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Healthcare Facility Disaster

Management

John D. Hoyle Sr.

OVERVIEW

Disaster preparedness in healthcare facilities has historically been a low priority and is often viewed as a chore or unnecessary mandate. Too often it has not received the support of top man- agement in a meaningful way. In some societies, healthcare is viewed as a right, with the expectation that the hospital be ready 24/7 to render care as needed. Lawyers may sue the unprepared hospital or healthcare professional after a disaster in some cul- tures. In past decades, many healthcare professional training programs, including those in the U.S., have not emphasized dis- aster preparedness in their curricula. Even residencies in emer- gency medicine sometimes neglect this important subject. Since the terrorist attacks of September 11, 2001 in the U.S., many healthcare training programs have begun educating students on this vital topic and its implications for their communities. Many hospitals have experienced a resurgence of interest in prepared- ness and have hired full-time emergency management personnel. In contrast, other institutions have only prepared minimally as required by outside entities (e.g., the local or national health authority or The Joint Commission in the U.S.). Hospital pre- paredness efforts have waxed and waned over the years, and the tempo of preparedness planning, training, and drilling has vacil- lated depending on national or local requirements or trends and real-world events. Because students in hospital and healthcare administration usually receive no training on this management topic, they are not fully cognizant of the possible demands that could be placed on them and their facility during a disaster or emergency situation. An additional factor inhibiting prepared- ness activities is the fact that individuals could work their entire careers in a hospital and never experience a disaster. At the time of this writing, preparedness efforts for hospitals, public health organizations, and long-term care facilities are gaining momen- tum. While the term “hospital” is used throughout much of this chapter, the principles discussed are meant to apply to all healthcare facilities.

History of Healthcare Disaster Planning and Preparedness

The initial efforts to formalize hospital disaster preparedness began in the United Kingdom in the days before the outbreak of WWII. As war with Germany became imminent, the British government completed planning activities started in the 1920s following the WWI bombings of London by Zeppelins. The government realized that modern airpower and munitions rep- resented a severe threat that could produce massive numbers of casualties. Therefore, they implemented many medical pre- paredness measures and created the Emergency Medical Service (EMS) in the Ministry of Health to coordinate these endeavors.1

The British EMS was unlike a 21st century prehospital system in the developed world, rather it represented a planning and con- trol agency. This group had authority over all healthcare services and had the power to regulate hospitals, designate duties for each category of hospital, create new hospitals in prefabricated huts at distant locations from target areas, and dispatch ambu- lance trains and buses to remove the injured to hospitals in safe areas.

The United Kingdom was divided into 12 planning regions, with the London region further subdivided into 12 sectors because of the heavy population density. Planners anticipated an initial casualty load of 35,000 victims from bombings.

Working with the military to devise estimated casualty fig- ures, EMS quickly placed orders for 150,000 beds with linens and blankets. At the same time, EMS also ordered 226,000 litters that, with their wire mesh, could be easily cleaned or even used as decontamination stretchers. The large number of litters was also desired to reduce the frequency of transferring patients from bed to bed as they moved through multiple treatment venues. Also ordered were massive quantities of pharmaceuticals and dressings to provide for 250,000 hospital beds, 3,000 First Aid Posts, and 2,000 smaller First Aid Points.1 Those staffing the First Aid Posts included physicians and nurses performing casualty

285 Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:39:28.

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clearing. Gas decontamination units were also organized and the EMS issued guidance documents.1

■ “Structural Precautions for Hospitals Subject to Bombing Effects”

■ “System for Wartime Organization of Hospitals” ■ “Formation of Casualty Bureaus” ■ “Medical Treatment of Gas Casualties” ■ “Training and Work of First Aid Parties”

Also during this period, numerous medical faculty members published books such as Medical Organization and Surgical Prac- tice in Air Raids, Casualty: Training, Organization and Adminis- tration of Civil Defense Casualty Services, and The Treatment of Burns.2–4

Before hostilities began, hospitals were reinforced with wooden beams and some constructed bed space and operat- ing rooms in their basements. Casualty Bureaus were created to organize the medical records on patients and the deceased, and report their statistics twice daily to the EMS. An alerting system for hospitals was established. Upon receipt of a warning, each hospital had specified actions to take in preparation for the arrival of casualties. The British government offered reimburse- ment to hospitals for upgrading their facilities and providing care to casualties.

The EMS had a Medical Director appointed for each region and sector whose responsibilities included1

■ Liaise with the hospitals in the region or sector. ■ Build cooperation in planning the precise use of each hospi-

tal. ■ Distribute medical personnel between the inner and outer

zone hospitals. ■ Act on behalf of the hospital while also being an agent of the

Ministry of Health.

Within the EMS headquarters, physicians were assigned as Prin- cipal Medical Officers of EMS for each of the following services1

■ First Aid Posts ■ Ambulances ■ Medical Equipment and Supplies ■ Evacuation Trains ■ Pathology ■ Radiology ■ Blood Transfusion ■ Dental

On September 3, 1939, the United Kingdom declared war on Germany. The Ministry of Health issued orders to evacuate completely certain hospitals to make capacity available for poten- tial war casualties. In addition, they removed civilian patients from hospitals located in areas at risk for German attack. By that evening, all such patient movements were completed. From 34 London hospitals some 3,000 patients had been transferred to their previously planned destinations by using 18 of the 21 improvised hospital trains. Approximately 2,000 children were evacuated to outlying hospitals by buses converted to hold 10 stretchers each. The London Passenger Transport Board had fit- tings and hardware prepared in advance to equip 320 buses for a medical evacuation role within 12–24 hours. In other parts of the United Kingdom similar plans resulted in a total of 163,500 beds

Table 20.1: Medical Guidance Developed for the United States During WW II

■ Equipment and Operation of Emergency Medical Field Units ■ Protection of Hospitals ■ Central Control and Administration of Emergency Medical Services ■ Guide for the Training of Volunteer Nurses’ Aides ■ Field Care and Transportation of the Injured ■ Treatment of Burns and Prevention of Wound Infection ■ The Clinical Recognition and Treatment of Shock ■ First Aid in the Prevention and Treatment of Chemical Casualties

being made available for casualties. The London area contained 51,000 of these beds. In subsequent days, the number of beds made available continued to increase. Later, the EMS relaxed some of its standards and the percentage of hospital beds held in reserve for casualties was decreased. Additionally, the EMS reimbursed hospitals for empty beds.1

Of special concern were the cancer specialty hospitals with their stocks of radium. Authorities feared that if the hospitals were bombed, the radium might be widely dispersed and, with its long half-life, would present an environmental hazard. EMS decided to assist those hospitals with protecting their therapy sources by drilling deep bore holes in which the radium con- tainers would be lowered during air raids. For those hospitals with small quantities of radium, a specially designed steel box was created for storage. Although many hospitals suffered bomb damage, both methods were successful in protecting the therapy sources.1

Special centers were also established for casualties with major psychiatric illness and orthopedic, plastic, chest, head, and burn injuries. The government took over country homes and schools and established 10,000 rehabilitation and convalescent beds in these facilities.1 All the organizational efforts by the EMS and hospitals proved to be effective when the bombing began.

The United States Prepares The United States government sent observers to Britain from

military and other agencies, including the National Fire Protec- tion Association, to observe the function of the U.K. civil defense, fire service, and EMS system. When these observers returned to the United States, they quickly began to develop systems mod- eled on the information obtained from the United Kingdom. On December 1, 1941, the Office of Civilian Defense (OCD) was created. On December 7, 1941, Japan attacked the U.S. naval fleet at Pearl Harbor, Hawaii. German submarines then launched tor- pedo attacks on freighters and tankers off the eastern seaboard of the U.S.

Following these attacks, officers of the U.S. Public Health Service (PHS) were assigned to OCD to begin developing orga- nizational schemes, medical doctrine, and determining supply requirements, while seeking the help of U.S. hospitals. The Amer- ican Hospital Association, the American Medical Association, and the American Nurses Association were also instrumental in promoting medical preparedness. Guidance was developed and included publications such as those listed in Table 20.1.5

Hospitals developed blackout plans and formed field medical teams composed of physicians and nurses. OCD provided each team with a two-suitcase set that contained surgical instruments, pharmaceuticals, and other medical supplies. The Military Mobi- lization Committee of the American Psychiatric Association

Koenig and Schultz's Disaster Medicine : Comprehensive Principles and Practices, edited by Kristi L. Koenig, and Carl H. Schultz, Cambridge University Press, 2009. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/apus/detail.action?docID=564432. Created from apus on 2018-03-07 11:39:28.

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HE A LT H C A R E FAC I L I T Y DI S A S T E R MA NAG E M E N T ■ 287

prepared a publication for OCD entitled, “Reactions of People Under Stress: Anxiety and its Control.”

Nurses took a leadership role in preparedness, and the pub- lication R.N. A Journal for Nurses carried many articles on the subject. Furthermore, the government established the U.S. Cadet Nurse Corps in 1943 to train nurses on a massive scale to meet the needs of military and civilian hospitals. Congress passed the Nurse Training Act and it became Public Law 74 on July 1, 1943. Women at least 17 years of age who were high school graduates and in good health were eligible to apply. A massive recruit- ing campaign ensued with various Hollywood stars promoting the program. Major corporations and women’s magazines ran advertisements featuring Cadet Nurses. A 10-minute film was produced with Hollywood actresses playing the role of Cadet Nurses. This film was subsequently shown in 16,000 movie the- aters before an audience of 90 million. The recruitment campaign was very successful and the yearly quota for 65,000 recruits was easily met. The last year for new admissions began in October 1945 and the final Cadets were graduated in 1948. The program was administered by the U.S. PHS, which had enlisted the par- ticipation of nearly all nursing schools.

The PHS not only paid the tuition but also a room and board monthly stipend. Students pledged that, in return for education, they would serve wherever needed by the government. The Cadet Nurses also were furnished uniforms specially designed for the program, bearing the insignia of the U.S. PHS. The program was an immense success with 124,000 nurses graduated by its end.6

By 1944, the Allied Powers were prevailing in the struggle and OCD began to dissolve itself. At war’s end in 1945, the United States quickly demobilized its military and the nation concentrated on the civilian economy.

The Cold War Period In 1949, the Soviet Union exploded an atomic bomb signal-

ing the start of the Cold War. In 1950, the U.S. Congress passed the Civil Defense Act and created the new Federal Civil Defense Administration (FCDA). The FCDA, like its predecessor the OCD, had a medical division and again enlisted the aid of hospi- tal and medical organizations. Planning focused on the massive casualties possible from nuclear weapons. Comparing possible casualty figures from a nuclear attack against the available num- ber of hospitals, medical resources were inadequate. In 1952, the FCDA developed the prototype Civil Defense Emergency Hospi- tal that contained 200 beds, operating room equipment, an x-ray unit, generators, a water tank, pharmaceuticals, and medical and surgical supplies. It was a complete but austere hospital, designed to be assembled in an existing building such as a school. Furthermore, the government developed First Aid Station units and created a huge medical supply stockpile that was distributed across the nation in 21 warehouse complexes. In addition to the portable hospitals, the supply sets in these warehouses comprised:7

■ First Aid Replenishment Unit – supplies to allow operation of a First Aid Station for up to 48 hours after a disaster. Weight: 1,026 kg

■ Hospital Replenishment Unit – supplies necessary for opera- tion of a 200-bed civil defense emergency hospital, or existing hospital, for 7 days. Weight: 5,464 kg

■ Blood Collecting Replenishment Unit – supplies for collect- ing 1,000 U of whole blood. Weight: 1,410 kg.

■ Intravenous Solutions Replenishment Unit – supplies designed to provide intravenous solutions and sets for 100 patients for 7 days. Weight 3,529 kg.

■ Medical Supplies, Hospital Back-Up – supplies in origi- nal manufacturer shipping containers sufficient for 10,000 patients for 7 days. Weight 71,840 kg.

■ Blood Expanders – 24 U of dextran injection. Weight 37 kg.

Subsequently, the FCDA created improved models of the Civil Defense Emergency Hospitals and supply quantities were increased. Later, the U.S. PHS assumed operation of the impro- vised hospital program and produced the largest and final model in 1962. Those hospitals were named Packaged Disaster Hospitals (PDHs). The United States had a total of 2,600 PDHs, which gave the nation a medical surge capacity of 512,000 PDH beds and 7,800 PDH operating rooms. Also created was a unit named the Hospital Reserve Disaster Inventory (HRDI). This unit con- sisted of pharmaceuticals, medical and surgical supplies, instru- ments, sterile gloves, x-ray contrast media, plaster bandages, and numerous other items. HRDIs were built in 100-bed increments and civilian hospitals could apply to receive an HRDI, at no cost, based on the number of beds they had. A hospital signed an agreement that it would integrate the HRDI items into its inventory, periodically using and replacing these supplies, thus keeping the materials from expiring. In addition, the FCDA dis- tributed publications such as Health Services and Special Weapons Defense, to train healthcare personnel about nuclear, biological, and chemical weapons effects.

Fallout shelters were also created during this period to protect the occupants from radiation in the event of a nuclear attack. Fallout shelters were equipped with food, water, sanitation kits, medical kits, and radiation measurement kits to support the civilian population in these structures. The medical kits came in two sizes depending on the capacity of the shelter and contained antibiotics, sulfa drugs, and other pharmaceuticals as well as first aid supplies.

The Medical Education for National Defense (MEND) pro- gram was another notable Cold War initiative to train physicians in the U.S. in disaster medicine. MEND enlisted the support of all the nation’s medical schools. Contracts to some universities were issued to create mass casualty curriculums. These, in turn, were distributed without charge to the medical schools to teach their students. The MEND Program operated from the mid-1950s until 1972 when it was cancelled.

All of the Cold War medical preparedness programs enjoyed the support of the various national and state medical and health- care organizations. Notwithstanding this fact, funding for the PDH program and the medical warehouses ceased in 1972. These programs were cancelled despite many protests, and by the mid- 1980s, most PDHs had been dismantled or given to the Agency for International Development. Parts of remaining PDHs were used to equip the first Disaster Medical Assistance Teams of the new National Disaster Medical System, which was created in 1984. The warehoused supplies were given to state surplus property programs and others were sold at auction.

The Modern Era In the U.S., various healthcare organizations and profession-

als made efforts to continue some of the momentum in medical preparedness that the Cold War created; however, with the demise of the Soviet Union, less attention was paid to these matters. Nevertheless, disasters continued to occur and various scientific

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journals reported recurring problems with emergency manage- ment systems. The 1995 sarin nerve agent attack by cultists in Tokyo caused worldwide concern and increased emphasis on both war-related and industrial chemical training, equipment, and preparedness.

In 1999, the Congress ordered the U.S. PHS to assume con- trol over the former Noble Army Community Hospital facility located at the recently closed Fort McClellan in Alabama and convert it into a mock hospital training facility. At this renamed Noble Training Center, civilian healthcare personnel, PHS offi- cers, and other emergency responders took courses in disas- ter medicine, hospital preparedness, and the medical effects of weapons of mass destruction.

The U.S. Centers for Disease Control and Prevention (CDC) developed the National Pharmaceutical Stockpile, later renamed the Strategic National Stockpile. This stockpile consists of antibi- otics, chemical agent antidotes, radiation treatment drugs, venti- lators, vaccines, and other pharmaceuticals and supplies config- ured into Push Packages (see Chapter 16). Each package weighs 50 tons and is ready at all times for immediate air delivery to a stricken area. Conceptually, from the time the order is received to ship supplies, a Push Package can be delivered to the des- ignated receiving point within 12 hours. Although New York City received a Push Package within hours following the ter- rorist attack of September 11, 2001, several days elapsed before these materials arrived in New Orleans after Hurricane Katrina. Pharmaceutical manufacturers also maintain additional vendor- managed inventory for the Strategic National Stockpile. Gov- ernments at the local, county, and state levels have undertaken planning to receive, store, secure, and distribute the Push Pack- age contents. The early training courses for this program were taught at the Noble Training Center. The U.S. Department of Veterans Affairs (the largest integrated healthcare system in the nation) has also developed disaster augmentation supply units for each of its approximately 162 hospitals nationwide.

The terrorist attacks of September 11, 2001 in the U.S. height- ened preparedness efforts worldwide. In this event, nearly 3,000 persons were killed and hundreds injured. Articles began appear- ing in the professional literature on mass casualty issues, univer- sities held disaster medicine seminars, and the U.S. PHS com- missioned numerous studies.

In the U.S., the American Hospital Association (AHA), American Medical Association, American Nurses Associa- tion and numerous healthcare professional organizations have become involved by promoting preparedness to their members, to healthcare facilities, and to communities at large as well as by supporting government preparedness programs. Examples are the support offered by the American Medical Association’s Cen- ter for Public Health Preparedness and Disaster Response.8 In a video, the organization describes the need for physician involve- ment and training in disaster medicine to include the knowledge needed for:

■ How to develop rapid protocols for triaging patients ■ How to access current antidotes and vaccines ■ How to link with local community resources and local public

health officials ■ How to assess and implement the local disaster plan ■ How to obtain reliable information about patients’ medica-

tions without their medical records ■ Ethics and rationing

Other examples of current preparedness efforts include numerous new publications. A few samples are listed.

■ Are You Prepared? Hospital Emergency Management Guide- book, by the Joint Commission on Accreditation of Health- care Organizations and Dr. Christopher Farmer. ISBN 0- 86688-953-1, 2002.

■ Emergency Preparedness, Response and Recovery Checklist: Beyond the Emergency Management Plan, by the American Health Lawyers Association. Washington, D.C., 2004.

■ Providing Mass Medical Care with Scare Resources: A Com- munity Planning Guide, Agency for Healthcare Research and Quality, AHRQ Publication NO. 07-0001 November 2006.

Likewise, the AHA and their affiliated organization, the American Society of Healthcare Engineers, continue to assist the preparedness effort with increased activities. Many healthcare professional societies promote preparedness to their member- ships with publications and seminars. Healthcare professionals contribute literature to professional journals and are serving on preparedness committees in their communities. The U.S. Agency for Healthcare Research and Quality of the Department of Health and Human Services (HHS) continues to produce publications covering many aspects of healthcare preparedness. The Health Resources and Services Administration of HHS supervises a hos- pital preparedness program and awards grants for healthcare preparedness activities and equipment.

STATE OF THE ART

Healthcare Facility Preparedness

Increased interest in addressing the need for surge capacity both in the prehospital and hospital settings emerged in 1995 with Presidential Decision Directive 39: U.S. Policy on Terrorism.9

This Directive resulted in local governments creating Metropoli- tan Medical Response Teams to increase their abilities to man- age mass casualties. The effort was later expanded when HHS broadened the concept of the National Disaster Medical System. Originally designed to include general medical and veterinary teams, the program subsequently created burn, mental health, crush injury, international response, and other specialty teams.

The U.S. Congress passed and allocated funding for the Defense Against Weapons of Mass Destruction Act, promoting surge capacity building.10 Other federal programs brought much needed weapons of mass destruction training to healthcare per- sonnel. Researchers published numerous articles and manuals, and policy makers developed seminars devoted to medical surge capacity building. In January 2001, The Joint Commission made significant improvements to its emergency management accred- itation standards that strengthened preparedness in hospitals. The Joint Commission also defined surge capacity to include potential patient beds, available space for triage, patient man- agement, decontamination, vaccination, available personnel of all types, necessary pharmaceuticals, supplies and equipment, and legal capacity to deliver care under situations that exceeded licensed capacity.11 The Joint Commission has continued to expand emergency preparedness standards requirements each year. A central principle to these standards is the requirement that accredited hospitals have an Emergency Management Commit- tee (EMC).

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HE A LT H C A R E FAC I L I T Y DI S A S T E R MA NAG E M E N T ■ 289

The Emergency Management Committee Each facility’s EMC should be given the charge to:12

■ Develop all-hazard emergency plans ■ Perform a hazard vulnerability analysis (HVA) ■ Coordinate with other community agencies such as fire,

police, EMS, public health, public works, the emergency management agency, hazardous materials unit, and ambu- lance dispatch center to encourage interoperability

■ Coordinate with the medical staff and each department of the facility

■ Assist in training stakeholders in the plans it develops

The Committee needs broad participation and must be mul- tidisciplinary. Participants should include representatives from hospital administration, the medical staff, nursing staff, emer- gency department, security department, environmental services, plant operations, materials management, pharmacy, laboratory, radiology, ancillary services, food service, volunteer services, and all other departments of the facility. Ideally, the leadership should appoint persons to the EMC with a known interest in disaster preparedness, or who are at least known for their enthusias- tic approach to projects. The chairperson needs to be carefully selected and understand how to lead a meeting. A secretary/ recorder should keep accurate minutes in a timely manner. A library of healthcare disaster materials needs to be established for all to use and each committee member should be notified as new publications become available. Members should be encour- aged and funded to attend healthcare disaster seminars and to observe as many drills and exercises as possible. Plans developed should be concise, straightforward, and widely promulgated to all operating departments and nursing areas. The inclusion of disaster plan knowledge as a factor in annual employee eval- uations is also an option. A good chairperson will continually challenge members to think of “what if ” or “worst-case scenar- ios” and stress that plans must be flexible because unforeseen incidents may happen.

In today’s world, EMCs need to consider the medical impact of biological, chemical, nuclear, and explosive weapons and adopt treatment protocols such as those found on the U.S. CDC website (www.bt.cdc.gov). The committee also needs to ensure that the hospital stockpiles sufficient personal protective equip- ment (PPE) for employees and medical staff members and trains these individuals in its proper use. Additional training should include methods of decontamination, protection of the phys- ical plant and the airflow into the hospital, obtaining supple- mental supplies, and ensuring the security of utilities and the physical plant. Communications, both internal and external, can prove vulnerable and systems frequently fail. Planning for alter- nate methods of communication including use of amateur radio operators and messenger services are indicated. The EMC has a large task and an even greater responsibility to the hospital and community it serves. Proper executive support and funding is essential.

Familiarization with Standards for Healthcare Emergency Management

It is essential that each member of the EMC is aware of stan- dards and guidance that have been promulgated for healthcare emergency management. The Joint Commission standards are one example of benchmarks for accredited facilities in the U.S.

or worldwide through the Joint Commission International pro- gram. The Joint Commission standards for hospital emergency management are contained in The Comprehensive Accreditation Manual for Hospitals. Comprehensive Accreditation Manuals have also been developed for

■ Ambulatory care ■ Behavioral healthcare ■ Healthcare networks ■ Critical access hospitals ■ Long-term care facilities

For members of the hospital EMC, the accreditation stan- dards are found in the Environment of Care (EC) Section. The standard EC.4.11 states: “An emergency in a health care hospital or in its community can suddenly and significantly affect demand for its services or its ability to provide those services.” There- fore, a hospital must have a comprehensive plan that describes its approach to emergencies in the hospital or in its commu- nity. The Comprehensive Accreditation Manual for Hospitals includes the term disaster under its definition of an emergency. The definition is somewhat long but comprehensive. The man- ual defines an emergency as: “A natural or man-made event that significantly disrupts the environment of care (for example, damage to the organization’s building(s) and grounds due to severe winds, storms, or earthquakes); that significantly disrupts care and treatment (for example, loss of utilities such as power, water, or telephones due to floods, civil disturbances, accidents, or emergencies in the organization or its community); or that results in sudden, significantly changed or increased demands for the organization’s services (for example, bioterrorist attack, building collapse, or plane crash in the organization’s commu- nity).”12 In 2009, the Joint Commission in their prepublication version of the chapter on Hospital Emergency Management states in Standard EM.02.01.01 that the Emergency Operations Plan identify “alternative sites for care, treatment, and services that meet the needs of its patients during emergencies.28 The numer- ous emergency management plan components, standards, and responsibilities of hospital leadership and medical staff are listed within EC.4.10 and EC.4.20.

In the U.S., staff members who are trained for decontam- ination that requires them to wear PPE must be familiar with and comply with the applicable standards of the Occupational Safety and Health Administration (OSHA) of the U.S. Depart- ment of Labor. OSHA regulates the safety and health of workers by setting and enforcing standards, as well as providing training, outreach, and education. Of particular concern to the EMC are the following standards

■ Title 29, Code of Federal Regulations (CFR) 1910.120 Haz- ardous Waste Operations and Emergency Response

■ Title 29 CFR 1910.132 Personal Protective Equipment Stan- dard

■ Title 29, CFR 1910.134 Respiratory Protection

OSHA has also produced a detailed publication that rec- ommends best practices.14 This publication discusses PPE and training for hospitals first receivers. Additionally, it contains valuable references that can assist the EMC in achieving a bet- ter understanding of the issues surrounding personal protective equipment (PPE) and for building a reference library. Specific

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MITIGATION Hazard Identification & Hazard Vulnerability Analysis (HVA) Public Education

RECOVERY Short & Long Term Priorities & Processes Securing Vital Resources Resumption/Restoration Procedures

PREPAREDNESS Resource Management Planning Training Exercises, Evaluation & Corrective Actions

RESPONSE Incident Management Liaison/Coordination Planning/Intelligence Logistics & Finance Operations

LIFE CYCLE

Figure 20.1. The four phases of Comprehensive Emergency Management.

recommendations regarding selection of PPE can be found in Chapter 13. There are other organizations and agencies with regulatory authority but the EMC should start with the Joint Commission and OSHA requirements.

Performing a Hazard Vulnerability Analysis The Joint Commission requires accredited hospitals to have

a formal document known as an HVA.15 This process is used to identify those risks in the community that could cause an inter- ruption or loss of a critical function or service, cause casualties, and possibly damage the hospital’s physical plant. Subsequent analysis of risks identified in the HVA can then be addressed in the Emergency Management Plan.

Remembering the four phases of emergency management can aid in the preparation of an HVA.

■ Mitigation – Those activities that can be taken, predisaster or emergency, to lessen the severity of an event. Also includes measures that will reduce the potential physical damage to the facility during an event

■ Preparedness – Those activities, programs, and systems that are in place before the disaster or emergency and that are used to support the response to the event. Creating inherent capacity for response to an occurrence is included

■ Response – Activities undertaken to address the immediate and short-term effects of a disaster or emergency. In the case of hospitals, it would involve casualty care

■ Recovery – Activities and processes that must be undertaken to restore predisaster normality to the individual, facility, or community that had experienced a disaster or emergency

The U.S. Department of Veterans Affairs Emergency Manage- ment Strategic Healthcare Group has envisioned these four phases as depicted in Figure 20.1.16

The American Society of Healthcare Engineers of the AHA pioneered the development of hospital HVA in 2001. That same year, the Kaiser Permanente Foundation Health Plan issued their version of HVA. Both are now used extensively by U.S. hospi- tals. The Kaiser Permanente HVA worksheets are shown in Fig- ures 20.2 and 20.3, and Tables 20.2–20.5.15

Once complete, the HVA requires a thorough review. After examination of the report, hospital emergency managers can determine the most likely threats to the community and hospital. Given this information, the institution can move to develop mit- igation, preparedness, response, and recovery portions of the emergency management plan that address these hazards. The chair of the EMC must challenge members to think “what if ” and “worst-case scenario,” as well as to consider the impact of multiple events occurring simultaneously.

The hospital should work in collaboration with the commu- nity. The HVA should be compiled with the assistance of the local emergency management agency, fire department, EMS agency, police, hazardous materials unit, and with input from commu- nity organizations. These include the American Red Cross Dis- aster Services, Salvation Army Disaster Services, and Voluntary Organizations Active in Disaster, as well as neighboring hos- pitals and the area hospital council. Furthermore, if there is a major waterway or airport in the area, then HVA discussions should include airport authorities, Army Corps of Engineers, Coast Guard, and state waterway police.

After generating the HVA, the next step is to rate the proba- bility of occurrence and level of preparedness for each event. The resulting information can then be used to prepare or strengthen the facility and the emergency management plan. Neverthe- less, it is possible that the HVA will not identify all potential casualty-producing incidents. The potential risks from poorly controlled nuclear weapons and radioactive material are increas- ing. Although the danger of all out nuclear warfare is probably

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HE A LT H C A R E FAC I L I T Y DI S A S T E R MA NAG E M E N T ■ 291

Medical Center Hazard and Vulnerability Analysis

Issues to consider for preparedness include, but are not limited to: 1 Status of current plans 2 Frequency of drills 3 Training status 4 Insurance 5 Availability of alternate sources for critical supplies/services

Issues to consider for internal resources include, but are not limited to: 1 Types of supplies on hand/will they meet need? 2 Volume of supplies on hand/will they meet need? 3 Staff availability 4 Coordination with MOB's 5 Availability of back-up systems 6 Internal resources ability to withstand disasters/survivability

Issues to consider for external resources include, but are not limited to: 1 Types of agreements with community agencies/drills? 2 Coordination with local and state agencies 3 Coordination with proximal health care facilities 4 Coordination with treatment specific facilities 5 Community resources

Complete all worksheets including Natural, Technological, Human and Hazmat. The summary section will automatically provide your specific and overall relative threat.

Figure 20.2. Medical center HVA. Used with permission from Kaiser Foundation Health Plan.

minimal, the possibility that terrorists could use one or several nuclear devices against a modern city should be addressed.

Common Factors in Disasters To facilitate their work, the EMC should consider several

factors that are common to many disasters.

1) Uncertainty – In the early stages of a disaster, it is often unclear what is transpiring, to what extent additional resources are needed, how many casualties have resulted, and the extent of the medical requirements. In addition, the exact location and magnitude of the incident may be unknown.

2) Casualty Arrival – In mass casualty incidents, especially those occurring over a wide area, the standard operating procedure of ambulance crews triaging patients and removing them in an orderly manner may not occur. In such disasters, it is com- mon for up to 80% of the casualties to self-refer and arrive at the hospital without the benefit of prehospital care and trans- portation. Casualties able to ambulate will often transport themselves to area hospitals rather than waiting for arrival of EMS professionals. Well-intentioned bystanders will often transport victims in their automobiles, including those with severe injuries. Patients contaminated with hazardous materials will arrive at the hospital without having first been decontaminated at the scene. This convergence phe- nomenon can inundate the hospital closest to the scene with casualties, whereas other nearby facilities may receive few to none of the victims. Last, less serious cases may arrive well ahead of the most seriously injured, many of whom may be trapped in rubble.

3) Communications – Communication systems connecting the hospital to the rest of the community are vulnerable. Tele- phone service may fail due to overloaded circuits or physical damage. Cellular telephone communication is unreliable as the available cells can quickly become saturated. This also

occurs with satellite telephones, as reported during Hurri- cane Katrina in the U.S. Monitoring local fire, EMS, and police frequencies and having direct radio communication with first responders can greatly aid the hospital incident commander in decision making. The hospital emergency management plan should also include a provision for the use of messengers to carry information throughout the hospital in the event of telephone and computer failures. As hospital pay phones frequently function when the regular hospital ex- change has failed, a supply of coins should be kept available along with signs that indicate these phones have been com- mandeered for hospital use only.

4) Patient Care Capacity – Maintaining patient care capacity including beds for those requiring hospital admission may be problematic due to a high in-patient census or the influx of numerous casualties. The early discharge of stable patients can help the situation but the process of doing so is time- consuming, especially when family members are unable to assist. Another option includes the use of other areas in the hospital such as meeting rooms, physical therapy suites, or auditoriums for patient care to temporarily increase surge space. Hospitals must plan for supplies and staffing of these areas during the preparedness phase.

5) Staffing – Ensuring the presence of sufficient numbers of physicians, nurses, and other support personnel to staff exist- ing patient care areas and temporarily expanded space used for surge can be problematic, depending on the type and location of the disaster. In a severe blizzard, many individ- uals may have difficulty reaching the hospital. In anticipa- tion of such circumstances, the emergency management plan should contain a list of volunteers who have four-wheel drive vehicles and are willing to transport employees and medical staff members to the hospital. In a hurricane, employees and physicians may be victims themselves, dealing with destroyed homes and offices and injured family members. In such

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SUMMARY OF MEDICAL CENTER HAZARDS ANALYSIS

N at

ur al

T ec

hn ol

og ic

H um

H az

m at

T ot

al f

or F

ac ili

Probability 0.00 0.00 0.00 0.00 0.00

Severity 0.00 0.00 0.00 0.00 0.00

Hazard Specific Relative Risk: 0.00 0.00 0.00 0.00 0.00

This document is a sample Hazard Vulnerability Analysis tool. It is not a substitute for a comprehensive emergency preparedness program. Individuals or organizations using this tool are solely responsible for any hazard assessment and compliance with applicable laws and regulations.

Hazard Specific Relative Risk to Medical Center

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Natural Technological Human Hazmat

R el

at iv

e T

hr ea

t to

F ac

ili ty

Probability and Severity of Hazards to Medical Center

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Probability Severity

R el

at iv

e Im

pa ct

o n

F ac

ili ty

Figure 20.3. Summary of center hazards analysis. Used with permission from Kaiser Foundation Health Plan.

instances, the hospital must support the staff and their family members with sleeping accommodations, shower facilities, and food service. In an infectious disease outbreak, some staff may be unwilling to report to work. Thus, the plan must account for the fact that not all staff will be willing or able to come to the hospital. The emergency management plan must provide a method for temporarily credentialing medical volunteers and a strategy for utilizing medical per- sonnel from country-specific systems such as the Medical

Reserve Corps or the National Disaster Medical System in the U.S.

6) Decontamination – Hospital personnel must be prepared to decontaminate victims needing such treatment prior to allowing them entrance to the facility. Decontamination is essential not only to support patient care but also to pre- vent cross contamination of the hospital itself. The health- care institution must maintain sufficient quantities of PPE to permit rotation of decontamination staff, taking into

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Table 20.2: Hazard and Vulnerability Assessment Tool for Environmental Events

SEVERITY = (MAGNITUDE - MITIGATION)

EVENT

PROBABILITY HUMAN IMPACT

PROPERTY IMPACT

BUSINESS IMPACT

PREPARED- NESS

INTERNAL RESPONSE

EXTERNAL RESPONSE

RISK

Likelihood this will occur

Possibility of death or injury

Physical losses and damages

Interruption of services Preplanning

Time, effectivness, resources

Community/ Mutual Aid staff

and supplies

Relative threat*

SCORE

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 - 100%

Hurricane 0%

Tornado 0%

Severe Thunderstorm 0%

Snowfall 0%

Blizzard 0%

Ice Storm 0%

Earthquake 0%

Tidal Wave 0%

Temperature Extremes 0%

Drought 0%

Flood, External 0%

Wild Fire 0%

Landslide 0%

Dam Inundation 0%

Volcano 0%

Epidemic 0%

AVERAGE SCORE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0%

*Threat increases with percentage. RISK = PROBABILITY * SEVERITY

0.00 0.00 0.00

Used with permission from Kaiser Foundation Health Plan.

consideration the fatigue factor and heat load stress when wearing PPE. The selection of PPE is a complex task but ide- ally should be approved for safe use with as many hazardous materials as possible (see Chapter 13). This is essential for worker safety.

7) Prophylaxis – It may be necessary to offer hospital employees and the medical staff antibiotics and vaccinations as prophy- laxis during an epidemic or after the terrorist release of a biological agent. A protocol is needed to ensure adequate supplies and efficient distribution methods.

8) Laboratory Support – Most hospital laboratories lack the capability to definitely identify many biological weapons agents, emerging infectious diseases, or hazardous materi- als. The EMC must know the capabilities of the in-house laboratory in these regards and ensure that arrangements have been made with state, national or international refer- ence laboratories to supplement diagnostic resources within the facility in the event of an outbreak or exposure.

9) Media Relations – Members of the media will telephone or quickly arrive at the hospital when disaster strikes. A plan must be in place to accommodate the media and also to man- age them, restricting their access to patient care areas and pre- venting them from disrupting the hospital’s response. Often, accurate information may not be immediately available to the healthcare facility’s designated public information officer. Other information may be known but disclosure may not be possible as it would violate federal privacy laws.

The U.S. Federal Emergency Management Agency’s (FEMA) Emergency Management Institute offers disaster public information training for health department and hospital personnel.

10) Morgue – Hospitals generally have limited refrigerated space for the temporary storage of the deceased. Consideration must be given to a potentially large death toll and the sub- sequent need for increased storage space for remains (see Chapter 21).

11) Utilities – A disaster event could curtail some or all of the hos- pitals utilities. Water is especially critical for hospital oper- ations and back-up supplies must be organized in advance. Storage of water on the grounds of the facility is one option. Generators supplying emergency power may prove unreli- able for extended operations. Plans should exist for renting generators and wiring them to the hospital’s electrical grid. If the hospital uses fuel oil to power the generators or boilers, the EMC should calculate the number of hours or days of supply the institution has on hand under both temperate and winter conditions.

12) Supplies – With the healthcare industry relying on just- in-time inventories, supply shortages may quickly mani- fest. Plans are needed for emergency resupply if contracted vendors cannot respond or normal supply channels are disrupted. Additionally, hospitals must include items appro- priate for pediatric care in their supply inventories as they must prepare for the arrival of pediatric patients.

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Table 20.3: Hazard and Vulnerability Assessment Tool for Technological Events

SEVERITY = (MAGNITUDE - MITIGATION)

EVENT PROBABILITY HUMAN

IMPACT PROPERTY

IMPACT BUSINESS

IMPACT PREPARED-

NESS INTERNAL

RESPONSE EXTERNAL RESPONSE

RISK

Likelihood this will occur

Possibility of death or injury

Physical losses and damages

Interruption of services

Preplanning Time,

effectivness, resources

Community/ Mutual Aid staff

and supplies

Relative threat*

SCORE 0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 - 100%

Electrical Failure 0%

Generator Failure 0%

Transportation Failure 0%

Fuel Shortage 0%

Natural Gas Failure 0%

Water Failure 0%

Sewer Failure 0%

Steam Failure 0%

Fire Alarm Failure 0%

Communications Failure 0%

Medical Gas Failure 0%

Medical Vacuum Failure 0%

HVAC Failure 0% Information Systems Failure

Fire, Internal 0%

Flood, Internal 0%

Hazmat Exposure, Internal

Supply Shortage 0%

Structural Damage 0%

AVERAGE SCORE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0%

*Threat increases with percentage. RISK = PROBABILITY * SEVERITY 0.00 0.00 0.00

Used with permission from Kaiser Foundation Health Plan.

13) Blood Products – During a disaster, blood and blood product usage may rise above normal levels. Hospitals must antic- ipate this contingency and plan to address any shortfalls. Conversely, in some types of disasters, additional blood is not needed. However, well-meaning volunteers may present in large numbers wanting to donate. A system for volun- teer management is important to avoid redirecting resources needed for control of the incident to handle this influx.

14) Medical Equipment – In a disaster situation, a hospital may face a shortage of beds, ventilators, respiratory therapy equip- ment and supplies, oxygen cylinders, intravenous infusion pumps, wheelchairs, and gurneys. Institutions must plan for supplemental delivery of these items.

15) Service Deliveries – Ensuring continuity of critical service deliveries such as medical gases, generator fuel, linens, med- ical and surgical supplies, foodstuffs, and waste removal is essential to continued operations. Plans must exist that main- tain the flow of these critically needed items.

16) Security – Plans are required for securing the facility and grounds, directing traffic, protecting human remains, and managing personal effects. During a disaster, requirements may exceed the capacity of the security department. In support of increased security demands, the emergency man- agement plan should assign nonsecurity personnel to pro- vide some security duties, such as traffic direction or super- vision of facility entrances. In addition, hospital security

plans must permit rapid implementation of a total facility lock-down, allowing only certain supervised entrances to remain open. This is especially important when faced with contaminated casualties. Reliance on local law enforcement personnel to respond and assist is usually not an option as they will be occupied managing the disaster within the community.

17) Care of Relatives – During a disaster, family members may rush to a hospital, even with just the suspicion that a family member was taken there. Plans must exist for receiving and assisting family members of victims.

18) Damaged Hospitals – Hospitals are susceptible to physical damage. Tornados, hurricanes, and earthquakes have repeat- edly compromised hospital function. Healthcare institutions must plan for emergent damage inspection and repair result- ing from these hazards. In severe situations, hospitals must also have a strategy to evaluate hospital structural integrity and evacuate the facility if necessary.

Health Facility Management of Disaster When a disaster occurs and the emergency management

plan is activated, the healthcare facility must quickly mobilize its resources and key personnel, ideally before the first casualty arrives. The hospital may organize its response in a variety of ways, as long as the Joint Commission or similar requirements for coordination with community plans are met.

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Table 20.4: Hazard and Vulnerability Assessment Tool Related to Human Activity

SEVERITY = (MAGNITUDE - MITIGATION)

EVENT

PROBABILITY HUMAN IMPACT

PROPERTY IMPACT

BUSINESS IMPACT

PREPARED- NESS

INTERNAL RESPONSE

EXTERNAL RESPONSE

RISK

Likelihood this will occur

Possibility of death or injury

Physical losses and damages

Interruption of services Preplanning

Time, effectivness, resources

Community/ Mutual Aid staff

and supplies

Relative threat*

SCORE 0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 - 100%

Mass Casualty Incident (trauma)

Mass Casualty Incident (medical/infectious)

Terrorism, Biological 0%

VIP Situation 0%

Infant Abduction 0%

Hostage Situation 0%

Civil Disturbance 0%

Labor Action 0%

Forensic Admission 0%

Bomb Threat 0%

AVERAGE 0.00 0 .00 0 .00 0 .00 0 .00 0 .00 0 .00 0%

*Threat increases with percentage.

RISK = PROBABILITY * SEVERITY

0.00 0.00 0.00

Used with permission from Kaiser Foundation Health Plan.

Table 20.5: Hazard and Vulnerability Assessment Tool Events Involving Hazardous Materials

SEVERITY = (MAGNITUDE - MITIGATION)

EVENT PROBABILITY HUMAN

IMPACT PROPERTY

IMPACT BUSINESS

IMPACT PREPARED-

NESS INTERNAL

RESPONSE EXTERNAL RESPONSE

RISK

Likelihood this will occur

Possibility of death or injury

Physical losses and damages

Interruption of services Preplanning

Time, effectivness, resources

Community/ Mutual Aid staff

and supplies Relative threat*

SCORE 0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = Low 2 = Moderate 3 = High

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 = N/A 1 = High

2 = Moderate 3 = Low or none

0 - 100%

Mass Casualty Hazmat Incident (From historic events at your MC with >= 5 victims)

Small Casualty Hazmat Incident (From historic events at your MC with < 5 victims)

Chemical Exposure, External

Small-Medium Sized Internal Spill

Large Internal Spill 0%

Terrorism, Chemical 0%

Radiologic Exposure, Internal

Radiologic Exposure, External

Terrorism, Radiologic 0%

AVERAGE 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0%

*Threat increases with percentage.

RISK = PROBABILITY * SEVERITY

0.00 0.00 0.00

Used with permission from Kaiser Foundation Health Plan.

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THE INCIDENT COMMAND SYSTEM

The Incident Command System (ICS) is a disaster manage- ment strategy that is growing in popularity among hospitals. The ICS was first developed by California firefighters for better management of wide-scale forest and wildfires. The group who developed the ICS was known as FIRESCOPE. ICS offers hospi- tals many advantages in managing their disaster responses17

■ Standard organization and procedures ■ Modular and scalable system for any sized disaster ■ Interactive management components ■ Management by objectives ■ Manageable span of control ■ Designated incident facilities ■ Comprehensive resource management ■ Integrated communications ■ Procedures for establishing and transferring command ■ Accountability ■ Easy integration with the community response ■ Avoiding duplication of effort

ICS is essentially a toolbox that provides utilities for the com- mand, control, and coordination of resources during a disaster. ICS clarifies roles and responsibilities between all persons in the system, while also organizing resources, personnel, facilities, equipment, and communications through common procedures.

The basic ICS is composed of an Incident Commander assisted by an Operations Section, Planning Section, Logistics Section, and Finance/Administration Section (see Chapter 9).

Operations Section

■ Directly manages all incident activities and implements the Incident Action Plan

■ Works closely with other members of the command and general staff to coordinate response tactics

Planning Section

■ Gathers, analyzes, and disseminates intelligence and infor- mation gleaned from available sources

■ Manages the planning process and maintains incident docu- mentation

■ Compiles and develops the Incident Action Plan ■ Tracks all incident resources ■ Manages the activities of assigned technical specialists ■ Develops the demobilization plan

Logistics Section

■ Meets the support needs for the incident, including ordering resources through appropriate procurement authorities from nonincident locations

■ Provides facilities, transportation, supplies, equipment, maintenance support, fueling, food service, and commu- nications

Finance/Administration Section

■ Establishes whether there is a specific need for financial, reim- bursement, and/or administrative services to support inci-

dent activities. Takes responsibility for time-keeping records and compilations of hospital costs incurred during the dis- aster response

MULTIAGENCY COORDINATION SYSTEMS

In large incidents, a Multiagency Coordination System (MACS) may be established. A MACS is a combination of facil- ities, equipment, personnel, procedures, and communications integrated into one common system and principally relying on an Emergency Operations Center (EOC). Within the EOC, a Med- ical Operations Center or joint public health command center is usually established. The hospital disaster command structure will usually report to this entity. A MACS is especially helpful in areas of high population density or where the disaster is geo- graphically widespread. Figure 20.4 illustrates the basic incident command structure.

THE HOSPITAL INCIDENT COMMAND SYSTEM

Initially developed as the Hospital Emergency Incident Com- mand System, in its fourth revision, the name was changed to the Hospital Incident Command System (HICS). The historical development of HICS is as follows.18

1987 – Hospital Council of Northern California adapts FIRESCOPE ICS to hospitals.

1991 – Hospital Emergency Incident Command System, version 1 (HEICS I) first released.

1993 – HEICS II released. 1998 – HEICS III released. 2006 – U. S. government funded project to revise HEICS. The

development of version IV creates the HICS in compli- ance with the National Incident Management System (NIMS).

The revision project involved an initial analysis by numer- ous organizations representing multiple disciplines, followed by a second multidisciplinary review group that performed review and comment by using a formal evaluation tool. Further assis- tance was rendered by the AHA, Joint Commission, Ameri- can Society for Healthcare Engineering, NIMS Integration Cen- ter, FEMA Emergency Management Institute, and the Health Resources and Services Administration.

The resulting HICS resources include19

■ Exercise scenarios ■ Planning guides ■ Job action sheets ■ HICS forms ■ Training materials

HICS adds healthcare-specific titles to the ICS. For exam- ple, on the organizational chart for the command and general staff, the Incident Commander (IC) has the prerogative to add components to the chart, identifying individuals who report to the IC. An example is a medical/technical healthcare specialist needed for a response to a particular disaster. Such individuals would include

■ Infectious disease consultants ■ Chemical and radiological consultants ■ Hospital administration representatives

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INCIDENT COMMANDER

OPERATIONS SECTION

PLANNING SECTION

LOGISTICS SECTION

ADMINISTRATIVE/FINANCE SECTION

Figure 20.4. Basic incident command diagram.

■ Hospital legal officers ■ Hospital risk managers ■ Medical staff officers

As previously mentioned, all ICS systems including HICS are modular and scalable according to the requirements to manage the disaster, the hospital size, and the availability of personnel and medical staff. The EMC should decide in advance what roles will be needed and initially staff these positions with on-duty person- nel. Following activation of HICS, additional personnel deter- mined by the hospital’s response needs would then be recruited to back-fill these positions.

The command and general staff sections of Operations, Plan- ning, Logistics, and Finance/Administration also follow a span of

control. Each section can be further divided into branches, with various defined groups, led by a supervisor, under the branch and reporting to the Branch Director. Graphically, the Operations section could appear as shown in Figure 20.5.17 An example of a Planning section chart appears in Figure 20.6.17 The Logistics section is graphically depicted in Figure 20.7.17

The Finance and Administration section of HICS includes important units for documenting costs and hospital and employee compensation during the hospital response and recov- ery phases. Because many hospitals have cash flow problems, this is a very significant postdisaster function. In the U.S., the hospital may be eligible for reimbursement from the federal government if the President declares the event a disaster. Also, the Procurement unit within this section must keep the hospital supplied with

Operations Section

Medical Care Branch Infrastructure Branch HazMat Branch Security Branch

Staging Manager

FUNCTIONS: Personnel Vehicle Equipment/Supply Medication

Business Continuity

HICS Specific

Inpatient Group

Outpatient Group

Casualty Care Group

Power/Lighting Group

Water/Sewer Group

Clinical Support Services Group

Patient Registration

Group

HVAC Group

Building/Grounds Damage Group

Medical Gases Group

Medical Devices Group

Environmental Services Group

Food Services Group

Detection / Monitoring

Spill Response Group

Victim Decon Group

Facility/Equip Decon Group

Access Control Group

Crowd Control Group

Traffic Control Group

Search Group

Law Enforcement Interface Group

Info Tech Group

Service Continuity Group

Records Preservation

Business Function Relocation Group

Branch

Figure 20.5. Operations section.

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Planning Section

Resources Unit Situation Unit Documentation Unit Demobilization Unit

FUNCTIONS : Personnel Tracking Material Tracking

FUNCTIONS: Patient Tracking Bed Tracking

HICS Specific

Figure 20.6. Planning section.

consumable items and must arrange contracts for emergency supplies. A typical Finance/Administration section chart would be similar to that shown in Figure 20.8.17

Every hospital has a defined table of organization for normal operations. HICS tables of organization provide a logical frame- work with which to coordinate the hospital’s response. Addi- tionally, these tables allow individuals with particular strengths, not listed on the table of organization for normal operations, to be used in the most effective manner. For example, the chief of surgery may request the assistance of another surgeon, perhaps

with military combat medical experience, to head the Medical Care branch that will deal with mass casualties.

In smaller incidents, it may not be necessary to activate and staff the five basic HICS positions. The Incident Commander may perform all the functions alone in some cases. What is essential is that the Incident Commander has a clear picture of the incident, the estimated casualty load, and the response needed, and staffs the HICS system accordingly. HICS training is available without cost online (courses IS-100HC and IS-200HC are found at: http://www.training.fema.gov/EMIWeb/IS/is200HC.asp).

Logistics Section

Service Branch Support Branch

Communications Unit

Staff Food & Water Unit

Employee Health & Well-Being Unit

Family Care Unit Supply Unit

Information Technology / Services Unit

Facilities Unit

Transportation Unit

Labor Pool & Credentialing Unit

HICS Specific

Figure 20.7. Logistics section.

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Finance / Administration Section

Time Unit Procurement Unit

Compensation / Claims Unit

Cost Unit

Figure 20.8. Finance and Administration section.

The National Incident Management System The ICS is an integral part of a post-September 11, 2001

U.S. initiative in managing all-hazard incidents. In 2003, the President of the United States issued Homeland Security Presi- dential Directive 5 (HSPD-5), directing the Secretary of Home- land Security to develop and administer the NIMS. This system provides a consistent nationwide framework that enables fed- eral, state, local, and tribal organizations to work together effec- tively to prepare for, respond to, and recover from all-hazard incidents regardless of cause, size, or complexity, including ter- rorist attacks. NIMS is built on existing concepts of incident management that have stood the test of time. NIMS represents a core set of doctrines, concepts, principles, and terminology that permit effective collaboration in incident management at all levels of governments and private organizations. HSPD-5 requires all federal departments and agencies to make adoption of NIMS by state and local organizations a condition for fund- ing from federal preparedness grants. The components of NIMS include19

■ Command and Management ■ Incident Management System ■ Multiagency Coordination Systems ■ Public Information Systems

■ Preparedness ■ Planning ■ Training ■ Exercises ■ Personnel Qualifications and Certification ■ Equipment Acquisition and Certification ■ Mutual Aid ■ Publications Management

■ Resource Management ■ Communications and Information Management ■ Supporting Technology ■ Ongoing Management and Maintenance

NIMS was launched by then Secretary of Homeland Secu- rity, Tom Ridge, on March 1, 2004. In September 2006, FEMA announced the publication: NIMS Implementation Activities for Hospitals and Healthcare Systems.19 The publication out- lines the 17 elements healthcare facilities must accomplish to become NIMS compliant and eligible for federal preparedness grants.

Element 1 – Adopt NIMS at the organizational level.

Element 2 – Manage all emergency incidents, exercises and “preplanned” events utilizing the HICS.

Element 3 – MACS: Develop connectivity capability with the area hospital command center, as used in catastrophic, wide geographical areas, or in smaller incidents to the local EOC, local 911 centers, local public health, EMS, local emergency operating center, and others as appropriate.

Element 4 – Public Information System – The healthcare facility manages information with the various healthcare partners and response agencies through a Joint Information System and Joint Information Center.

Element 5 – The hospital/healthcare facility/healthcare system will track NIMS activities annually as part of the organized emergency management plan.

Element 6 – Development and coordination of a system to track local, state, and federal preparedness grants. Docu- ment that preparedness grants received meet any funding commitments.

Element 7 – Revise and update plans and procedures to incor- porate NIMS components in all emergency phases and activ- ities.

Element 8 – Participate in and promote interagency mutual aid agreements with public and private sectors.

Element 9 – Train those personnel who have emergency pre- paredness and response duties in NIMS by completing the free online course IS-700 NIMS: An Introduction. This online course can be found at http://www.training.fema. gov/EMIWeb/IS/is700.asp.

Element 10 – Train those personnel who have emergency pre- paredness and response duties in the National Response Plan by completing the free online course IS-800 NRP: An Intro- duction. This course can be found at: http://www.training. fema.gov/EMIWeb/IS/is800HC.asp.

Note: for both courses, it has been recommended that a phased approach would allow employees and physicians to complete the training without a time constraint burden on the hospital. Successful completion of both courses could be an element in the employee periodic performance evaluation.

Element 11 – The organizations primary emergency prepared- ness and response personnel complete free online courses: IS-100HC: Introduction to the Incident Command Sys- tem for Healthcare/Hospitals, and ICS 200HC: Applying ICS to Healthcare Organizations. These free online courses can be found at http://www.training.fema.gov/EMIWeb/ IS/is100HC.asp and http://www.training.fema.gov/EMIWeb/ IS/is200HC.asp.

Element 12 – Preparedness Exercises. The organization’s emer- gency management program training and exercise documen- tation reflects the use of NIMS/ICS.

Element 13 – Participate in an all-hazard exercise program based on NIMS that involves responders from multiple disciplines, agencies, and organizations.

Element 14 – Hospitals and healthcare systems will incor- porate corrective actions into preparedness and response plans/procedures.

Element 15 – Maintain a current resource inventory of medical- surgical supplies, pharmaceuticals, PPE, staffing, etc.

Element 16 – To the extent possible and permitted by law, the organization should work to establish common equipment and communications data interoperability with other local hospitals, EMS, public health, and emergency management agencies.

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Element 17 – Apply standardized and consistent terminology, including the establishment of plain English communication standards across the public safety sector.

The Hospital Physical Plant and its Preparedness The EMC is most focused in the facility’s emergency response

to direct patient care and often forgets that a fully functioning physical plant is essential for optimal patient outcomes. Rarely do hospital personnel, even executives, think about the physical plant becoming nonoperational. Hospitals and other healthcare facilities have suffered significant damage resulting from hur- ricanes, tornadoes, fires, and earthquakes. Therefore, the EMC must become familiar with the physical plant and its systems, and work with the plant operations leader toward preparedness. Ideally, the head of plant operations should be a member of the EMC. The critical hospital systems that must remain functional include

■ Electrical ■ Heating, ventilating, and air conditioning (HVAC) ■ Water and sewer ■ Medical equipment including vacuum and medical gases ■ Various life support and critical care systems ■ Communications systems: pagers, public address, comput-

ers, and radios

ELECTRICAL

In the U.S. model, there has historically been a disparity between what building codes require that emergency genera- tors support and the hospital’s electrical power requirements for patient care. The codes are designed to address life safety issues and protect the occupants in the event of a power failure, fire, or other emergency. The level of electrical generator support is limited to that required to permit the occupants to exit the building safely. The code does not recognize the need to pro- vide power for operating autoclaves, laboratory and radiology equipment, and other devices necessary for hospital function during a disaster. The members of the EMC should know what equipment and what locations receive power from emergency generators in the event of a power failure, how long the fuel supply will last when the generators are running, and how long they will run if the fuel must be shared with the boilers. Fur- ther action may be necessary to ensure these additional essen- tial components receive emergency power. Another approach to minimize the threat of power disruption is to provide nor- mal electrical service to the facility from two different utility substations.

Time of year can also increase the fuel consumption needs of boilers as well as pose other challenges. During a blackout in a New England winter, a small community hospital initially received emergency power from its generators. The hospital had an above-ground fuel storage tank and had forgotten to connect the immersion heater to the generator circuitry. After several hours the fuel cooled, became more viscous, and resulted in a generator shutdown.

In August 2003, a considerable portion of the northeast United States experienced a blackout, at first thought to be caused by a terrorist attack but later found to be caused by faulty equipment in Ohio. Hospitals throughout the region were forced to use emergency power–supplied by generators. As had been reported in previous disasters, several institutions experienced

failure of this critical equipment and lost power. This illustrates the importance of the EMC needing to identify and maintain equipment and locations that receive emergency power from the generators.

An additional concern created by use of emergency generator power is the extent to which the laboratory and radiology can operate their equipment relying on this source. It is more than a question of furnishing generator power to these departments. Some devices have unique requirements relating to electrical current flow and personnel must know whether the cyclical fluc- tuation of the generator will cause delicate equipment to mal- function or fail completely. Such conditions must be anticipated pre-event and addressed through discussions between the EMC and plant operations representatives.

Because generators and transfer switches can malfunction even after proper maintenance, the hospital should have an ample supply of flashlights, battery-powered lights, headlamps, and batteries as a safeguard against generator failure. Illumination sources using light-emitting diodes conserve battery power and should be considered.

Natural gas is a common fuel and may power the hospital’s air conditioning system, boilers, hot water, cooking ranges, ovens, and generators. Although natural gas is more reliable during storms than overhead electrical lines, it is extremely vulnerable to earthquakes and mudslides.

HEATING, VENTILATING, AND AIR CONDITIONING

In compliance with ventilation codes, a hospital can draw in more pounds of air per day than pounds of water. The typical hospital will have multiple handling units that pass the incoming air through mechanical or electronic filters, heat or cool the air, humidify or dehumidify the air, and send it to the various areas of the hospital. This air does not linger in the building and is removed by exhaust fans. Hospitals have high energy costs due to compliance with these building codes. Little recirculation is permitted as an infection control measure, and a large number of air exchanges per hour are required. If the hospital does not have adequate emergency generator capacity, there will be a shutdown of this system and also air conditioning. If the air conditioning chillers are fueled by natural gas, the loss of this supply will also shut down the units. During and after Hurricane Katrina in the U.S., many hospitals in the affected area experienced tempera- tures of over 37◦C, creating a significant hardship for patients and staff. Certain types of equipment cannot function in that temper- ature range. Because the applicable codes do not require emer- gency generator power to HVAC equipment, the prudent facility spends the extra money and purchases larger-capacity genera- tors after a thorough analysis of emergency electrical needs. This pre-event purchase analysis can pinpoint the multiple needs not addressed by regulatory codes that are required to oper- ate the hospital and provide patient care. Whatever the type of disaster, planners must keep foremost in their minds that loss of power or other utilities can also overload the facility with casualties.

The hospital’s HVAC system can become a safety hazard in the event of a chemical spill. Transportation and industrial accidents can release chemicals that are carried through the air. If a hospital is downwind of a chemical plume, it will quickly draw the chemical into the building by the air-handling units, and this may in turn sicken or even kill staff and patients. The EMC, as an all-hazard planning committee, must be cognizant of this possibility and plan accordingly.

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The first consideration is the location of the air intakes for the hospital. Because many chemicals are heavier than air, ground level air intakes are particularly susceptible to drawing in con- tamination. Some hospitals have intakes mounted on the side of the building, which is better, especially if they are 4.6 m or more above the ground. The best location is on the roof; however, even roof top units do not guarantee that the hospital cannot become contaminated. Due to the risk of terrorism, the hospital must be mindful of the need for security of these air-handling intakes. The reader can learn more about protecting the building and its occupants by reviewing Guidance for Protecting Building Environments from Airborne Chemical, Biological or Radiological Attacks.20

To protect the facility from such an event, the EMC must develop a plan to lock all external entrances to the hospital and to guard them. The engineering department must rehearse the shutdown of all air-handling units to prevent the chemical or smoke from entering into the building. Also, security officers should be taught this procedure to assist the engineer on duty or in case the engineer becomes incapacitated. If evacuation of the facility is not appropriate, using this shelter-in-place strategy to protect patients is best.

WATER

Water is an absolute necessity to keep the hospital function- ing. The EMC should determine whether the utility company feeds water to the hospital from two directions. This is a safe- guard in the event of a main break. Another option is to have a continuous loop that surrounds the hospital property. Some hos- pitals have storage tanks that are constantly refreshed by a main water line filling them. An additional tank for fire protection is also a prudent investment. Alternative strategies for water supply include bottled water, arrangements with water-hauling compa- nies, and pre-event discussions with the community emergency management agency for assistance. In the case of slow-onset events such as hurricanes, the hospital can fill water bladders if they have them. These can be purchased in a variety of sizes. Bladders are also useful for onsite storage of delivered water if a means of extracting the water is available.

The EMC must also develop a water-rationing plan including alternate means of disposing of human wastes. To avoid further loss of limited supplies, patient and employee commodes can be lined with plastic bags. Following use, several ounces of chlorine bleach can be added and then the contents can be double bagged. Determine as part of the plan how the facility will dispose of human waste. A standby contract for portable toilets can be helpful, especially for hospital personnel and visitors.

Some hospitals have wells on their campuses and the EMC must ensure the pumps are connected to the emergency genera- tor. Wells, however, can be damaged or destroyed by earthquakes and some other types of disasters.

DAMAGE CONTROL

Healthcare facilities can be damaged in a disaster; however, they are expected to remain functional and continue providing patient care. For the protection of patients and personnel, the facility should have a damage control plan. The damage control plan should be developed jointly by the plant operations per- sonnel and the EMC. The plan outlines a methodology whereby reports are received from the various departments regarding damage their area has experienced at a central point such as the hospital EOC. At the same time, management staff should dis-

patch employees to conduct a rapid needs assessment of every floor and department. These employees then report their find- ings to the EOC. A person/position designated in the Damage Control Plan then reviews the damage list and determines the emergency repair priorities in consultation with the Incident Commander and Chief of the Operations Section. The work of the damage control team can be greatly facilitated if the following equipment is contained in a storage area on site: floor plans, rolls of plastic and lathing strips for covering windows, spools of wire, sprinkler plugs, hand tools, gasoline-powered rescue saws with blades for steel and concrete, dewatering pumps, portable oxy- acetylene torches, flashlights, headlamps, portable flood lights, sheets of exterior plywood, saws, pry bars, and materials for controlling chemical spills. Large-sized facilities should consider creating several such storage areas. The hospital must aim toward self-sufficiency for the first 72 hours and not expect much assis- tance from emergency response agencies because these groups are fully committed in a disaster and their capabilities are fre- quently exceeded.

SUPPLIES

From a preparedness standpoint, a weakness in the hospital industry is the Just-in-Time inventory system. Although such systems improve cash flow and are efficient during routine oper- ations, they cannot be relied on in a disaster, especially one that covers a large geographical area such as Hurricane Katrina. Because a Just-in-Time system relies heavily on truck transporta- tion, this can become problematic due to obstruction of trans- portation corridors after a disaster.

The AHA’s Association for Healthcare Resource and Materi- als Management (AHRMM) in concert with the Health Indus- try Group Purchasing Association and the Health Industry Dis- tribution Association created a preparedness document.21 This publication consists of a core and pediatric inventory and then adds specific items needed for managing the effects of terrorist attacks with chemical, radiological, explosive, nuclear, or bio- logical weapons. The document also contains recommendations for staff PPE. Laboratory and radiological supply needs are not included. The Minnesota Department of Health’s website con- tains a more refined list.22

As previously cited in the section on History of Hospital Disaster Planning, the United States no longer has the mas- sive reserves of medical and surgical supplies of past years. In addition, reliance on the military medical service is somewhat problematic. Their first commitment is to national defense, so they are restricted in the degree to which their participation in civilian disaster response is possible. In addition, the reduction of combat support hospitals and other field medical units as well as diminished military medical supply inventories also limits their ability to respond.

The EMC should carefully consider the cited lists, determine desired inventory levels, and decide whether the hospital can afford to increase supply levels of frequently used items. Addi- tionally, the materials management department can craft pre- event purchase orders, arranging contracts with suppliers for emergency shipments and mutual aid agreements with neigh- boring hospitals or as part of a multihospital system. These arrangements should be made as part of community-wide plan- ning to avoid multiple facilities in the region depending on the same supplier. Standby agreements should also be established with medical suppliers outside the immediate area for use if local suppliers are unable to deliver the requested inventory.

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COMMUNICATIONS

Communications problems are a recurring issue in most dis- asters. The EMC should review the stability of existing commu- nications systems in the hospital such as the telephone, paging, and computer systems. Emergency responders increasingly rely on web-based toolboxes for disaster management. If the hospital also uses these tools and the Internet fails, an auxiliary system must be available. Implementation of paper documentation is an option.

The use of cellular telephones may prove unreliable as avail- able circuit capacity can quickly be exceeded. The same occurs with regular telephones. For any given system, the equipment is designed to handle only a certain percentage of the telephones in the area at any one time. If too many individuals attempt to place calls simultaneously, the system will not function even if there is no physical damage. During Hurricane Katrina, even satellite telephones proved unreliable for the same reason. As an alter- native to the usual communication devices, the hospital should consider purchasing handheld portable radios. In addition, it is prudent to have a hospital radio system for communicat- ing with local responders and the area emergency management agency. The greater Cincinnati area pioneered a radio system linking all hospitals, the dispatch center, weather bureau, and three mobile units in 1965. A supervisory committee provides system quality and procedure review, updates policies, and is contemplating a third system revision with 800-MHz units at the time of this writing. This system has proven effective over the decades.

The hospital EMC can also establish a relationship with an area amateur radio unit that performs disaster and emergency communications. These operators can be very helpful to the hospital for both internal and external communications. Such emergency radio teams usually belong to organizations such as the Amateur Radio Emergency Service, the Radio Amateur Civil Emergency Service, or the Salvation Army Team Emergency Radio Network.

For internal communications, the EMC should devise a plan to use messengers should other systems fail. These individuals can visit each important location within the hospital and collect and distribute the messages.

SURGE CAPACITY FOR HEALTHCARE FACILITIES

Background

Beginning in the early 1990s, increased attention has been paid to surge capacity issues. The U.S. suffered devastating hurricanes, earthquakes, and terrorist attacks and is concerned about mass casualties from a pandemic. Canada had a severe acute respira- tory syndrome outbreak that could have overwhelmed national healthcare assets, and did in Toronto. Many other nations have experience significant events such as tsunamis, catastrophic earthquakes and terrorist attacks. There have been numerous articles and seminars on surge capacity. While the concepts have been well defined, substantively little has been done to opera- tionalize them. One reason for this is that there is little funding to hospitals to encourage development of surge capacity.

The loss of surge capacity has a variety of causes. The U.S. government cancelled the Packaged Disaster Hospital and Hos- pital Reserve Disaster Inventory Programs. In addition, managed care and the move to the outpatient care model have contributed to hospital closures and conversion of this space to other uses. To

Table 20.6: U.S. Population, Hospitals, and Bed Statistics

Hospitals Year Population (All Types) Staffed Beds

1965 194,600,000∗ 1990 248,709,873 6,649 1,213,000 2000 281,421,906 5,810 984,000 2005 295,895,897 5,756 946,997 2006 298,754,819 5,747 947,412

∗ Packaged Disaster Hospital Program: 512,000 beds and 7,800 equipped operating rooms were available.

Source: U.S. Census Bureau and American Hospital Association Research Department.

reverse this tread, the development of surge capacity will require new emphasis on personnel, medical supplies and equipment, and patient care space, frequently referred to as the 3S concept: “stuff, staff, and structure” (see Chapter 3).23

In 2005, the U.S. government developed a Target Capabili- ties List that identified priorities for Medical Surge and Medical Supplies Management and Distribution.24 This was updated in 2007. The list defines medical surge as, “the capability to rapidly expand the capacity of the existing healthcare system (long-term care facilities, community health agencies, acute care facilities, alternate care facilities and public health departments) in order to provide triage and subsequent medical care. This includes providing definite care to individuals at the appropriate clinical levels of care, within sufficient time to achieve recovery and min- imize medical complications. Medical surge is defined as rapid expansion of the capacity of the existing healthcare system in response to an event that results in increased need of person- nel (clinical and nonclinical), support functions (laboratories and radiological), physical space (beds, alternate care facilities) and logistical support (clinical and nonclinical equipment and supplies).”24 The document lists a variety of critical tasks in the areas of developing and maintaining plans, critical items, perfor- mance guides, and a variety of benchmarks. It is a comprehen- sive product that aims for high levels of preparedness, backed by exercises.

Hospital administrators, however, have expressed concern that little is being done at the federal level to help the nation’s hospitals achieve these levels of competence in surge. They think that current initiatives fall short of the medical preparedness measures that were implemented between 1950 and 1975 as cov- ered earlier. Yet the population of the United States continues to grow.

In the U.S., there are fewer medical assets per person today than there were many years ago. In many countries, hospitals often strain under their current patient loads and would not be capable of managing an increased demand for care associated with a catastrophic event such as a pandemic or an earthquake. As illustrated by this example from the U.S., as the population has grown, the number of hospitals and beds (and thereby patient care capacity) has declined (see Table 20.6).

Creation of a Surge Program

The creation of surge capacity requires philosophical as well as financial support. Everyday operational requirements of hospi- tals and physicians’ practices make this difficult. The American

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College of Healthcare Executives policy statement on the role of healthcare executives in emergency preparedness calls on its members to 1) be involved in emergency preparedness, 2) ensure that their organizations develop an emergency operating plan, 3) prepare the facility to become a casualty itself from the disaster, 4) become active in interagency planning efforts and encourage adoption of an ICS, and 5) support the NIMS system among oth- ers.25 Healthcare executives may need to delegate these respon- sibilities. If so, they should ensure that their designees develop robust surge capacity programs, including designation of alter- nate care sites. The Joint Commission also urges hospitals to create surge capacity; it produced a publication regarding surge hospitals and safe care of patients.26

A surge capacity plan must consider all the hazards likely to create a sudden increase in healthcare demands. A pandemic would stress the hospital with patients from their own immediate service area and be coupled by loss of staff who become ill or stay home to care for ill family members. Staff in hospitals in earth- quake prone areas should anticipate receiving large numbers of victims with crush injuries. A hospital in a community with a refinery or chemical plant could expect to receive patients with blast, burn, and pulmonary injuries.

Types of Surge Capacity

The hospital can expand capacity by using space within its own grounds and also in the community. This requires an inventory of available space that can potentially be used for patient care. Examples are conference rooms, meeting rooms, physical therapy departments, solariums, and hallways.

Capacity can be acquired outside the main hospital by using auxiliary buildings on the hospital campus. Some hospitals have purchased tents to be erected on the hospital grounds. Such tents can be equipped with heating and cooling equipment. Off cam- pus surge capacity can be planned with community leaders and local public health officials. Such external capacity is best used for less acute patients or as a step-down facility during the casualty- producing period and can be established in a variety of buildings of opportunity such as convention centers, schools, and ware- houses with owner approval. Pre-event planning must include an extensive review of the physical structure and environment. Sanitation and water availability are essential.27

Supplies

A variety of supplies are needed to support surge capacity and these include cots/litters, bedding, medical and surgical sup- plies, oxygen, pharmaceuticals, and sanitation supplies. Pre- event planning to acquire and store these items is necessary whether it be on the hospital grounds or held in reserve by a vendor. Some hospitals have acquired excess inventory by slowly buying the supplies over time and then rotating them into normal hospital operations. Other hospitals have stored supplies in trail- ers or cargo containers. It would be helpful if funds became available from third parties to permit acquisition of these sup- plies, such as the stockpiles and units of previous years. In the U.S., the CDC Strategic National Stockpile has limited quan- tities of medical and surgical consumables and should not be counted as the only source. In the prepublication version of the 2009 Emergency Management Standards for hospitals, the Joint Commission does not mandate that hospitals maintain a specified supply level. It does require that if the local commu-

nity cannot provide the resources to support the hospital’s surge capacity for 96 hours, the hospital must identify response pro- cedures for this eventuality.11 Other standards discuss alternate care sites and requirements for the emergency operations plan to identify sites, staffing, supplies, and methods for transporting patients.11

Staffing

Adequate staffing remains a challenge because there is currently a shortage of nurses and other healthcare professionals in the United States and some other countries. Beds are frequently closed due to lack of staff. In a catastrophic situation, especially one that requires the implementation of alternate care sites, pre- event plans are needed for management of volunteers, who in some cases are credentialed by states for disaster medical work. Emergency credentialing of volunteers can also be achieved by hospitals when additional staff are required within the first few hours.29 Inclusion of retired personnel is an option but due to possible degradation of skills, these individuals should provide care to less acutely ill patients. Local emergency medical tech- nicians, Red Cross volunteers, and home health aides can all be used in an auxiliary role to assist regular care providers; however, even reliance on primary staff personnel may not be feasible. The Hawaii Department of Health funded a study to assess the attitudes of all state licensed physicians and nurses regarding their willingness to work in a nonhospital field medical facility. The response was highest for “natural” disasters and lowest for radiological incidents.30 A study in Maryland of health depart- ment personnel found up to 50% of public health nurses would not report for duty during a pandemic.31 So even if “stuff and structure” are available, the staff may not be.

The U.S. Agency for Healthcare Research and Quality has produced many documents recommending ways to make the best possible use of existing staff and supplies during mass casualty events.32,33 In addition to these publications, the Agency has also produced an online interactive tool that estimates resources needed for such emergency responses.34

Evacuation

For many decades, hospitals and other healthcare facilities have included evacuation procedures in their emergency plans, but the emphasis was on a response to fire events. The plans focused on movement of patients from the hospital wing on fire to an adja- cent area and safely sequestering them behind fire-rated hallway doors and smoke barriers. This was the practice of “horizontal” evacuation. “Vertical” evacuation was usually in their written plan but not given a great deal of attention. Vertical evacuation moved patients from one floor to another. Even less effort was expended creating plans to clear the entire building and move patients to alternate treatment sites.

In a study of hospital evacuations in the United States from 1971 to 1999, Sternberg et al., found 275 reported evacuation incidents.35 Many occurred in 1994, the year of the Northridge earthquake. The causes of these evacuations are shown in Table 20.7. In an article by Schultz et al., the authors studied hospital evacuations after the Northridge earthquake so that postevent decision making and evacuation techniques could be examined to improve the management of future evacuation events. The article also described a standardized data collection tool.36

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Table 20.7: Causes of Hospital Evacuations in the U.S., 1971–1999

23% Fire within hospital 6% Fire in community

18% Hazmat within hospital 6% Flood

14% Hurricane 5% Utility failure

13% Human threat 4% Hazmat in community

9% Earthquake

Following the 1994 Northridge earthquake in southern Cal- ifornia and the 2005 Hurricanes Katrina and Rita in the U.S., issues related to hospital evacuation received greater attention. Standards from the Joint Commission require both evacuation and alternate care site plans. Many hospitals have improved their evacuation plans and have held evacuation drills. A notable com- munity example is the Reno-Washoe County, Nevada hospital evacuation project. Undertaken with a grant from FEMA through the state emergency management agency, planning began on types of evacuations, methods of evacuation, review of trans- portation assets, staffing requirements, patient supplies and crit- ical medications, and who could receive evacuated patients and continue care until the hospital returned to baseline operations.37

The planning group also performed a real-time exercise to exam- ine employee reactions and the amount of time required to achieve total evacuation from the hospital campus. The chosen facility froze their census at midnight for purposes of the exer- cise. Analysis of the exercise findings determined the amount of time and labor needed to accomplish a total hospital evacuation. The results of the planning and exercise led to the creation of the Multi-Casualty Incident Plan: Mutual Aid Evacuation Annex that was approved by the District Board of Health as policy for Washoe County.37

Evacuations can be partial or total depending on the situa- tion. When an EMS helicopter crashed on the roof of a Michigan trauma center in 2008, leaking fuel flowed down an elevator shaft necessitating a partial evacuation of several floors. The associ- ated loss of power required the use of stairwells to evacuate the patients and the injured pilot.

Evacuation plans have some common elements.

1) There is the need for a facility evacuation plan coordinated with the local community as well as a decision tree used to determine whether an evacuation order should be issued (Table 20.8).

2) Variance in philosophy on the order of patient evacuation (intensive care unit patients first or ambulatory patients first) is found in hospital evacuation plans. General consensus indicates that in emergency situations, one must accomplish the greatest good for the greatest number. An article pub- lished by Schultz et al., investigating hospital evacuations after the Northridge Earthquake in California suggests that ambulatory patients should be evacuated first when time is critical. When greater time for evacuation exists, intensive care unit patients should be transferred first.38

3) Internal patient transportation aids may be necessary. Devices most useful for individual patient movement are wheelchairs, wheeled-stretchers, backboards, and blankets. A staff member is assigned to each to make turnaround as

rapid as possible. External patient transportation planning must account for the number of ambulances, wheelchair carriers, and commercial buses in the community, including how to contact them on short notice.

4) Procedures should exist for discharging as many patients as possible, including follow-up care instructions, medications if needed, and transportation to their domicile if a friend or family member is not available.

5) A patient tracking system is needed to monitor patients, vis- itors, destinations, and hospital staff members who accom- pany patients to alternate treatment sites (Figure 20.9).

6) Coordination with the local EMS system and EOC is neces- sary.

7) Medical records, medications, and medical support equip- ment should be sent with the patient to the receiving location. Special precautions are needed for controlled pharmaceuti- cals and syringes.

8) Traffic patterns, both vehicular and pedestrian, must be con- trolled. The hospital will receive an influx of ambulances, buses, EMS personnel, and others that must be managed for maximum evacuation efficiency. For example, if sufficient elevators are available, one can be designated for ingress of EMS ambulance personnel arriving to transport patients, and one for those exiting the facility. This prevents congestion at elevator lobbies. All unnecessary vehicles should be moved from the ambulance/bus staging area to allow optimal use of space.

9) Flashlights, headlamps, and battery-powered backup lights in corridors and stairwells are useful.

10) Staging areas are needed for patients waiting to depart the facility. This strategy prevents unnecessary exposure to out- side elements. These should be under the control of an expe- rienced fire or EMS officer, preferably equipped with a hospi- tal frequency radio, who can supervise transportation assets in an efficient manner. Additionally, an internal triage team of physicians and nurses should be stationed in the patient staging area and in the vicinity of the loading point to render care as needed.

11) A method is needed to notify patients’ family members of their alternate care destinations.

12) External security of the patient loading area is necessary to protect the patients and their privacy. Additionally, the hos- pital facility itself must be secured.

13) Receiving facilities must develop memoranda of agreement with neighboring hospitals as well as hospitals 80–160 km away to provide mutual assistance. Joint evacuation planning that clarifies the roles and responsibilities of the evacuating hospital and the receiving hospital is necessary (Table 20.9).

14) Situations could arise in which other healthcare facilities may be unable to assist as receiving hospitals and so alter- nate care sites must be identified. Pre-event planning should include the creation of alternate care sites such as auditori- ums, hotels/motels, and schools that could be used to house patients when hospitals are unavailable. Although these sites have been used by others in need, they are not ideal for the practice of modern medicine. Nevertheless, they should be considered as they may be the only locations for sheltering patients too ill to return home.

15) The command structure must be clearly delineated. Policies created by the Continuum Health Partner Hospitals of New York City suggest using the HICS in reverse. For example,

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Table 20.8: Hospital Evacuation Checklist

Evacuating Hospital

Pre-event Actions Completed To Do

Does staff have family evacuation plans to include when to go, where to go, what to do with pets, food and clothes, important documents, and how to communicate?

Has a memorandum of understanding been established with a partnering facility (a like organization in size and specialties) that addresses the sharing of staff, what is expected of the evacuating organization to bring with them, how staff will be utilized, reimbursement, liability, housing for evacuating staff, how workers’ compensation will be handled, continuity of patient care, and location for evacuating organization’s administrative staff ?

Have healthcare providers been credentialed and privileged for the partnering organization?

Is there a written designation of who has authority to activate an evacuation, determine who will be evacuated, and what the “trigger point” will be?

Are evacuation actions placed within the responsible individual’s incident command Job Action Sheets?

Has the expectation of who is to assist in the evacuation of the hospital (to include nonstaff physicians who have privileges) been placed in personnel policies?

Has the expectation of who is to travel to the partnering facility with patients and work there under the established protocols (to include medical staff/residents/fellows) been placed in personnel policies?

If a patient’s physician cannot be contacted to authorize movement and coordinate transfer, who will do that?

Has a designated “safe” location within the facility been identified for patients and staff who must remain with patients who cannot be evacuated?

Have personnel from the Emergency and Engineering Departments been designated to either remain within the facility or locate to a temporary site until the event concludes for the purpose of reopening the building? Are agreements in place for staff’s temporary housing?

Have those persons designated to either remain in the facility or be in the “first back” group been advised to have several days of appropriate clothing and food?

Has an evacuation staging area been coordinated with local law enforcement so that they can block roads?

Has transportation for patients and staff who will accompany them been arranged?

Has a reentry plan been developed to include checking and starting of equipment, cleaning, preparing for the reception of victims and return of patients, restocking supplies and medications, return of staff, contacting the licensing agency, advertising that the facility is “open for business,” and other key items that staff will identify?

Have protocols for the preservation of specimens, blood, and if applicable, research data and specimens been developed?

Has the Engineering Department developed a protocol for closing the facility and turning off major equipment (e.g., air handlers, power, emergency power, water, medical gases)?

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Table 20.8 (continued)

Have windup flashlights been considered instead of battery powered?

Have exercises been conducted (may be tabletop exercises with administrative staff) where the evacuating organization practices procedures and the partnering organization practices preparing for and receiving patients?

Have both organizations visited each other’s facility to gain a better understanding and appreciation of the issues each organization faces by this effort?

Evacuating Hospital

Evacuation Actions Completed To Do

Has the Hospital Command Center and ICS been activated?

Has the partnering hospital been notified of the evacuation?

Has local law enforcement been notified to block roads leading to the evacuation staging area?

Have local and state officials been notified of impending evacuation?

If applicable, have corporate entities been notified of impending evacuation?

Have hospital board members been notified of impending evacuation?

Have patients’ f amilies been notified of evacuation and where the patients will be transferred?

Has local EMS been notified to divert any incoming patients?

Has an identification device been placed on the patient (e.g., wrist band, triage tag)?

Is the patient’s chart in a waterproof container, along with medications, valuables, and personal items?

Have both patients and staff been provided with “go nourishment kits” with water and nonperishable food? Keep insulin and sources of carbohydrates

with diabetic patients.

Have physicians of the transferred patient made arrangements with physicians within the partnering organization for continuity of patient care?

Have the drivers been provided maps that include alternate routes to the partnering hospital?

Does the driver or staff member have a communication device?

Is there a patient tracking system that includes logging patients’ names to the specific ambulances they are in and providing a copy to either the driver or staff member accompanying them and instructing the accompanying persons to insert the time that patients leave the facility, the time of arrival, and the receiving physicians’ names?

Has an administrative staff member visited the partnering facility to assist in arrivals prior to dispatching any patients?

Once a patient has been removed from the room, place an identifying label on the door to show that the room has been cleared. This will assist in clearing the hospital and making sure that no one is left behind.

Used with permission from the South Carolina Hospital Association.

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GNYHA Draft 08/20/07

Patient Critical Evacuation Information Tracking Form

NOTE: After completion of form please make THREE copies: ONE for sending facility, ONE for EMS, and ONE for receiving facility.

Sending Facility: ________________________________________________________________________

Receiving Facility: _________________________________________________________________

Patient Name: (PRINT) ______________________________________________________________

Date of Birth: ____ /____/____ Sex: Male Female

Transferring Facility Medical Record Number: __________________________________________

Method of Transport: Ambulatory Wheelchair Basic Life Support Advanced Life Support

Emergency Contact: ____________________________________ Telephone #_________________

Notified of Transfer : YES NO

Attending Physician: ____________________________________ Notified of Transfer: YES NO

Primary Diagnosis: ___________________________________________________________________

Do Not Resuscitate: YES (attach copy) NO Advanced Directives: YES (attach copy) NO

Healthcare Proxy: YES (attach copy) NO

Date transferred: ___________________ Time of arrival at receiving facility: __________________

Equipment owned by sending facility accompanying patient during transport: ________________________________________ ________________________________________ ________________________________________ ________________________________________

________________________________________ ________________________________________ ________________________________________ ________________________________________

COMMENTS: __________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Prepared by GNYHA based upon documents developed by the New York State Department of Health, Continuum Health Partners, and Lourdes Hospital.

Figure 20.9. Patient critical evacuation information tracking form.

the Logistics Chief controls the movement of patients and supplies, whereas the Planning Chief assumes responsibility to track evacuated patients through the evacuation process and on to a final destination.39

The Recovery Phase of the Disaster Each disaster has four phases: mitigation, preparedness,

response, and recovery. Following the response phase, the hos- pital must recover and return to baseline operating status. If the physical plant has been damaged, the hospital can seek finan- cial help from the U.S. Public Assistance program of FEMA or parallel programs in other countries. Here the Finance/ Administration section of the hospital’s ICS has a critical role. The Documentation Unit, Time Unit, Procurement Unit, and Compensation/Claims Unit must collect data and prepare them for presentation to FEMA. The Public Assistance program fol-

lows the rules and regulations elucidated by the Stafford Act. The Finance/Administration Chief needs a financial team to tab- ulate the costs the hospital has incurred related to the disaster. This team also provides documentation to the hospital’s insur- ance companies as it relates to property, liability, and business- interruption insurances. Patients’ health insurance companies can also be billed. Unreimbursed and donated care should be carefully documented as well as invoices for supplies and per- sonnel wages. Such information can then be presented to the hospital’s insurers and FEMA. Because of the healthcare insti- tution’s high cash demands to pay employees and vendors, the hospital may continue to incur bad debt and uncompen- sated care above the norm. To maintain cash flow, the hos- pital should discuss periodic interim payments with major health insurance companies (including the government pro- grams Medicare and Medicaid in the U.S.) in advance of a disaster.

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Table 20.9: Receiving Hospital Evacuation Checklist

Receiving Hospital

Pre-event Actions Completed To Do

Has a memorandum of understanding been established with a partnering facility (a like organization in size and specialties) that addresses the sharing of staff, what they are expected to bring with them, how staff will be utilized, reimbursement, liability, housing for evacuating staff, how workers’ compensation will be handled, continuity of patient care, and location for evacuating organization’s administrative staff?

Have healthcare providers from the partnering organization been privileged and credentialed?

Has a location for the evacuating organization’s administration to operate been identified?

Has the partnering organization been provided a list of the types of medical specialists available to them?

Has lodging for the evacuating hospital’s staff been identified?

Have arrangements been made with suppliers for additional food, linens, medications, supplies, equipment, and additional items and has a “trigger point” been identified for ordering and receiving them?

Has it been determined where incoming patients will go (both ambulatory and nonambulatory)?

Instead of discharging patients to make room, examine possible temporary arrangements (nontraditional care sites) for the patients to avoid revenue losses.

Explain to the staff the protocols that have been established with the evacuating hospital and its staff.

Have exercises been conducted where the evacuating organization practices evacuation and their partnering organization practices preparing for and receiving patients, beginning with a table top exercise with administrative staff?

Have visits been made to the partner facility to gain a better understanding and appreciation of the issues each organization faces by this effort?

Establish drop-off points so as not to interfere with day-to-day traffic.

Receiving Hospital

Evacuation Actions Completed To Do

Once notified of evacuation, establish a Hospital Command Center and activate the ICS.

Activate initial receiving areas.

Prepare beds or other locations to receive patients.

Coordinate with suppliers for additional items.

Prepare area for evacuating organization’s administrative staff.

Notify staff of incoming patients.

Notify the licensing agency.

Notify lodging facility.

Notify local health department.

Contact local law enforcement for keeping facility roads clear.

Maintain integrity of identifying information and medical records.

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Table 20.9 (continued)

Summon additional staff per protocol.

Alert behavioral health staff and chaplains.

Set up area to receive donations of money and goods.

Receiving Hospital

Preevacuation Actions Completed To Do

Establish memorandum of understanding with partnering facility (like organization) that addresses the sharing of staff, what is expected of the evacuating organization to bring with them, how staff will be utilized, reimbursement, liability, housing for evacuating staff, how workers compensation will be handled, continuity of patient care, and location for evacuating organization’s administrative staff.

Credential and privilege healthcare providers with the partnering organization

Establish a location for operations for the evacuating organization’s administration.

Provide to partnering organization a list of the types of medical specialists available to them.

Assist in locating lodging for the evacuating hospital’s staff.

Arrange with suppliers for additional food, linens, medications, supplies, equipment, and additional items; and establish a “trigger point” for ordering and receiving them.

Determine where incoming patients will go (both ambulatory and nonambulatory).

Examine possible temporary arrangements (nontraditional care sites) for existing patients to avoid revenue losses that would result from discharging them.

Explain to staff the protocols that have been established with the evacuating hospital and its staff.

Coordinate exercises in which the evacuating organization practices evacuation and their partnering organization practices preparing for and receiving patients – even if it is a tabletop exercise with administrative staff.

Visit each other’s facility to gain a better understanding and appreciation of the issues each organization faces by this effort.

Establish drop-off points that do not interfere with day-to-day traffic.

Af ter receiving notification of evacuation, establish a Hospital Command Center and activate the ICS.

Activate drop-off points.

Prepare beds or other locations to receive patients.

Coordinate with suppliers for additional items.

Se t up area for evacuating organization’s administrative staff.

Notify staff of incoming patients.

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310 ■ JO H N D. HOY L E SR.

The hospital’s capital requirements following a cataclysmic event must be fully understood. It is imperative that the hospital have solid documentation and meet the various deadlines for filing claims.

RECOMMENDATIONS FOR FURTHER RESEARCH

Protecting the Hospital from Chemical and Biological Threats

The hospital physical plant should be protected from chemical, biological, or radiological plumes that could be drawn into the building by its air-handling equipment. As stated earlier, a hospi- tal draws in more kilograms of air daily than kilograms of water to meet the infection control codes. This represents a significant vulnerability to the hospital. Incidents with tank cars carrying toxic industrial chemicals are fairly common and some have led to deaths. A hospital cannot allow itself to become internally contaminated, as it then becomes not only a dangerous environ- ment for occupants, but its critical role of providing healthcare to the community is also compromised.

The U.S. Army has consistently sought better devices to detect harmful agents and has a need for real-time, detection from a distance. To that end, the Army has experimented with laser beams that could reach out a few kilometers, sample the air, and sound an alarm if a harmful agent is detected. This standoff capability has also been developed into a package that can be carried by a helicopter and reach out several miles.

If this technology is successful, hospitals could incorporate this type of system into their overall response plans. On receiving the warning, the hospital could shut down its air-handling sys- tems and perform a facility lockdown to protect occupants. Exist- ing monitors are not necessarily real time and require follow- up of samples to analyze bioparticles. Research is needed into this technology to give not only real-time warning but also to allow technology to detect the presence of harmful agents before they can reach the hospital so timely protective actions can be taken.

Improved Reserve Supply Inventory Just-in-Time inventory control systems are in use in hospi-

tals across the United States and some other parts of the world. Therefore, a shortage of medical and surgical supplies and phar- maceuticals can be expected during a disaster. Research is needed on how to provide supply packages to equip providers to treat patients suffering from trauma, burns, respiratory injuries from chemicals, biological-induced illness, and radiation exposure. In addition, funding is needed to support the purchase, storage, rotation, and transportation of medical equipment to resupply hospitals on a timely basis. Such supply packages would contain the basic materials needed by physicians to treat the casualties from these events. This medical reserve inventory must be avail- able at the local and regional levels to bridge the gap before supplies are available from outside sources such as the CDC Strategic National Stockpile program in the U.S.

Hospital Preparedness Funding At the time of this writing, the U.S. Office of the Assistant

Secretary for Preparedness and Response in HHS operates a bioterrorism grant program to assist hospitals with disaster pre- paredness. Awards to grantee hospitals are small. Preparedness costs money and health insurance companies do not consider this

in their reimbursement formulas. Although communities rou- tinely fund the operations of fire, police, and EMS through taxes, they do not share tax revenues for disaster preparedness with the first receivers of the victims – the hospitals. More funding for healthcare facilities is necessary for a comprehensive prepared- ness effort.

Research is needed to determine international, national, state, and local government priorities for funding hospital disas- ter preparedness as well as the perspective of the health insurance industry in this regard. From the research data derived, strategies can be crafted to obtain such specific funding. Hospitals must be willing to accept such funding as restricted grants and to moni- tor and document that the funds are being for their designated purpose.

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