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Information Management During Mass Casualty Events
Steveti B Nelson MSc RRT FAARC
Introduction Identifying Risks to Information Identifying Information Needs
Process Inventory Systems Inventory Vendor Inventory Impact Analysis
Impacts on and Alternatives to Existing Clinical Information Systems Sharing Information Information-Collecting for Post-Event Analysis Summary
Preparing for a mass casualty event starts long before the event. Being able to provide care during an event requires collecting information about processes, equipment, supplies, and personnel to anticipate different situations. Planning should include an impact analysis to identify and prioritize critical services that need to be maintained. Impact analysis is carried out in concert vfith the entire health care delivery organization, not by individual departments. Planning may include addressing inadequate staffing, disrupted supply chains, and loss of information systems. Care may need to be provided in alternate locations, without access to the usual information resources. Mass casualty events also depend on the availability of communications to inform otbers on the emergency response teams, as well as to inform patients and the public. Key words: mass casualty, information technology. [Respir Care 2008;53(2):232-238. © 2008 Daedalus Enterprises]
Introduction
Mass casualty preparedness is an art. There is no con- crete definition of a mass casualty event; it may be as small as a multi-vehicle accident in a rural community that
Mr Nelson presented a version of this paper at the 40th RESPIRATORY CARE Journal Conference, "Mechanical Ventilation in Mass Casualty Scenarios," held July 16-17, 2007, in Reno, Nevada.
Mr Nelson is an employee of Sun Microsystems, Santa Clara, California, a company that provides products and services that could be used in a mass casualty situation.
Correspondence: Steven B Nelson MSc RRT FAARC, Sun Microsys- tems, 8314 W 128th Street, Overland Park KS 66213. E-mail: sbn kc@mac.com.
overwhelms an emergency room for hours, a weather event that effects thousands in a city for weeks, or a pandemic outbreak that cripples health care delivery in a large region for months. It is broadly considered to be any event that causes more casualties or patients than for which the local health care agencies can provide care.
Preparation suggests that all risks should be evaluated and expected; however, that is probably not possible, since, in the words of the former United States Secretary of Defense, Donald Rumsfeld:
. . . there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don't know we don't know."'
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Table 1. Simple 2X2 Matrix to Prioritize Risks*Mass casualty inforrnation management starts by i tifying risks to information and communications. Risks are identified by understanding the processes involved in pro- viding patient care, the systems and software that provide essential information to patients and practitioners, and the vendor resources that provide everything from staffing to disposable gloves and circuits. Once this information is collected, an impact analysis will assist in prioritizing re- sponses to establish appropriate levels of care during an event. Departmental preparations need to include methods to communicate with staff, other agencies, the public, and patients.
This paper is intended to be supplementary to a corpo- rate or institutional disaster plan. It is aimed at departmen- tal issues that may need particular attention. Data-center disaster recovery and business continuity plans are in the realm of information technology departments. They may not include protecting the information assets that depart- ments tend to accumulate. Identifying them is important td assure that a department can continue to function as ef- fectively as possible.
Be prepared to adapt any plan as soon as it is imple- mented. As Prussian Field Marshal Helmut von Moltke is credited with saying, "No plan survives first contact with the enemy," or in this case, no plan survives past the arrival of the first patient.
Situational awareness is a term derived from military tactics. It has its modern roots in the Korean War, where fighter pilots learned tb observe the other pilot's actions and orient accordingly; before making decisions and act- ing. In a mass casualtyjscenario, it can also mean that you have all the information you need to avoid being surprised in the current situation.? Disasters and mass casualty events do not follow predictable, linear progressions, so decisions and actions need to be based on "what is," not on "what should be." Observations need to be constantly updated as mass casualty events progress. The collection and exchange of information is critical to provide responses to a chang- ing scenario.
Identifying Risks to Information
Departmental preparation starts by identifying threats and risks to the flow of information. A threat is an event with an adverse impact or outcome. A simplified defini- tion of risk is the probability of a threat occurring, multi- plied by the consequences. For example, a threat might be an ice storm. The risk of an ice storm disabling a commu- nity for several days is measurable in Missouri, but the risk is practically nonexistent in southern Arizona.
Risks are managed in 4 ways. They can be removed; reduced, assigned, or accepted. Removing a risk may be the most difficult, especially if there is a potential for human input. Managing a server in a respiratory care de-
Probability Low Probability High
Effect low I 2 Effect high 3 4
* Risks with low probability and low effect (area 1) require minimal or no depanmetital effort to addtcss. whereas risks in area 4 probably require institution.wide policies or procedures.
partment is a risk that can be removed by turning the system over to an information technology group. Risk re- duction may be accomplished by using redundant comput- ers or making backups of programs and databases. Assign- ing risk means that a third party, such as an insurance company or computer service bureau, will assume the risk for you. Finally, in many cases where the effect or prob- ability of a risk is low, it is may be easiest to accept the risk. I
Risk analysis is a specialized area of practice. It is gen- erally carried out on a regional basis by a coordinated team that includes first responders and health care delivery or- ganizations. It is commonly included as part of a hazard vulnerability analysis, which takes a very broad view of an impact on an area.
The same principles, however, can be applied at a sim- plified level to departmental situations. There are many elaborate schemes to identify the impact of a specific risk, but a useful, quick analysis can be done using a standard 2X2 matrix as shown in Table 1. A risk that falls in square 1 may require minimal attention, whereas a risk in square 4 will usually require a great deal of planning, including coordination among several departments or or- ganizations. Some scales break down the effects into a quantitative series of dollar values and the probabilities into percentage ranges, which may be overly fastidious from a departmental viewpoint. An example of a depart- mental risk analysis is the use of reusable versus dispos- able ventilator circuits. A communicable disease outbreak may have a greater risk of cross-contamination of venti- lator patients from the processing of reusable circuits than a multiple-victim transportation accident, but disposable circuits may become scarce commodities during an out- break. The type of event may be a determining factor in the decision.
Threats may have widely varying onsets. A massive outbreak of a communicable disease may be detected days or weeks before it causes an impact that stresses the local health delivery system. This allows time to prepare for the event by adjusting staffing to appropriate levels, ordering and stockpiling supplies, and activating disaster plans. In 2005, Hurricane Katrina was predicted to hit the Gulf Coast region several days before actual landfall. This al- lowed pre-staging emergency resources at a safe distance from the expected affected areas. Despite these efforts.
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further aggravation brought on by compounding disastrous events impaired the subsequent ability to respond. The severe acute respiratory syndrome (SARS) epidemic, once it was recognized, also allowed governments a period of time to formulate monitoring and responses to prevent further spread of the disease. Singapore's governmental response was well documented about detecting, protect- ing, and monitoring their population.^
Other threats may allow a few hours for preparation. Flash floods, failures of earthen dams, blizzards, and other meteorological events are typical. An event with a similar onset might include preparation for an influx of patients from an adverse event outside the local region.
Finally, some threats occur with little or no warning. Tornadoes, earthquakes, transportation accidents, and ter- rorist events, including nuclear, chemical, or biological attacks, fall into this category. In the case of Greensburg, Kansas, on May 4, 2007, the first instance of an Enhanced Fujita Scale-5 tornado provided less than 20 minutes of warning to the hospital. Patients were all safely removed to a secure area shortly before the hospital was destroyed by the 1.7-mile-wide tornado. The massive radar echo was observed by the National Weather Service in Dodge City, Kansas, which issued a "tornado emergency" for only the fourth time since that designation was created in 1999."*
Risks that are particular to information systems may occur independently of mass casualty events but can still have as dire a consequence on the ability to deliver health care. Most common in this category is a computer virus that disables information systems or the network infra- structure. Hospital information-technology departments are tasked with providing protection for these events, and that discussion is outside the scope of this paper. However, it is the responsibility of all computer users to know the acceptable-use policies and understand how to prevent in- troducing computer viruses into systems.
Identifying Information Needs
Knowing the many possible sources of information and how information is managed is the first step to being able to determine which are critical to have access to or main- tain during mass-casualty events. Departmental prepara- tion includes an inventory of processes, systems, and ven- dors.
Process Inventory
The process inventory should identify critical pathways needed to initiate care, report and chart, and discharge and transfer patients. These pathways will also include sched- uling appropriate resources, and handling supplies needed for patient care.
Process inventories are useful when loss of information systems requires reverting to a manual system. The pro- cess inventory will show the functions that need to be restored first in order to continue providing patient care. The process inventory may also be used to create paper forms to facilitate manual data collection and later data entry when systems are again available.
Even though there was not a concomitant mass casualty event, in 2002, Beth Israel Deaconess Medical Center in Boston had a network configuration problem that caused a complete shutdown of their clinical information system for about 4 days. They were able to revert to a paper-based system that allowed critical processes to continue. This included hand-delivery of around 3,000 laboratory tests per day.5 Their openness about the event has provided valuable guidance to other hospitals when planning for loss of information infrastructure.
Systems Inventory
The systems inventory should include hardware and soft- ware normally used within the department. In many cases this will extend beyond the hospital's information systems. In this sense, a system is a collection of interrelated ele- ments that are each required to provide a service. Respi- ratory care departments have a history of being early adopt- ers of technology and may not realize the extent of dependence on technology.
The systems inventory needs to include all devices nec- essary to provide patient care: not just computers and ter- minals. If a ventilator is connected to a remote monitoring and alarm location, each component between the endotra- cheal tube and the monitoring technician must be cata- loged if it is necessary to maintain this functionality.
Caregivers at the bedside may be using personal digital assistants to record information or calculate values. Is any proprietary software being used? Can you transfer the soft- ware to other devices, or is there an alternative available on personal computers? Wireless communication systems from companies such as Vocera Communications, Spec- traLink, and Nortel are being deployed within departments. How will loss of a communication system impact the abil- ity to deliver care? A number of departments have devel- oped internal Web sites for documenting policies and pro- cedures, or for training. Is this information available from an alternative source? If temporary workers are brought in, can they find this information quickly? Devices that can run off standard replaceable batteries may be more useful during extended outages than devices that require recharg- ing from wall outlets. What devices will survive extended power outages?
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Vendor Inventory
Vendor inventories extend beyond simple contact infor- mation for existing suppliers. They may include alternate supply sources and external staff resources.
Identification of critical supplies can lead to evaluating alternatives. A ventilator that requires a unique circuit may be less desirable than one that can use circuits crafted from rolls of bulk tubing, l^ocal suppliers may not be able to respond, so a list of vendors outside the region should be created. This might include the contact information for national sales offices of preferred vendors. If an event is widespread, a plan dependent on sharing supplies and re- sources with other regional health care providers (a so- called mutual aid agreement) may fail.
Contact information for staffing resources is useful for short-duration events. Longer-duration events may require access to state licensing boards to verify credentials if there is an influx of people from outside the region. The American Association for Respiratory Care (http:// www.aarc.org/links/links_affiliates.asp) and National Board for Respiratory^ Care (http://www.nbrc.org/stateli- cagencies.btm) maintain Web sites with this information. The American Association for Respiratory Care has also been useful in quickly notifying qualified personnel about specific needs during past events.
Table 2 provides a starting point for the different types of inventories. Specific details will be different for each
such as hospital, field hospital, orcare delivery location home care.
Impact Analysis
After tbe inventories are done, an impact analysis, some- times called a "business impact analysis," can be used to determine interdependencies between departments and ser- vices. It is used to set criteria for returning critical areas to service in order to meet patient-care needs. Impact analy- sis is done at an institutional level and uses departmental input and direction. From an information-technology per-
spective, it prioritizes the systems that need to be opera- tional, along with an expected time frame. From a respi- ratory care perspective, it may include increasing staff hours, altering routine procedures altogether.
The impact analysis
therapy orders, or stopping some
will also define an end point for an event, or what is considered the return to a normal oper- ating state. The definition of "normal" may well be dif- ferent for each affected department, so that some depart- ments may be able to recover faster than others.
Table 2. Sample Items for Information Resource Inventory
Inventory Examples
Processes
Systems
Vendors/suppliers
New-patient notification Change to patient care Progress notes Discharge and transfer notes Staff scheduling Inventory management
Devices
Hospital information system terminals Department Web server
Diagnostic and monitoring equipment Personal digital assi.stants, laptops, portable
computers Software Staff assignment software Productivity software Monitoring software Department-specific spreadsheets Software licenses Network resources Department web pages Vendor manuals Procedure manuals
Consumables Order Receive Stock Staffing
Local agencies AARC mailing lists NBRC credential verification State licensing agencies Supplemental equipment
Regional emergency response organizations
AARC = American Association tor Respiratory Care NBRC = National Board for Respiratory Care
Impacts on and Alternatives to Existing Clinical Information Systems
Different types of threats have different impacts on in- formation management. The major impact on information services during a mass casualty event is managing the sudden influx of patients. Electronic medical records sys- tems should expand to meet the patient registration de- mands. Workflow analysis and simulated disaster testing will help determine the surge capacity of the system in meeting the demand. The ability to enter unidentified pa- tients into the system should be verified before an event happens. Once a patient is identified, there needs to be a method to merge that record to an existing patient record so tbat the patient's complete history is rejoined and avail- able.
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A facility may need to set up temporary patient-care sites in a remote location, such as a school, auditorium, or parking lot. For instance, the Carolinas Medical Center's Carolinas MED-1 mobile hospital system (http://www. carolinasmed-l.org)6 has two 53-foot tractor trailers (one trailer for patient care, with nearly 1,000 square feet of indoor treatment space, and one trailer for support and storage), 6 critical care beds, 7 general beds, a dental/ ear-nose-and-throat treatment chair, a tent system that can add 100 exterior beds, level-1 trauma center, diagnostic capabilities, pharmacy, laboratory, radiology, ultrasound, and telemedicine uplinks. Getting access to clinical infor- mation systems at a remote facility may be a simple matter if the communications infrastructure remains intact. Alter- natively, the electronic medical records system should be evaluated to see if it can run in a disconnected mode, and if it operates differently, training needs to be made avail- able to highlight the differences.
Most commercial clinical information systems are com- posed of huge databases that run on large servers in con- trolled environments with massive storage arrays and re- quire software that is only licensed to run in a specific configuration. They generally include automated data en- try from a diverse collection of diagnostic devices and have network connections to terminals located in nearly every department and at patient bedsides. In the event of a disaster none of those may be available or the facility itself may be rendered unusable.
A disaster may require that an electronic medical records system be created de novo. There are a number of open- source electronic medical records systems that can be eas- ily and quickly installed on computers as small as a laptop and deployed to any health care site.'' Open-source elec- tronic medical records systems avoid the problems of com- mercial licensing issues. They can be placed in remote venues as a stand-alone solution, configured for office or clinic settings, or be used to run large multicenter institu- tions. VistA is the most widely known example. It has been used to provide electronic medical records in hospi- tals and care facilities in the Veterans Administration sys- tem since 1985.* World VistA, an open-source collabora- tion, was begun in 2002 to add functionality for services that were not found in VistA, such as pediatrics and ob- stetrics support (http://www.worldvista.org).
VistA is a flexible electronic medical records system that includes modules for home-based primary care, home telehealth and out-patient clinics, as well as all of the standard functions a hospital requires. VistA's National Health Exchange and Patient Data Exchange modules pro- vide a simple interface to send or retrieve patient infor- mation with other institutions using VistA or its deriva- tives. Small systems can be configured to provide only the services that are required for a site.
A benefit of an interoperable, stand-alone system is that data can be collected on paper records in real time. It can then be transcribed by staff later, even from remote loca- tions, and synchronized with the patient record when the time is appropriate. If an alternative to the existing elec- tronic medical records is chosen, training and refresher courses must be provided to familiarize workers prior to use. Quick-reference guides should also be available to help new users get oriented. Configuring only the func- tions that are required for immediate patient care will re- duce the set of instructions that need to be learned.
Sharing Information
Information will be needed by a number of different groups, and creative measures may be required to keep all of them informed. Procedures need to address information needs of personnel notifications, patient records, public information, and interagency communications.
The regular respiratory care staff requires access to the usual information sources, including scheduling and record- keeping. If existing staff needs to be supplemented with additional personnel, special procedures may need to be created that can rapidly create and activate accounts and provide system access for them.
Contacting staff may become difficult if telephone ser- vice is disrupted. Standard land-line phones are the slow- est to be reconnected, whereas cellular service can be re- stored in as little as a few hours. Portable cell towers can be moved into an area on small trailers and connected to telephone switching offices. However, cellular service may be overwhelmed by voice calls. Most cell phones are ca- pable of receiving text messages. Text messaging service requires less bandwidth and provides reliable delivery. Mes- sages can be received while a phone is in use on a voice call or stored and sent to a phone when it is turned back on.
Cell phones may be used to send broadcast messages to large numbers of people in a designated group, or in a geographic area. Systems such as Chatter (http:// www.2chatter.com), GroupCast (http://www.groupcast. com), and MobileSphere (http://www.mobilesphere.com) can be used to send messages to cell phone users who request being included in the notification service. These services can be configured for department staff notifica- tions, replacing traditional phone trees that depend on peo- ple to perform a task. Other populations that might be affected by an event, such as elderly, asthmatic, or im- mune-suppressed patients can also received targeted no- tices. Other types of systems, such as CellCast (http:// www.cellcast.co.uk), broadcast messages to all cell phones in a particular cell service area. Such systems are useful when indiscriminate emergency messages need to reach an area. As a response to the April 2007 shooting incident on
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the Virginia Tech campus, a number of universities have instituted broadcast text messaging systems.'"
An essential function of any electronic medical records system used in a mass casualty event is the ability to generate copies of patient information as patients are dis- charged or sent to other care venues. The Certification Commission for Healthcare Information Technology tests programs for functionality, interoperability, and security. WorldVista, discussed in the previous section, is certified as meeting all requirements, along with almost 100 other products.'2
Patients and the public will need to know what health services are available, where they are if they have been relocated, and hours of operation for clinics. They may need to access information for self-care or instructions for particular threats, such as quarantine-in-place procedures to prevent being exposed to or spreading agents. Informa- tion should be provided in an on-demand format to allow accessing it at the patient's convenience and at a pace that the user can understand. Broadcast media, such as radio or television, are appropriate for specific types of information but cannot provide on-demand access at present.
Communication and coordination during a mass casu- alty event are carried out by a regional response team. Depending on the level of involvement, it may include city, county, state, and federal resources. The response to hurricane Katrina demonstrated the difficulty that all the agencies had exchanging information, ranging from sim- ple radio communication to supply lines to personnel al- location. In the aftermath, a number of lessons are being applied by response teams to existing mass casualty pro- grams to ensure basic communications are available be- tween the various agencies.
Low-tech and no-tech solutions should not be over- looked. Following the Greensburg, Kansas, tornado, the Kansas Adjutant General's office printed regular newslet- ters that highlighted community events and pointed out potential health issues during the cleanup.'^ Paper forms, derived from the process inventory, might be used in the absence of electronic systems.
Information-Collecting for Post-Event Analysis j;
Keeping track of evjerything that happens during a mass casualty event is usually not at the top of any administra- tive list, since the focus is simply providing health a situation where the
I care m delivery system has become over-
whelmed. However, overlooking valuable lessons learned is a mistake.
During the Hurricane Katrina disaster, both responders and impacted residents kept Web logs ("blogs") that re- corded their thoughts and feelings and provided insight into the event as it progressed. In the process, they pointed out what worked well and what problems they found.'"'^
From this nontraditional source of information, responders were able to communicate with others in the field and adapt as the situations were changing.
Internet communications can also provide information about impending disasters. In 2002, China was not pro- viding accurate information about what they dismissed as a "flu outbreak." Canadian epidemiologists monitoring In- ternet Web sites and e-mail communications were able to collect information to suggest a more serious problem was occurring. Because of Canada's appeal to the World Health Organization, China finally revealed the extent ofthe SARS epidemic within their country.'*
Finally, the United States Department of Homeland Se- curity provides a Web site that publishes lessons learned, best practices, and after-action reports.'"' It requires regis- tration before access is granted. Over 6,500 documents are in the collection, including reports from actual incidents, as well as summaries of field exercises. It includes both positive and negative observations so that adverse deci- sions can be avoided.
Summary
The need for information accelerates during a mass ca- sualty event. Responses to events require the ability to collect information and analyze it in an environment that may be continually changing. Loss of communications infrastructure hampers this ability. Preparation may reduce this impairment.
Successful preparation for a department includes cata- loging the information required by processes, systems, and resources needed to provide acceptable levels of care for a given event. Reviewing alternatives to existing communi- cation and information infrastructure can prepare a depart- ment for using altemative technology, or even no technol- ogy. A post-event analysis will provide an opportunity to improve the response to subsequent events.
The last step in any plan should include the processes that need to be back in place before the event can be considered at an end, and normal operations can resume. There may be a phased return, as in a decreasing patient loads, or a complete cut-over, such as a return to a desig- nated facility. Ultimately, every crisis will have a conclu- sion.
REFERENCES
1. U.S. Department of Defense, news transcript. DoD News Briefing. Sec Rumsfeld and Gen Myers. 02/12/02. http://www.defenselink. mil/transcripts/transcript.aspx?transcriptid=2636./4ccei.serf yanuary 15, 2008.
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2. Wikipedia contributors. Situation awareness. Wikipedia, The Free Encyclopedia. http://en.wikipedia.org/wiki/situational_awareness. Accessed January 15, 2008.
3. Centers for Disease Gontrol and Prevention. Severe acute respiratory syndrome—Singapore, 2003. Morb Mortal Wkly Rep 2OO3;52(I8): 405-411.
4. Wikipedia contributors. Greensburg, Kansas. Wikipedia, The Free Encyclopedia. http://en.wikipedia.org/wiki/Greensburg,_Kansas./ic- cessed January 15, 2008.
5. Bednarz A. Hospital sounds alarm after 3-day struggle. 11/25/02. Network World, http://www.networkworld.eom/news/2002/l 125be- thisrael.html. Accessed January 15, 2008.
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http://www.doctorsgadgets.com/forum/open-source-medical- software/129-list-open-source-emr-projects.html. Accessed January 15, 2008.
8. Department of Veterans Affairs. VistA Monograph 2005-2006. Wash- ington DC. May 2005. http://www.va.gov/vista_monograph/docs/ vista_monograph2005_06.pdf. Accessed January 15, 2008.
9. Georgetown University. Emergency text messaging to launch. [George- town] University News, August 21,2007. http://explore.georgetown.edu/ news/?lD=26590. Accessed January 15, 2008.
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11. Mayer K. [Denver] University's emergency plan to include text mes- saging September 07, 2007. http://www.du.edu/today/stories/2007/ 08/2007-08-31-emergency.html./4ccei.ieJ7a«Ha/->' 15, 2008.
12. Certification Commission for Healthcare Information Technology. WorldVistA CCHIT Certified Ambulatory EHR 2006. http://www. cchit.org/certified/. Accessed January 15, 2008.
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Discussion
Branson: How do you collect in- formation?
Nelson: That's what the LLIS (Les- sons Learned Information Sharing) Web site (http://llis.gov) has: all of the retro- spective information. So they try to re- member what happened, but there isn't
a good method. The last thing people are going to be doing is thinking, "Let's write down every little step we took and deconstruct this later." But LLIS is a good place to look for it.
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