to a disaster or public health emergency include access control to medical facilities; credentialing of employees, responders, and volunteers; crime scene and evidence preservation; infrastructure and resource protection; and crowd control.15,17,24–25 HAZMAT/CBRNE PREPAREDNESS There is no question that in the current state of health system and public health preparedness the medical community is ill-prepared to deal with an incident that involves the management and treatment of multiple potentially contaminated victims, including those from chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Multiple recent reports of hospital preparedness cite decontamination capabilities as a serious weakness of disaster readiness plans.4–5,8–9,11,15–16,26–27 One study cites as few as 6% of Level I trauma centers as having the necessary equipment on hand to safely decontaminate a single patient.26 Planning for these events has traditionally centered around the fallacy that patients will be decontaminated at the scene by first responders and then be triaged, treated, and transported to the ED. The decontamination process serves a dual purpose. First, it removes the potential agent that is causing harm to the patient, and second, it prevents the spread of secondary contamination to other patients and hospital staff. We have come to realize from recent incidents involving victim contamination that many ambulatory victims will leave the scene and bypass EMS decontamination and triage, seeking medical care on their own.11,15,19–20 The reality of dealing with an intentional release of chemical, biological, or radiological agent is that by the time acute care facilities can be made aware that an event has taken place, they may have already been contaminated themselves.22 The specifics of hospital decontamination and worker safety are discussed in Chapter 14. Throughout the nation, trauma systems, acute care hospitals, and first responders are unprepared for handling an event involving the release of a nuclear, biological, or chemical (NBC) agent.8,15,26 Largely, this is due to ineffective planning and relying on resources that may not be available 55133_CH01_Reilly:Achorn Int’l 12 | Chapter 1 5/13/10 12:08 PM Page 12 Introduction to Hospital and Healthcare Emergency Management during a disaster or public health emergency.15 The most often cited weaknesses are an overall lack of training, lack of personal protective equipment (PPE), lack of resources and equipment to rapidly and reliably perform preliminary agent detection, and lack of appropriate medical facilities, equipment and supplies to effectively isolate infectious patients and manage them through the course of their illnesses.8,15,21–22,26 COLLABORATION AND INTEGRATION WITH PUBLIC HEALTH In order for disaster preparedness and response to be successful, it must involve interagency resources and consider the 3C’s of emergency response planning: Collaboration, Cooperation, and Coordination. Response plans cannot be designed and implemented in a vacuum. Disaster response and recovery operations will certainly consist of a multiagency response at the local, state, and federal levels. In order to ensure that the response plan is valid, and will operationally integrate with other key responding agencies, the planner must collaborate with fellow agencies and develop plans that involve aspects of interagency response. Interagency planning groups, such as the Local Emergency Planning Committee (LEPC), operate under the assumption that if a hazardous event occurs, all key public safety and health agencies will respond in a unified approach with common goals to protect the welfare and safety of the community. These principles of collaboration, cooperation, and coordination among the agencies that will likely respond to a disaster or other public health emergency will minimize unnecessary redundancy in response plans and create partnerships with agencies that can provide expertise and resources during the public health emergency response. In a large-scale disaster or act of terrorism, such as the World Trade Center attacks in 1993 and 2001, the Oklahoma City bombing in 1995, and the 1994 and 1995 sarin attacks in Tokyo, continuous medical monitoring and follow-up of the survivors, responders, and participants in these events is needed to detect the associated long-term health effects. With the exception of large academic medical institutions that may perform epidemiologic analysis on specific cohorts of individuals, the public health community must recruit and maintain a database of affected individuals so they can study the long-term impact of these events on the health of the population. It is important to note that although the imminent threat of danger may no longer be present, the need for medical care, disease surveillance, and follow-up studies is essential to the completion of the public health role in a disaster or other public health emergency. Additionally, public health agencies at the federal, state, and local levels have the responsibility under the National Response Framework (NRF) to coordinate and serve as the lead agency for disasters involv- 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 13 Healthcare Emergency Management Activities | 13 ing mass care. This may include assisting both hospitals and communities to establish alternate care sites (ACS) where patients can be directed to receive medical treatment during a public health emergency, which will allow a hospital to use its resources to treat higher acuity patients and remain open to handle routine emergencies during a pandemic or other public health emergency. EDUCATION AND TRAINING Reports have suggested that healthcare workers lack the knowledge to detect and manage a patient who has been exposed to a chemical or biological agent.6,27–28 The Health Resources and Services Administration (HRSA) survey helped to illustrate the lack of training and education among trauma center and hospital staff by reporting that only eight states required employees to be trained in disaster-related topics, two states required training in biological agent topics, and two states required training for chemical-related topics.8 Additionally, training for EMS personnel was equally poor because only six states required prehospital providers to have education on disaster-related topics, only one state required biological agent training, and three states required education on chemical agents.8 EQUIPMENT AND SUPPLIES In the GAO’s report of hospital preparedness in August 2003, they reported several findings on hospital equipment and supply resources. The survey showed that for every 100 beds, 50% of hospitals had fewer than 6 ventilators, fewer than 3 PPE suits, fewer than 4 isolation beds, and could only handle fewer than 6 patients per hour through a 5-minute decontamination shower, given their current state of preparedness.9 Additionally, the GAO reports that most first responders lack a reliable means to detect chemical and/or biological agents in the field, and do not typically have the proper PPE to protect themselves from agent exposure.9 The HRSA evaluation of state trauma systems showed that the availability of PPE for healthcare workers was significantly lacking among states because only one state (Ohio) had enough PPE resources immediately available for its EMS personnel, and only one state (New Jersey) had enough PPE resources immediately available for its hospital personnel if a chemical or biological agent release occurred.8 In addition to PPE issues, hospitals and trauma centers often lack the inventory of equipment and supplies necessary to effectively treat an influx of potentially affected patients.8–9,14–16,26 Many hospitals, in a strategy to reduce overall costs, replenish their central supply on a “just-in-time” basis, clearly ineffective in preparing to treat a mass 55133_CH01_Reilly:Achorn Int’l 14 | Chapter 1 5/13/10 12:08 PM Page 14 Introduction to Hospital and Healthcare Emergency Management influx of patients.18 Pharmaceutical access is another concern among healthcare facilities. As demonstrated in the fall 2001 anthrax scare, hundreds of postal and healthcare workers required postexposure prophylaxis after potential exposure to the agent. Maintaining an adequate pharmaceutical stock of essential antibiotics, antidotes, and specialty medications in case of a disaster is often viewed as cost prohibitive due to the shelf life and daily usefulness of certain drugs.18 Although this has improved slightly over the past 6 years, hospitals around the country still struggle to build the internal capacity necessary to perform emergency decontamination of patients from hazardous substance incidents and properly protect their staff, patients, and visitors from secondary contamination. WORKER SAFETY A report released by HRSA on the national state of the trauma system and EMS preparedness for disasters and mass causality events showed that only one state in the country thought that its hospital workers would be adequately protected in the event of a biological (but not chemical) agent attack.8 Additionally, only one state reported that its EMS system would have access to PPE in the event of a bioterrorism event.8 Similar research has underscored a general lack of protection for the public health workforce against any type of chemical, biological, or radiological contamination in the event of a disaster.8 A major role for the public health community during an event is to ensure the health and safety of all disaster workers.13,15 DRILLS AND EXERCISES Criticisms regarding drills and exercises are notable throughout the preparedness literature.6,9,11,15,21,26 Comments include statements that exercises are not realistic, drills tend to be conducted with advanced warning on shifts with favorable staffing levels, and with equipment and resource levels at their best, etc. Therefore, the drills bias any useful results from the exercise.15 The purpose of conducting drills and exercises (besides remaining in compliance with accrediting bodies) is to assess whether or not a facility is adequately prepared to handle an incident with relatively low probability, but with extremely significant impact on the health system, and to identify areas that need improvement on an operational and planning level.15 Exercises that simply go through the motions or are conducted with limited realism, under optimal conditions, or are simply haphazardly conducted to meet regulatory or legal requirements are futile and worthless assessment tools that will only perpetuate a hospital’s state of unpreparedness.15 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 15 The Role of the Hospital/Healthcare Emergency Manager | 15 EMERGENCY DEPARTMENT DISASTER OPERATIONS The importance of the ED’s role in disaster and emergency preparedness is discussed in several sources.4–12 The American College of Surgeons mentions that the ED is a major strength of a trauma center.12 They refer to the ED staff as “highly competent” and often “experts” in the medical management of chemical, biological, and radiological casualties.12 Among the many strengths of the ED is the ability to integrate two major components of the trauma system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in the chain of survival by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate lifesaving medical care until specialty resources become available.4–11 TRAUMA CENTERS The roles of trauma centers during a disaster or public health emergency are consistent with their daily activities in the treatment of injured patients. Triage and treatment of injured victims after a disaster is frequently discussed as a central role of the trauma center in the aftermath of a disaster.6,8–11,13,15–16,18,23,25–29 It is well documented that trauma centers are adept at the care of the injured victim, and are viewed as the best choice for the triage and treatment of disasterrelated injured victims.4–10,12,14,17,23,25–31 Trauma care is identified most frequently as the major strength of the trauma center and the trauma system. Another expectation is that trauma centers and acute care hospitals will be able to treat mass numbers of affected patients as well, including the rapid triage and treatment of all casualties (including those from CBRNE events), decontamination and/or isolation, and quarantine of contaminated or potentially infectious patients. Trauma centers are also expected to have access to essential equipment, supplies, and pharmaceutical agents.4–6,8,14–15,17,23,27–29,32 The Role of the Hospital/Healthcare Emergency Manager What then, is a hospital or healthcare emergency manager? A hospital or healthcare emergency manager is an individual employed by a healthcare organization whose job is to coordinate the emergency management functions of the hospital. This may include many responsibilities 55133_CH01_Reilly:Achorn Int’l 16 | Chapter 1 5/13/10 12:08 PM Page 16 Introduction to Hospital and Healthcare Emergency Management depending on the hospital or healthcare system, the location of the facility, the size and type of facility or organization, and specific local issues or threats and activities. While there may be variation in the role, almost universally the hospital/healthcare emergency manager will perform hazard vulnerability analysis, planning activities, coordination of the hospital’s disaster and other emergency management planning groups or committees, design and conduct training programs, perform drills and exercises, interact with other agencies and organizations involved in healthcare emergency management (e.g., local public health department, local office of emergency management, EMS, local law enforcement, and state agencies), and maintain compliance with regulatory agencies and accreditation organizations such as the JCAHO. Many hospital or healthcare emergency managers are individuals who have these duties in addition to their normal occupational roles in the healthcare organization. Typical positions within healthcare organizations that also perform emergency preparedness activities include nursing managers, educators, administrators, security managers, environmental health and safety administrators, facilities or physical plant directors, or emergency medical services coordinators. Few hospitals have taken the initiative to hire a full-time emergency preparedness coordinator for several reasons. First, there is no direct revenue return on investment in hospital preparedness. Emergency management is rather a fixed but necessary operating cost. In the United States, hospitals and healthcare organizations need to generate a profit. Even in not-for-profit hospitals, CEOs need to be able to show that profit increased in order to justify growth and add services for their patients. Activities that cannot improve the profitability of the organization often remain unfunded. Second, there is a shortage of qualified individuals to fill these positions. As mentioned before, most hospitals have added the duties and responsibilities of preparedness onto an existing full-time employee and this individual had to teach themselves how to perform these added duties. Most individuals who serve in full-time hospital emergency manager positions have a public safety background or a clinical background and have had to learn the discipline of emergency management. Until recently there have been few higher educational opportunities for people who wish to learn the discipline of healthcare emergency management. In 2010, the Federal Emergency Management Agency’s (FEMA) Higher Education Program listed only 10 undergraduate and graduate programs combined that focus on both healthcare and emergency management. Many of these are new programs that have only been in existence for a few years. There have been degree programs in general emergency management, but only a few that apply this discipline to the public health or hospital environment. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 17 References | 17 If you don’t seek out a formal degree, how do you become knowledgeable in hospital emergency planning? Initially, it begins with your current role. If you are a healthcare worker who needs to learn the finer points of emergency planning, drills and exercises, and incident management, then you could benefit from FEMA’s independent study program or professional development series. On the other hand, if you are an emergency management professional with little knowledge of the healthcare environment, you may benefit from continuing education in health and medical issues such as the strategic national stockpile, emerging infectious diseases and pandemics, the health and medical impact of terrorism and weapons of mass destruction, and the health impact on populations displaced as the result of disasters. This text is designed specifically for individuals who wish to learn the applied discipline of healthcare emergency management, and for all other personnel in a hospital or from other disciplines who will work with either a hospital or any other aspect of a healthcare system in planning for and responding to disasters, terrorism, and public health emergencies. Whether you are a college or graduate student learning the fundamentals of public health or healthcare emergency management, or a current healthcare professional looking to increase your current knowledge in order to apply emergency management principles to your trade, this book is designed to meet your needs. There is a lot to learn, and this text is just the beginning. This emerging field is exciting, challenging, and rewarding. We wish you luck on your journey! References 1. 2. 3. 4. 5. 6. U.S. Department of Labor, Occupational Safety and Health Administration. Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. Washington, DC: OSHA; 2005. OSHA publication 3249–08N. Joint Commission Resources. Emergency management standards. Environ Care News. 2007;10(12):2–8. Joint Commission Resources. Preparing for catastrophes and escalating emergencies. Environ Care News. 2008;11(1):1–3, 11. American College of Surgeons. Resources for Optimal Care of the Injured Patient: 1999. Chicago: American College of Surgeons; 1999. American Trauma Society and U.S. Department of Transportation, National Highway Traffic Safety Administration. Trauma System Agenda for the Future. National Highway Traffic Safety Administration; October 2002. Report #3P0138. American College of Surgeons. [ST-42] Statement on disaster and mass casualty management [by the American College of Surgeons]. American College of Surgeons Web site. http://www.facs.org/fellows_info/statements/st-42.html. Published 2003. Accessed December 28, 2009. 55133_CH01_Reilly:Achorn Int’l 18 | Chapter 1 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 5/13/10 12:08 PM Page 18 Introduction to Hospital and Healthcare Emergency Management Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Upper Saddle River, New Jersey: Brady/Prentice Hall Health; 2003. U.S. Department of Health and Human Services, Health Resources and Services Administration. A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events. Washington, DC: Health Resources and Services Administration; 2002. U.S. General Accounting Office. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. Washington, DC: U.S. General Accounting Office; August, 2003. Report GAO-03-924. Frykberg ER. Disaster and mass casualty management: a comment on the ACS position statement. Bulletin of the American College of Surgeons. 2003;88(8):12–13. White SR. Hospital and emergency department preparedness for biological, chemical, and nuclear terrorism. Clin Occup Environ Med. 2002;2(2):405–425. Trunkey DD. Trauma centers and trauma systems. JAMA. 2003;289:1566–1567. Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001. May AK, McGwin G Jr, Lancaster LJ, et al. The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries. J Trauma. 2000; 48(4):666–672. Rubin, JN. Recurring pitfalls in hospital preparedness and response. J Homeland Security. January, 2004. http://www.homelanddefense.org/journal/Articles/ rubin.html. Accessed August 18, 2009. U.S. General Accounting Office. SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases. Washington, DC: U.S. General Accounting Office; May 7, 2003. Publication GAO-03-769T. Feeney J, Parekh N, Blumenthal J, Wallack MK. September 11, 2001: a test of preparedness and spirit. Bulletin of the American College of Surgeons. 2002;87(5). Barbera JA, Macintyre AG, DeAtley CA. Ambulances to nowhere: America’s critical shortfall in medical preparedness for catastrophic terrorism. In: Howitt AM, Pangi RL, eds. Countering Terrorism: Dimensions of Preparedness. Cambridge, MA: MIT Press; 2003:283–297. Reilly MJ, Markenson D. Hospital emergency department referral patterns in a disaster. Prehosp Disast Med. 2009;24(2):s29–s30. Reilly MJ. Referral patterns of patients in disasters—who is coming through your emergency department doors? Prehosp Disast Med. 2007;22(2):s114–s115. Kellerman A. A hole in the homeland defense. Modern Healthcare. 2003;33(16):23. U.S. Department of Defense, Army, SBCCOM, Federal Domestic Preparedness Program. NBC Domestic Preparedness Senior Officials’ Workshop (SOW) [CD-ROM]. SBCCOM; 1999. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003;54:147–155. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41(4):457–462. Feliciano DV, Anderson GV Jr, Rozycki GS, et al. Management of casualties from the bombing at the Centennial Olympics. Am J Surg. 1998;176(6):538–543. Ghilarducci DP, Pirallo RG, Hegmann KT. Hazardous materials readiness of United States Level 1 trauma centers. J Occup Environ Med. 2000;42(7):683–692. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 19 References | 19 27. 28. 29. 30. 31. 32. American College of Surgeons. Disasters from biological and chemical terrorism—what should the individual surgeon do?: a report from the Committee on Trauma. American College of Surgeons Web site. http://www.facs.org/ civiliandisasters/trauma.html. Accessed December 30, 2009. American College of Surgeons. Statement on unconventional acts of civilian terrorism: a report from the Board of Governors. American College of Surgeons Web site. http://www.facs.org/civiliandisasters/statement.html. Accessed December 30, 2009. Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health threat with a trauma system response. J Trauma. 2003;55(6):1014–1021. MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA. 2003;289:1515–1522. Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published evidence regarding trauma system effectiveness. J Trauma. 1999; 47(3);S25–S33. Peterson TD, Vaca F. Commentary: Trauma systems: a key factor in homeland preparedness. Ann Emerg Med. 2003;41(6):799–801. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 20 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 21 Chapter 2 Healthcare Incident Management Systems Arthur Cooper, MD, MS Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Discuss the fundamental principles of healthcare incident management systems. ■ Describe the incident command system structure and its application to the healthcare environment. ■ Discuss the importance of interagency cooperation and collaboration when managing disasters and public health emergencies that impact the healthcare system. Overview Making method out of madness The aim of this chapter is to arm the busy healthcare staff, clinician, or emergency manger with a basic understanding of incident management 21 55133_CH02_Reilly:Achorn Int’l 22 | Chapter 2 5/13/10 1:15 PM Page 22 Healthcare Incident Management Systems systems as applied to the healthcare and hospital environment, including the Hospital Incident Command System (HICS), not as a substitute, but as a rationale for incident management training and the need to understand the application to a hospital or healthcare system. This chapter will cover the fundamental principles of healthcare incident management systems, including one system modified specifically for the hospital, the Hospital Incident Command System. Such systems are vital to the management of disasters, acts of terrorism, and public health emergencies involving healthcare organizations because, without the effective coordination of resources achieved through use of a healthcare incident management system, chaos, rather than order, will prevail. After a concise introduction to set the stage, the chapter will consider the historical background, foundational principles, incident leadership, command structures, HICS organization, training systems, HICS implementation, logistic concerns, practical concerns, and interagency relationships essential to successful healthcare incident management, before delivering its conclusions. Case Study A Cloud in the Midnight Sky You are the administrator on duty (AOD) when you are called by the physician in charge of the emergency department, who reports that numerous arriving patients are exhibiting spasms of severe coughing triggered by “something in the air.” While you consider your next steps, your spouse calls to tell you there has been a large explosion at a nearby tank farm adjacent to a large industrial facility. Television reports document widespread panic at the scene and in the immediate vicinity of your hospital, which is located about two miles (three kilometers) east of the site. It is past midnight; only caretaker staff are on duty (except in your critical and acute care units) and hospital staff await your orders. The following questions race through your mind. How would you begin to answer them? ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Does a bona fide disaster exist? Should I declare a disaster now? Should I seek additional information before declaring a disaster? Should I implement the hospital’s emergency operations plan? Should I activate the hospital’s command center? How will I ensure the safety of staff and patients? Should I mobilize additional hospital staff? Should I lock down the facility? Should all emergency patients be decontaminated? Should public health agencies be notified? 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 23 Historical Background | 23 ■ ■ ■ Who should I ask for necessary additional resources? Are there potential threats to the hospital itself? How will I coordinate and supervise all the staff? The decisions are yours to make. The answers may be found in this chapter. Introduction “Who’s in charge? They’re all in charge!”1 Understanding the Incident Command System (ICS) applied during disasters may prove a daunting task, even for healthcare executives experienced in interpreting complex tables of organization that baffle other managers, clinicians accustomed to solving and treating complex medical problems, and staff prepared to work in the complex healthcare environment. However, as recently stated so eloquently by Lieutenant Thomas Martin of the Virginia State Police in the illuminating video, The Many Hats Of Highway Incident Command (http://cts .virginia.edu/incident_mgnt_training.htm), the principles of incident command are fundamentally no different from the everyday manners children learn as youngsters, as elegantly and clearly described in the poignant work by author Robert Fulghum, All I Really Need To Know I Learned In Kindergarten.1,2 Within this simple framework, the responsible healthcare emergency manager can readily answer the question, “Who’s in charge?” The answer, of course, is that they’re all in charge, of what they’re in charge of—because all those involved in the disaster response are responsible for their immediate tasks, their communication with others, and first and foremost, their own and others’ safety. Historical Background “The best way to predict the future is to create it.”3 Modern incident command grew from the experience of firefighters in combating the California wildfires of the mid 1970s. Inadequate communication and ineffective collaboration between the numerous agencies battling these natural disasters led to the deaths of many firefighters whose lives need not have been lost. The subsequent after-action reports identified numerous critical weaknesses in the organization and delivery of many responders’ agencies and efforts, including lack of accountability, barriers to communication, poor planning processes, 55133_CH02_Reilly:Achorn Int’l 24 | Chapter 2 5/13/10 1:15 PM Page 24 Healthcare Incident Management Systems overloaded incident commanders, and absent response integration. The dawning realization that deficient and defective command and control were mostly responsible for these tragic fatalities led California fire chiefs to develop an “interoperable” system for emergency response, whereby all the involved agencies could communicate with one another and collaborate in the field, based upon a common organizational structure that all such agencies could understand and apply. This new system, called FIRESCOPE (Firefighting Resources of California Organized for Potential Emergencies), was based upon principles gleaned from military experience and management theory, especially the management by objectives concepts introduced in 1954 by Peter F. Drucker in his classic work, The Practice of Management.4 Its core purpose was to provide a standardized, on-scene, all-hazard incident management dogma that allowed its users to quickly implement an integrated organizational structure that was not impeded by jurisdiction boundaries, and was flexible and scalable enough to match the needs and resources for single, expanding, multiple, and complex incidents, despite their special circumstances and unique demands. It rapidly evolved into the Incident Command System (ICS) that has gradually been adopted by most fire and emergency services nationwide, the purposes of which are to ensure the (1) safety of responders and others, (2) achievement of tactical objectives, and (3) efficient use of resources. As a result, ICS was subsequently designated for use throughout the United States by the federal Superfund Amendments and Reauthorization Act (SARA) of 1986 (PL 99-499), Occupational Health and Safety Administration (OSHA) rule 1910.120, and, most recently, Homeland Security Presidential Directive 5 (HSPD 5),5 in addition to numerous other state and local regulations. Its early success also led the California Emergency Medical Services Authority to adapt and periodically revise it for use in all disasters involving hospitals, such that it now serves as the basis of the Hospital Incident Command System (HICS) used by most hospitals in the Americas and, increasingly, worldwide. Specific instruction in HICS is available through both the California Emergency Medical Services Authority HICS Web site (http://www.emsa.ca.gov/HICS/default.asp), and the Emergency Management Institute’s Web site (http://training .fema.gov), within the independent study ICS courses IS-100.HC and IS-200.HC revised in 2007 for healthcare providers.6 Foundational Principles “Management by objectives”4 The three key strategies of the disaster response, in order, are to (1) protect and preserve life, (2) stabilize the disaster scene, and (3) protect and preserve property. Healthcare providers intuitively understand the first 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 25 Incident Leadership | 25 purpose, and intellectually understand that the third purpose is essential to the first because healthcare providers cannot perform their lifesaving tasks without the appropriate facilities, equipment, and resources. The second purpose, however, may be less obvious. This is because an organized disaster response can occur only within the context of a stable work environment—an environment that is difficult to achieve in the first minutes after disaster strikes, when chaos is the rule, even in greatly complex work environments, such as hospitals, that are highly self-regulated. Thus, an incident management system is needed to bring order to the chaos, the sine qua non of which is an incident command structure characterized by the three key tactics that must underlie all of incident command—unity of command, span of control, and clarity of text. Unity of command refers to the principle that sharing of information among all personnel involved in a disaster response is vital, but such individuals receive formal orders from, and make formal reports to, a single supervisor in order to preserve the viability of the chain of command. Span of control refers to the principle that in a high stress environment, no line supervisor can effectively coordinate the efforts of more than three to seven, and ideally no more than five, subordinate personnel. Clarity of text refers to the principle that all communications, written and spoken, must be transmitted in the simplest, most generic language possible, avoiding the use of words or jargon likely beyond the understanding of many emergency responders, so as to ensure that all personnel involved in the disaster response understand both the general strategy of the Emergency Operations Plan (EOP) and the special tactics being applied to combat the disaster. Incident Leadership “Coordination, Communication, Cooperation”1 Healthcare incident management systems achieve their goals by ensuring what have been termed the “3 Cs” of incident command: coordination, communication, and cooperation, of which the most important is cooperation, because it makes coordination and communication feasible. However, effective incident management requires not only universal education in disaster management appropriate to the functional job description of the individual healthcare employee—awareness, technical, and professional—but also frequent drilling in the implementation of the hospital disaster plan, especially its incident command structure. Most texts and training rightly emphasize that the individuals designated to fulfill specific functional job descriptions must be appropriately trained to do so; therefore, hospital executives who perform similar tasks during routine hospital business must step aside and yield these responsibilities to those who have been trained 55133_CH02_Reilly:Achorn Int’l 26 | Chapter 2 5/13/10 1:15 PM Page 26 Healthcare Incident Management Systems to do so. However, this notion ignores long-established realities of human behavior—the boss is still the boss, even if untrained in disaster management—so every effort should be made by senior executives to ensure that all hospital executives receive training in disaster management and incident command that will enable supervisors to function in their assigned roles even when disaster strikes. Physicians commonly presume that because the first key purpose of incident management is to protect and preserve life, they should be in charge of emergency operations. However, physicians often overlook the fact that while they must clearly be in charge of all aspects of medical care, they generally comprise no more than approximately 10% of the total number of hospital personnel. Typically, the healthcare needs of the hospitalized patient require an average of 10 other personnel to support the treatments prescribed and the operations performed by a single physician or surgeon. Moreover, the physician’s expertise—and most valuable contribution to the hospital disaster response—lies in the medical care of the hospitalized patient, rather than its operational, logistical, or planning support. Command Structure “[ICS is] the system to achieve the coordination necessary to carry out an effective and efficient response.”7 Two basic c

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ommand structures, and variations thereof, are utilized worldwide: (1) the Hospital Incident Command System (HICS), developed by the California Emergency Medical Services Authority and promulgated both by its originator (http://www.ems…
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