Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions

1. Mole Hills with Mountainous Potential: Facing the Challenges of Health Care Institutions Churton Budd Paul Rega Kelly Burkholder-Allen

2. “In every country, we should hit their organizations, institutions, clubs, and hospitals”, it reads. “The targets must be identified, carefully chosen and include their largest gatherings so that any strike should cause thousands of deaths”From the Manual of Afghan JihadHamza Hendawi, The Associated Press; Feb. 2, 2002

3. State of Health Hospital Preparedness: • In spite of preparedness requirements within the industry, hospitals typically are the weakest link with respect to community preparedness • Systemic constraints are the major cause • Analysis of numerous exercises conducted throughout the U.S. have yielded a predictable list of pitfalls that continue to hinder hospitals in effective preparedness

4. Ten Commandments of State and Local Emergency Management for Health Care Administrators • Thou shall respect that all disasters are local • Thou shall recognize FEMA’s influence on the Health Care Industry • Thou shall know the terms “Pre-hospital”, “EMA’s”, “EOC’s”, and recognize that they are different • Thou shall participate WILLINGLY in local emergency preparedness activities • Thou shall drill and exercise internally and externally, and “play well with others” • Thou shall forget the misguided notion that you may know everything there is to know about emergency management • Thou shall “meet and greet”….forming mutual aid agreements and addressing contract issues before they are needed • Thou shall make up for lost time as soon as possible • Thou shall lead responsibly those in your charge • Thou shall be prepared to deliver medical care for at least 72 hours….ALONE

5. Systemic Constraints=Minimal Surge Capacity • 30% operating at a financial loss • Increasing costs, decreasing reimbursement • ED’s have become PCP’s for many • Staffing shortages are becoming a norm • Loss of experienced and mature staff • Increasing governmental regulations and un-funded mandates • Accreditation Requirements

6. Predictable Pitfalls:inherent system limitations • Communications • Security • Management of Staff • Decontamination equipment, procedures, and training • JIT inventory management • Management of Behavioral Casualties • Management of Special Needs population • Underestimating the media response • Exercise realism, content, and corrective actions

7. Financial Resources: • Profit margins are declining • From 5.8% to 4.2% from 2002-2003 (AHA) • Plan development, staff training, equipment maintenance are not reimbursable • HRSA funding just recently began to trickle down—$498 million to states, territories, and freely associated states (OH 1/17 states to receive “double digit” figure) • Empty beds do not generate revenue

8. Hospital Surge Capacity: ED’s • Surge capacity is a significant issue • 900 hospital closures since 1980 • ED visits rose to 95 million in 1997 to 108 million in 2000 • Less than 10% of all ED visits are classified as non-urgent by CDC standards (ACEP) • Many of the nation’s EDs are operating at/above capacity---crowding is the most severe in major metropolitan area ED’s • A GAO report revealed that two thirds of our ED’s are diverting ambulance patients • 20% of the time (4 hours/day) • Diversion has a cascade affect on hospitals in the surrounding area

9. Staffing: • Hospitals are experiencing shortages of a variety of health care providers • Nursing shortages continue and will get worse • More care delivered by physician extenders and nursing assistants • GAO Report revealing that large numbers of hospital staff working overtime and taking “call” • Numerous published studies highlighting the “selectivity” that staff may exhibit in their willingness to report for duty in a variety of disasters/WMD events, and their perception of barriers that would impact the ability of staff to report for duty in such events

10. Mr. Administrator----TEAR DOWN THOSE BARRIERS!!! • Fear for safety (self and family) • Transportation issues • Conflicting emergency response obligations • Military reserves • Volunteer firefighting • Affiliation with DMATs • Issues: • Long distance phone service • Ability to utilize email • Pet care • Child care • Elder care

11. Un-Funded Mandates and Accreditation Requirements: • Clarification for HIPPA, EMATALA, OSH, and EPA regulatory requirements and their applications in emergency situations is vital • JCAHO adaptation to a post-September 11, 2001 world • Mandates imposed by other accrediting agencies

12. Communications: • Redundant communications are essential • Both internal and external • Interoperability of communication equipment within a community is a must • The PIO managing both internal and external communications must be in sync with hospital policy and community activities

13. Security: • Hospital Security forces to maintain daily operations are stretched at present • Local law enforcement will not be able to assist in the event of a large scale event • Instituting a “Lock Down” will require additional security challenges • In the event of an epidemic such as SARS, securing the quarantined and limiting entry will create additional issues

14. Management of Staff: • Even staff with specific roles and defined tasks must have an understanding of the roles of other participants • HEICS clearly delineates lines of authority, yet provides flexibility to adapt to evolving events • Frequent training is the key to success by promoting standardization and interoperability

15. JIT Inventory Management: • Hospitals have transitioned to JIT inventory management strategies raising concerns about surge capacity for essential supplies—the 24-48 hour “Stand Alone” is jeopardized • Pharmaceuticals • Soft medical supplies • Hard medical supplies • Other resources necessary to maintain a sudden increase in daily operations

16. Behavioral Casualty Management: • Few hospital plans address the needs that the behavioral casualties will bring with them • It is estimated that for every physical casualty caused by a terrorism, there will be 4-20 psychological victims • In the first two weeks following 9/11, St. Vincents Hospital in NYC provided counseling and support to more than 7,000 people and received more than 10,000 calls to its help line

17. Family Information: • In large scale events hospitals will receive an influx of family members seeking information regarding loved ones. They will have needs as well: • Clerical and Social Service • Food and possibly Shelter • Information about and location of loved one • Space away from Media If your EMP has not planned for the management of families---take action immediately!

18. Special Needs Population • The disabled • Mobility impaired • Hearing impaired • Visually impaired • Cognitively impaired • Elderly • Pediatric • Pregnant females • Non-English speaking

19. The Disabled: • One out of every five Americans has a disability • One out of ten has a severe disability • Approximately 9 million have disabilities so severe that they require personal assistance with ADL’s---many of these individuals receive this assistance from family • 54 million US citizens have a disability • 58% have NO PLANS for safe and expedient evacuation from their homes • 50% of the employed disabled report that there are no plans in their workplace for safe and expedient evacuation • Nearly 800,000 disabled persons live in assisted living facilities

20. People with Disabilities: • Prior to the 1993 WTC attack, people with disabilities opted not to be identified as disabled---that changed! • A December 2001 survey released by the National Organization on Disability yielded the following: • 58% of people with disabilities said that they did not know who to contact about emergency plans for their community • 61% said that they had not made plans to evacuate their homes quickly and safely • Among the employed, 50% said that no plans have been made to evacuate their workplace safely

21. Planning for Management of Disabled Individuals • Persons with a disability have unique limitations and abilities • Include outside agencies in your hospital planning activities and exercises—their input and feedback is essential to success • Practice evacuation plans by having the planners simulate disabilities---much can be learned on either end

22. Service or Assistance Animals • There are many types of specially trained dogs providing assistance to disabled individuals have you factored these animals into your planning: • Hearing dogs for the deaf • Seeing-eye-dogs • Motor or mobility assistance dogs

23. Mobility Impaired: • People who use wheelchairs or other assistance devices may have a wide variety of abilities and limitations—it is difficult to generalize their needs • 1.5 million Americans use a wheelchair • How would you evacuate wheelchair dependent and other mobility impaired individuals in stairwells? • Does your facility have evacuation devices that can be used?

24. Hearing Impaired: • Hearing impairments range from a mild loss of hearing to profound deafness • 28 million Americans have a hearing deficit • 500,000 are completely deaf • Communication in times of an emergency can be aided by: • Establishing eye contact and facing the light • Speaking slowly and clearly • Using facial expressions and hand gestures • Providing written instructions or other written communication • Providing flashlights for signaling to health care providers • Using pictographs and communication boards

25. Visually Impaired: • 8 million Americans live with limited vision • 130,000 are legally blind • The visually impaired may vary in degree from having limited to no vision, planning for the safe management and care of these individuals cannot be overlooked • Even those who are independent, cannot be left in unfamiliar surroundings without assistance • In an emergency situation, provide clear and simple instructions---practice evacuation simulating visual impairment • Braille

26. Cognitively Impaired: • 7 million Americans have mental retardation • People with developmental disabilities may experience limitations with cognitive abilities, motor abilities, and social abilities---they may have difficulty recognizing rescuers or being motivated to act in an emergency • Visual perception of written instructions or signs may be confused • Sense of direction may be limited • Ability to understand is often more developed than the individual’s vocabulary • The individual should be treated as an adult who happens to have a cognitive or learning disability

27. Assisting the Cognitively Disabled: • Be patient • Break down information into simple steps • Use signs and symbols • Read information to them • Do not talk down to or treat as if they are a child

28. The Elderly: • By 2020 California and Florida will double their 1993 elderly population • By 2030, older adults will account for 20% of our population in the U.S.—an increase from 13% in 2001 • 1994-1995, 1.86 million individuals >65 reported difficulties with 2 or more ADL’s • Between 1960 and 1994, the oldest old increased by 274%

29. Defining the Elderly: • Elderly: >65 • Young Old: 65-74 • Aged: 75-84 • Oldest Old: >85

30. The Elderly: • Many of the services traditionally provided at hospitals are now being delivered in the home setting • More elderly are living independently longer • Greater dependency upon health care infrastructure to provide life-sustaining equipment, treatments, and medication • ↑ age = ↑ vulnerabilities • ↓sensory perception • ↓ strength • Poor exercise tolerance • Poor thermoregulation • Pre-existing conditions • Socio-economic hardships

31. Children Are Not Little Adults

32. Pediatric Patients: • Pediatric patients differ from adults physiologically, psychologically, anatomically, cognitively, and mentally • They have immature motor and cognitive skills which predispose them to remain in harm’s way • Triaging Pediatric patients presents challenges—especially if your facility does not have a pediatric department • JUMP-Start Triage captures the subtle nuances of the pediatric population • Pediatric patients are at risk for emotional trauma---assessment of emotional trauma should be included in the triage process • Work with staff from the Pediatrics Department to establish Mass Casualty management of pediatric patients

33. Pediatrics: • Greater number of respirations • ↑ risk for inhalation aerosolized agent or toxic substance • Short in stature • ↑ risk of inhaling more concentrated dose of substance that is heavier than air • Inadequate skin keratinization • ↓ capacity to protect skin from dermal injury • ↑ capacity to absorb toxins thru skin • Greater Body Surface Area • ↑ potential to lose body heat • ↑ potential to absorb toxins thru skin • Less Internal Fluid Reserves • Prone to dehydration and shock---making timely fluid replacement a priority

34. Pediatrics:

36. Pregnant Females: • Performing triage on pregnant females can be present challenges • Involve OB/Gyn staff in the planning for reception of pregnant females • Pre-position ultrasound equipment in ED, or work with OB department to set up and staff a secondary Triage area

37. The Non-English Speaking: • The use of pictographs can be used to replace spoken language • Does your facility have large pictographs that can be used with traditional signage to direct individuals? • In the absence of an interpreter, communication boards can bridge many of the language barrier gaps in emergency situations

38. Underestimating the Media • If it happens….they will come • Preparation is a must • Review and define the roles and responsibilities of the PIO • Your PIO should be planning today for tomorrow’s events

39. Exercise Planning and Realism • Large plans ≠ preparedness….in fact, they frequently invoke a false sense of preparedness • Preparedness is more of a process than a product---exercising the plans is a vital part of the process • As with plans, exercises should be flexible yet have pre-determined objectives • Whether conducting a full functional or a tabletop exercise---an After Action Report and a “hot wash” should be the beginning point for plan revisions

40. The only thing harder than explaining why you need to prepare for a disaster is to explain why you didn’t Leslie Stein-SpencerChief of EMSIllinois Department of Public Health

41. Using JCAHO Standards! • E.C.1.4.: requires development of an EMP that ensures an effective response to emergencies affecting the environment of care • E.C.2.4.: requires implementation of the EMP • E.C.2.9.: requires execution by conducting drills

42. Keeping the mole hills mole hills • E.C.1.4---The organization has an Emergency Management Plan • Intent: The EMP comprehensively describes the organization’s approach to responding to emergencies within the organization or in its community that would suddenly and significantly affect the need for the organization’s services, or it’s ability to provide those services. The plan addresses the following: • Mitigation: actions taken in attempt to lessen the severity and impact of a potential emergency • Preparedness: actions taken to build capacity and identify resources that may be used in an emergency • Response • Recovery

43. Maintaining the mole hills • E.C.2.9.1.: Drills are conducted regularly to test emergency management • Intent: The response phase of the EMP is tested twice a year, either in response to an actual emergency or in planned drills. Drills are conducted at least four months apart and no more than eight months apart.

44. E.C.1.4 and E.C.2.4 Requirements: • Execute Hazard and Vulnerability Analysis • Identify all of the hazards that could occur in your community, their likelihood, and their probable impact: • Security • Utility Failures • Natural Events, Technological Events, Human Events • Structural Implications • Other Your local EMA already has already performed a HVA for your community----use it as a springboard www.ashe.org for “Hazard Vulnerability Assessment Tool”

45. Analyzing and Integrating the HVA • Organize the analysis so that it integrates into the overall EMP • Assess each risk according to your organizations’ ability to: • prepare for • respond to • mitigate against • recover from

46. Mitigation, Preparedness, Response, and Recovery: Identification and Processes for: • Coordination with Community Emergency Planners in establishing priorities among the potential emergencies • Identification of procedures to mitigate, prepare for, respond to, and recover from the priority emergencies • Defining the role that your institution will play and integrate it into your community’s EMP • Delineating lines of authority

47. Activation of the EMP Notification of outside agencies Notification of personnel Back-up communication systems Management of all resources personnel, materiels Management of patient care activities Evacuation Transportation and transfer of patients Establishment of alternate care sites Back-up utility services Re-establishment of continuous operations Processes for:

48. Identification of isolation and decontamination sites and practices Orientation and education programs for the staff Ongoing monitoring of performance in drills and actual emergencies Annual review of the EMP Post exercise corrective action planning post Staff Needs: housing transportation incident stress debriefing family support activities Processes for:

49. Decontamination Issues: • Little attention has actually been paid to the decontamination process • Even experienced HazMat teams have limited experience • Protocols to meet the needs of the chemical and vapor decontaminated are necessary • Critical assessment of: • Inherent delays in mass decon at a scene • Decision-making process to provide water decon (ambient temperature, type of agent exposure, symptomatology, liquid vs. vapor vs. radiological vs. biological)

50. Mass Decontamination: • Identify the agent • Evacuate from the source • Decontaminate--timely • Treat the symptomatic • Observe the asymptomatic for delayed onset of symptoms • The reality is that those who survive to rescue will survive