VHA, D o d , & civilian collaboration during mass casualty disasters

1. VHA, Dod, & civilian collaboration during mass casualty disasters Association of VA Surgeons Kenneth A. Lipshy, MD, FACS- ACS COT Reg 13 VA Chair Aug 2019

2. DOES the VA have any role during a national mass casualty disaster?Absolutely & More than you may think!

3. OBJECTIVES: • Education of Surgeons regarding the VA-DoD roles during Mass Casualty Civilian or DoD Disasters, assuring that the Surgical Chiefs have the appropriate information to discuss their program’s role when the NDMS is activated or during other civilian or DoD Mass Casualty Disasters. • Overview of Handbook 0320.2 Comprehensive Emergency Management Program April 12 2013. • Overview of VA Patient Reception Plans (NDMS) • Overview of potential sites of interaction between DoD and VHA. • Discussion of several DoD incidents in locations whereby assistance could have been requested of the VA.

4. CEMP: COMPREHENSIVE EMERGENCY MANAGEMENT PROGRAM- April 12 2013; VHA DIRECTIVE 0320 Provides guidance and direction for the VHA Comprehensive Emergency Plan (CEMP), which includes the following: • Ensuring the provision of medical support to VA-Department of Defense (DOD) for military contingencies as defined under the VA-DOD Memorandum of Understanding. • Planning and implementing the VA-DOD Contingency Hospital System and VA support of DOD during war and national security emergencies. • Planning VA support of NDMS through a field-based organization of Regional and Area Emergency Managers and support staff. • Developing and maintaining national interagency working relationships to facilitate VHA’s participation in coordinated Federal planning and response to disasters and emergencies.

5. Where does the VA-DOD MOU and Response Framework originate?

6. HISTORY OF THE NATIONAL RESPONSE PLAN • Disaster Relief Act / Public Law 93-288 (1974) • FEMA (1979) • Robert Stafford T. Disaster Relief Act (1988) • Federal Response Plan (1992) • Homeland Security Act (2002) • NRP- National Response Plan (2004) • National Disaster Medical System (NDMS) • NIMS- National Incident Management System • National Preparedness System • Strategic National Risk Assessment • NRF- National Response Framework (2008) • Presidential Policy Directive 8 (PPD8) (2011)

7. National Response Framework • The NRF is the Response portion of the National Planning Frameworks. • The NRF is a guide to how the Nation responds to all types of disasters and emergencies. • The NRF is always in effect, and elements can be implemented at any time. • It is built on scalable, flexible, and adaptable concepts identified in the National Incident Management System (NIMS). • The NRF is composed of a base document, Emergency Support Function (ESF) Annexes, Support Annexes, and Incident Annexes . The annexes provide detailed information to assist with the implementation of the NRF. • Each Incident Annex lists a Coordinating Agency (which has primary responsibility for that Annex), and Cooperating Agencies (that provide support to the Coordinating Agency). • VA is not listed as a Coordinating Agency on any of the Incident Annexes, but it is listed as a Cooperating Agency on 5 of the 7 annexes. • VA support, activation of NDMS, and other medical responses generally fall under ESF 8 – Health and Medical Support, of the NRF.

8. WHAT IS THE NATIONAL DISASTER MEDICAL SYSTEM (NDMS)? • The NDMS is an interagency partnership between the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS)/FEMA, the Department of Defense (DoD), and the Department of Veteran’s Affairs (VA) • Created in 1984 to supplement State and local agencies during disasters and provide backup during oversees conflict. • Based on the 2005 Memorandum of Agreement between these agencies.

9. Components of NDMS: • Response Teams: HHS DMATs, DMORTS, IMSuRT & NVRTs; • Patient Movement (usually DoD Airlift) and Reception (VA and DoD managed FCCs); • Definitive Medical Care (participating local hospitals)  DMAT- Disaster Medical Assistance Team, DMORT- Disaster Mortuary Operational Response Team, NVRT- National Veterinary Response Team

10. NDMS ACTIVATION • In the event that the local medical systems within a disaster area are overwhelmed, there may be a need for a system to move patients out of the disaster area. • If State or local authorities are unable to provide sufficient support, Federal authorities may deploy appropriate assets to assist (e.g., HHS Public Health Service, DoD, VA medical assets). • NDMS is responsible for coordination and tracking of patient movement during this process.

11. What are the Components of NDMS?How is the VA involved in these activities? ANSWER: The VA provides support to NDMS for all phases • Medical response (Federal Medical Shelters, Augmentation of medical teams, DEMPS, and so on); • Transport (DUVs); • Reception (FCCs); • and even Definitive medical care if an evacuated patient is a veteran or active duty member. • HHS is the lead agency for all matters health and medical.  VA provides support for this mission (and others) based on the need and availability.

12. Federal Coordinating Centers (FCC) • There are 65 FCC locations throughout the United States, 14 are DoD and 51 are VA facilities. • Each VA FCC has an Area Emergency Manager (AEM) assigned as the FCC Coordinator. • The FCCs main function is to receive patients and coordinate their ability to receive definitive medical care at participating hospitals.  • The AEM facilitates these processes for the facility director.  • The FCC does not actually provide or coordinate the medical care itself.

14. VA-DOD Contingency plan during Armed conflict - Patient Reception Centers (PRC): • VA agrees to provide health care backup to DoD in times of war or national emergency • Provide ability to activate PRC’s within 24 hours

15. Public Law 97-174 • This designation stemmed from the VA/DoD Health Resources Sharing and Emergency Operation Act (Public Law 97-174), enacted on May 4, 1982. • Gave the VA a new mission: to serve as the principal health care backup to DoD in the event of war or national emergency that involves armed conflict. • In addition to the contingency mission, this public law amended Title 38, United States Code (U.S.C.), to promote greater peacetime sharing of health care resources between VA and DoD. • In response to the law, a Memorandum of Understanding (MOU) was executed between the Secretary of Defense and the Administrator of the Veterans Administration (presently the Secretary of Veterans Affairs),specifying each agency's responsibilities under the law. • The VA agreed to serve as the primary medical backup systems for DoD and to furnish health services to armed forces on active duty on a higher priority than was done previously.

16. Differences Between NDMS FCC and VA/DoD Contingency Hospital System Primary Receiving Center (PRC): • A PRC is a Military Treatment Facility (MTF) or VA Medical Center (VAMC) designated for coordinating and/or providing treatment to sick and wounded military personnel returning from armed conflict or national emergency. • FCCs may receive, triage, stage, track and transport inpatients, affected by a disaster, to a participating NDMS inpatient hospital capable of providing the required definitive care. • Military, family members, or other beneficiary patients will more than likely be eligible for care in a Federal treatment facility, The mission of a PRC is to receive and treat sick and wounded military personnel returning from armed conflict or national emergency. • SEE NEXT SLIDE FOR DIFFERENCES

18. As a Federal Facility, VA Hospitals may become the primary receiving center. • “The VA agreed to serve as the primary medical backup systems for DoD and to furnish health services to armed forces on active duty on a higher priority than was done previously.”

19. When might a DoD “Mass Casualty” event occur whereby the VA is required to provide medical support for the military service staff? • Massive influx of military casualties from overseas conflict. • Act of war on US soil • Localized act of terrorism • Conflict or other disaster on DoD Property

20. DEMPS: Disaster Emergency Medical Personnel System (VA Handbook 0320.03) • Veterans Health Administration's MAIN DEPLOYMENT PROGRAM FOR CLINICAL AND NON-CLINICAL STAFF TO AN EMERGENCY OR DISASTER. • The DEMPS Program may be used for an internal VA mission, as well as supporting a mission after a Presidential Disaster Declaration under the National Response Frameworks Emergency Support Function #8 (Public Health and Medical Services). • When disasters such as hurricanes, earthquakes, floods, etc., occur and the state and local resources to handle the response/recovery process are overwhelmed, the state in which the disaster occurs may request federal assistance. • In this case, a Presidential Disaster Declaration is issued and the National Response Framework (NRF) is activated. • Once the damage to the area and needs have been assessed, and it is determined that medical resources are required, the Federal Emergency Management Agency (FEMA) or the Department of Health and Human Services (HHS) may task VA to provide these resources. • Generally, these requests are for medical personnel (nurses, physicians, pharmacists, etc.), pharmaceutical (or other medical) supplies, and medical equipment. • However, depending on the mission, VHA may deploy non-clinical staff to support the infrastructure of the deployment. http://www.va.gov/VHAEMERGENCYMANAGEMENT/CEMP/CEMP_DEMPS.asp

21. SUMMARY: FORMAL SCENARIOS Requiring VA involvement: • VAMC is required to engage in PRC activities and manage injured military personnel. • Primary VA PRC is overwhelmed and needs to rely upon a VA Secondary Support Center (SSC) for assistance. • Backup during massive overseas conflict. • HHS can activate the NDMS International Medical Surgical Response Team (IMSuRT), thereby deploying surgeons to regions of need- the VA has supported/augmented with clinicians in the past (Post earthquake in Haiti).  • A VAMC finds itself impacted by a disaster and has an internal mission to deploy surgeons to keep up with veteran patient casualties or unstable community or military casualties.

22. AFFILIATION OF Department VA Affairs and Homeland Security- ACTIVE SHOOTER PLANNING • The Homeland Security paper “Active Shooter Planning and Response in a Healthcare Setting,” (2015) supports the work of the Hartford Consensus as well as the Committee for Tactical Emergency Casualty Care (TECC) • “Once a known threat has been stopped or located, or if the suspect cannot be immediately located, law enforcement will transition towards victim rescue and providing life-saving medical aid to wounded persons.” • Published by the Healthcare and Public Health Sector Coordinating Council • Partners with the Interagency Security Committee (ISC) • A Primary Member of the ISC: Department of Veterans Affairs

23. SUMMARY: Non-Formalized Potential Roles of VA: • Transferring postop stable patients from a DoD FCC to the VA to make room for acutely injured patients at the DoD Medical facility. • Urgent transfer of acutely injured patients to their facility due to proximity of / or overwhelmed DoD or Community support (i.e. Patients migrate to the VA when their community hospital across from the VA has a lengthy backup or the VA is on the way to community hospital and roads are obstructed). • Storage site for mass casualty response team equipment (VA All-Hazard Emergency Caches). • NDMS Medical Surgical Response Team (IMSuRT)- Haiti.

24. QUESTIONS?Kenneth.Lipshy@va.gov

25. Contributors:

26. Resources • James Payne, MS, CEM, CHEC-III; VHA Office of Emergency Management; Area Emergency Manager; Durham. (NDMS Presentation). • Paul Brannigan, VHA Office of Emergency Management; Regional Emergency Manager, Duluth Georgia • Deneen Carter-Coleman. VHA Office of Emergency Management; Area Emergency Manager; Richmond. • Division Director, National Disaster Medical System HHS/ASPR/OEM Andrew Garrett, MD, MPH; Andrew.Garrett@hhs.gov; • Jeffrey A. Bailey, MD, FACS; Col, USAF, MC, FS; Emeritus Director, Joint Trauma System; Defense Center of Excellence • FHPR- Federal Health Protection and Readiness: http://ndms.fhpr.osd.mil/ • HHS- PHE - Public Health and Medical Emergency Support Site: http://www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx • VEMEC- Veterans Emergency Management Evaluation Center http://www.publichealth.va.gov/about/vemec/index.asp Dept. of Veterans Affairs 16111 Plummer Street (152) North Hills, CA 91343 vemec@va.gov

27. Other important links • http://www.healthadministration.org/resources/the-national-disaster-medical-system/ • FEMA- http://www.fema.gov/national-response-framework • FEMA- https://www.fema.gov/national-incident-management-system • FEMS- http://www.fema.gov/national-preparedness-system# • http://www.dhs.gov/presidential-policy-directive-8-national-preparedness • VHA Directive 0320 COMPREHENSIVE EMERGENCY MANAGEMENT PROGRAM • VHA Handbook 0320.04 DEPARTMENT OF VETERANS AFFAIRS AND DEPARTMENT OF DEFENSE CONTINGENCY PLAN