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WakeMed Health & Hospitals. Raleigh, North Carolina. Medical Disaster Planning and Response Process: Pre-event Disaster Planning National Emergency Management Summit New Orleans March 5, 2007 Barbara Bisset, PhD MPH MS RN EMT Executive Director Emergency Services Institute. Objectives.

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WakeMed Health & Hospitals

Raleigh, North Carolina

Medical Disaster Planning and Response Process:

Pre-event Disaster Planning

National Emergency Management Summit

New Orleans

March 5, 2007

Barbara Bisset, PhD MPH MS RN EMTExecutive Director

Emergency Services Institute


Awareness of

  • Key Considerations
  • Disaster Phases
  • Five Planning Tiers
  • Contingency Business Plans
  • Resources for Healthcare Planners
key considerations defining events
Key Considerations:Defining Events
  • Do NOT define events by the number of casualties
  • Loss of mission critical systems is an event
key considerations internal versus external events
Key Considerations:Internal versus External Events

Three potential scenarios

  • Hospital only
  • Community only
  • Hospital and the community
key considerations events do not have boundaries
Key Considerations:Events Do Not Have Boundaries

Events may or may not be contained within one geographic location

Events can easily cross over county and/or state lines

key considerations hospitals are first receivers
Key Considerations: Hospitals Are First Receivers

Literature documents that greater than 85% of the population will likely bypass community emergency response systems and will report to the hospital that they normally go to for service

key considerations capacity versus capability
Key Considerations: Capacity versus Capability

Capacity (Volumes of Patients)

  • Most hospitals are already at full capacity
  • Rapid versus gradual influx of patients
  • Expansion / surge spaces
key considerations capacity versus capability1
Key Considerations: Capacity versus Capability

Capability (Types of Patients)

  • Specialized populations
    • Burn victims
    • Pediatric populations
    • Need for isolation rooms
    • Decontamination procedures required
  • Requires specialized equipment, supplies and staff
key considerations covert versus overt
Key Considerations:Covert versus Overt
  • May or may not be an identifiable “scene”
  • Patients may already be in the hospital system before there is an identified event
key considerations warning versus no warning events
Key ConsiderationsWarning versus No Warning Events

Notification Systems

  • Advisory
  • Alert
  • Activation
  • Updates
key considerations type of casualties
Key Considerations:Type of Casualties

For every one physical casualty, you can expect four to twenty mental health casualties

key considerations special needs populations
Key Considerations: Special Needs Populations

Special needs populations

  • Often are those who are “left behind”
  • Many times cannot afford the expense of taking personal actions
  • Medical needs will be accelerated in emergency events
key considerations ethical considerations
Key Considerations: Ethical Considerations
  • Limited resources
  • Level of care
    • Sufficient versus “normal”
key considerations communications
Key Considerations: Communications
  • All communication systems that you use on a daily basis will rapidly become overloaded and/or will fail
  • Hospitals can expect thousands of calls (if the normal communication systems are working)
key considerations communications1
Key Considerations: Communications
  • Information may most likely be:
    • Inaccurate and/or incomplete
    • Delayed
  • Rumors can run rampant
  • Intelligent community
  • Event may involve risk communications
key considerations campus security
Key Considerations: Campus Security
  • You cannot treat patients if you do not have a safe environment
  • The crowds will come
key considerations staffing
Key Considerations: Staffing
  • Employees and/or their families may be victims of the event
  • May have fear of responding
  • May need to alter duties
  • Staff may be needed from resources outside the facility
key considerations decision making
Key Considerations:Decision Making
  • If event requires a rapid activation, the steps taken in the first ten minutes will affect patient outcome and success of response
  • Normal “decision makers” may be unavailable
key considerations availability of vendors
Key Considerations:Availability of Vendors
  • Multiple agencies may have agreements with the same vendors
  • Vendors contact may need to be 24/7
key considerations financial cost
Key Considerations:Financial Cost
  • Cost of event can rapidly escalate
  • Details and documentation are needed for insurance and other potential sources of reimbursement
key considerations regulatory agencies
Key Considerations: Regulatory Agencies
  • Regulatory standards apply during emergency and disaster events. Recognize in catastrophic event life saving measures will be a priority.
    • Division of Facility Services
    • Occupational Safety and Health Administration (OSHA)
    • Emergency Medical Treatment and Active Labor Act (EMTALA)
    • Fire Marshall Having Jurisdiction
    • Environmental Protection Agency
    • Health Insurance Portability and Accountability Act (HIPAA)
    • Medical and Nursing and Allied Health Practice Boards
key considerations documentation
Key Considerations: Documentation
  • Documentation of response to event is often uncoordinated and is generally the weakest link
  • Many decisions may go undocumented
mitigation phase
Mitigation Phase
  • Critical systems on emergency power
  • Redundant systems
  • Construction and designs of space
preparedness phase
Preparedness Phase

Employee Training

1. Awareness Level

  • Quick Response Guides

2. Active Participant Level

  • Quick Response Guides
  • Standing orders / Protocols
  • Other duties as assigned

3. Expert Level

  • Knowledge of details of plans
  • Job Action Sheets
  • Key Assumptions
  • Crisis Management
preparedness phase1
Preparedness Phase

Equipment and Supplies

  • Just-in-time inventories versus preparedness for greater than 72 hours
  • Specialty equipment for capability events
  • Mobility of equipment
preparedness phase2
Preparedness Phase

Staff Assignments

  • Active and Reserve Teams
    • All employees are essential
  • Systems for rapid activation and deployment
  • Task Forces
  • Strike Teams
response phase
Response Phase
  • Incident Recognition
  • Notification
  • Mobilization
  • Incident Operations
  • Demobilization
  • Transition to Recovery
response phase1
Response Phase
  • Authority to activate emergency operations plans
    • Consider immediate threats
    • Time to respond – e.g. setting up decontamination operations
  • Implement incident command for all events
  • Develop focused action plan
  • Better to over commit than to under commit
recovery phase
Recovery Phase
  • Be prepared for extended operations
  • Incident command in place until operations return to “normal”
  • Opportunity for organizational learning
  • Develop After Action Report (AAR)
    • Follow identified actions through completion
planning in five tiers
Planning in Five Tiers
  • Personal
  • Department
  • Organizational
  • Participate in regional planning
  • Participate in state and other organizations planning efforts
tier one personal and family preparedness
Tier One:Personal and Family Preparedness
  • Every employee needs to have a plan
  • Includes:
    • Home inventories
    • Evacuation routes
    • Personal packs with self sustaining supplies, important papers
    • Work Pack
    • Emergency Car Kit
    • Pet Plan
tier two department plans
Tier Two:Department Plans
  • Every department is essential
  • Each department needs to understand their preassigned role
tier three organization s plan
Tier Three:Organization’s Plan

Details how the hospital responds as a system

  • Hospital Command Center
  • Policies, Procedures, Emergency Operations Plans
tier three organization s plan1
Crowd Control

Restricted Access


Special Needs Populations

Management of Communications from the Public

Epidemiological Events

Management of Staff

Expectation of Employees

Emergency Credentialing

Capability Events


Mass decontamination


Management of Donations

Management of Volunteers

Capacity Management

Tier Three: Organization’s Plan

In addition to the standard planning

tier four community and regional planning
Tier Four:Community and Regional Planning
  • Hospitals must take a leadership role with community and regional partners
  • Cannot operate in a vacuum
    • Public Information
      • Joint Information Centers
    • Multiple agency plans need to be coordinated
      • Selection of Ambulatory Care Centers
    • Mutual Aid Agreements
tier five planning with the state and organizations
Tier Five:Planning with the State and Organizations
  • Need to understand state plans and know individuals in key state and organizations agencies
    • Public Health
    • Office of Emergency Medical Services
    • Hospital Association
    • Law Enforcement
    • Emergency Management
business continuity planning
Business Continuity Planning
  • Continued access to services
  • Record preservation
  • Business relocation plans
national incident management system nims
National Incident Management System (NIMS)
  • Department of Health and Human Services in collaboration with the National Incident Management Systems (NIMS) Integration Center
  • Seventeen elements for hospitals
  • Compliance by August of 2008 if want to receive federal preparedness dollars
nims seventeen implementation activities
NIMS:Seventeen Implementation Activities

# 1 Organizational Adoption

# 2 Command and Management (ICS)

# 3 Multi-agency Coordination System

# 4 Public Information Systems

  • Joint Information System (JIS) and Joint Information Center (JIC)

# 5 Implementation Tracking

  • Annual Emergency Management report
nims seventeen implementation activities1
NIMS:Seventeen Implementation Activities

# 6 Preparedness Funding

# 7 Revision and Updating of Response Plans annually

#8 Mutual Aid Agreements

# 9 Training IS 700 NIMS

  • All personnel who have a leadership role in emergency preparedness, incident management or incident response need to take the course
nims seventeen implementation activities2
NIMS:Seventeen Implementation Activities

# 10 Training IS 800 National Response Plan

  • Must be completed by individuals whose primary responsibility in a hospital is emergency management

# 11 Training ICS 100 and 200

  • Must be completed by those who have a direct role in emergency preparedness, incident management or response

# 12 Training and Exercises

  • Must include incident command structure
nims seventeen implementation activities3
NIMS:Seventeen Implementation Activities

# 13 All Hazard Exercise Program

# 14 Corrective Actions Reports

nims seventeen implementation activities4
NIMS:Seventeen Implementation Activities

# 15 Response Inventory

  • NIMS Typing of resources

# 16 Resource Acquisition

  • Relevant national standards and guidance are used to achieve equipment, communication and data interoperability.

# 17 Standard and Consistent Terminology

  • Plain English communication standards across the public safety sector
  • Common language between Emergency Management, Law Enforcement, EMS, fire public health and hospitals
national incident management structure versus hospital incident command structure
National Incident Management Structure versus Hospital Incident Command Structure
  • National committees collaborated
  • Reconciled discrepancies as HEICS (III) did not
    • Include multi-agency cooperation
    • Public information systems
    • Proper incident command system language
hospital incident command hics version iv
Hospital Incident Command (HICS)(Version IV)
  • Incident Command must be incorporated into the response to every events
  • HICS is NIMS compliant
  • HEICS III and HICS IV Position Crosswalk
  • Job Action Sheets
hospital incident command hics version iv1
Hospital Incident Command (HICS)(Version IV)
  • Seventeen internal and external events identified
    • Incident Planning Guides
    • Incident Response Guides
  • Education Tools
  • HICS Implementation Tools
the joint commission proposed elements to emergency management standards
The Joint Commission:Proposed Elements to Emergency Management Standards

Need to think of critical capabilities beyond 72 hours


Agency for Healthcare Research and Quality


Best Practices for the Protection of Hospital Based First Receivers


Emergency Management Principles and Practices for Healthcare Systems


Hospital Incident Command (HICS IV)


National Incident Management System

  • Key challenges
  • Phases of disaster
  • Tier Planning
  • Resources for Healthcare Planners

WakeMed Health & Hospitals

Raleigh, North Carolina