Structuring the Administrative Side of a Hospital For Disaster

Charles M. Little, DO FACEP

Department of Emergency Medicine

University of Colorado Denver

Today’s Objectives

• Outline the administrative needs in disaster response

• Describe the US integrated disaster response system– NIMS

• Delineate how hospitals fit into the structure• Describe typical hospital emergency

preparedness activities• Discuss examples of typical responses

Federal StructureBottom Up Approach

• Individuals, Households, – Private Sector, NGOs– Emergency Preparedness

Starts Here!

• Local Officials– Primary Responsibility for Preparedness &

Response

• States– Governor, Homeland Security Advisor, EMA,

State Coordinating Officer (SCO)– Coordinates Resources & Support from other

States & Federal Government

Hospital StructureThere are three groups of the administrative structure:

Administration

Nursing

Ancillary

Physicians and Licensed Independent Practitioners

Emergency Management Plan• Mitigation/Preparedness & Program Support

– Hazard Vulnerability Analysis – Mitigation– MOUs & Other Agreements– Training Records– Exercise Plans & Records

• Response & Recovery– Emergency Operations Plan

TJC 2009 EM Standards

Emergency Operations PlanComponents

• 6 Critical Function Areas– Communication– Resources– Safety & Security– Staffing– Utilities– Clinical & Support Activities

Major Points

• Emergency Operations Plan– Annexes

• Need for ICS– The UCH experience

EOP – Critical Function Areas• Communication

– Systems & Strategies

• Resources– Inventory, Acquisition, Monitoring, and Replenishment– Hospital Resource Directory– Staff Support– Shared Resources and Assets– Transportation

• Safety & Security– Internal Safety & Security– Control Access & Movement– Coordination of Security with External Agencies– Management of Hazardous Materials & Waste– Radioactive/Biological/Chemical Isolation & Decontamination

EOP – Critical Function Areas

• Utilities– Electricity, Water, Fuel, Medical Gasses, etc.

• Clinical & Support Activities– Management of Patient Clinical Activities– Evacuation– Surge Activities & Altered Standards of Care– Clinical Services for Vulnerable Populations– Patient Hygiene and Sanitation– Patient Mental Health Needs– Decedent Management– Clinical Documentation and Tracking

Support AnnexesCoordination of Common Functional & Admin Processes

• Critical Infrastructure and Key Resources• Financial Management• Private Sector Coordination• Public Affairs• Tribal Relations• Volunteer and Donations Management• Worker Safety and Health

Incident AnnexesDescribe CONOPS for Specific Contingencies & Hazards

• Biological Incident

• Cyber Incident

• Nuclear/Radiological/Chemical Incident

• Mass Evacuation Incident

Incident Command System (ICS)

• Originated 1970s– Fire service based

• Tested in multiple disasters

• Similar organization across all responders

– NIMS: National Incident Management System

– Joint Commission

ICS Purposes• Using management best practices, ICS helps to

ensure:– The safety of providers and others.– The achievement of tactical objectives.– The efficient use of resources.

• Flexible based on complexity of the incident

Incident Complexity and Resource NeedsIncident Complexity Resource Needs ICS Structure

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90% of Incidents only require a simple ICS structure!

ICS Structure

Who should be Incident Commander?

Training

FEMA IS – 100, 200,700

IS- 800

Advanced IS – 300, 400

Training, Credentialing, and Exercising– Do you have sufficient qualified

personnel to assume ICS Command and General Staff positions?

– Can you verify that personnel meet established professional standards for:• Training?• Experience?• Performance?

– When was the last tabletop or functional exercise that practiced command and coordination functions? Did you participate in that exercise?

Chief Executive

• Delegate Command Authority to Incident Commander.

• Provide Policy Guidance on Priorities and Strategic Direction based on situational needs.

• Provide Financial Authority and Restrictions.• Provide Reporting Requirements• Provide Guidance on Demographic and Political

Implications

Incident Command

• The activities at the Command Center (such as a Hospital Command Center-HCC) are directed by the Incident Commander (IC)

• IC has overall responsibility for all activities within the HCC

• The IC may appoint other Command Staff personnel to assist as the situation and resources warrant

Building Command & Staff Depth

• Three to five persons should be trained for each command position in case a prolonged response is required

• Training and exercises should be used as a means of preparing personnel to competently and confidently assume one or more roles based on situational need and available resources.

• Completion of the specified NIMS courses, either online or in the classroom, should help to prepare those persons likely to assume command roles.

Special ICS Issues

• Unified command– Possible working with outside agencies

Emergency Operations PlanComponents

• Activation & Termination of EOP, HCC, ICS• Integration with Community ICS & Partners

– Status/Capacity, Resource Sharing, Patient Tracking/Management, Event Management

• HCC Specific ICS Job Action Sheets & Forms– Only those that may be activated by your facility.

• Relevant Annexes, Policies & Procedures– Based on HVA top priorities (3-5)– Surge Capacity, Pan Flu, Evacuation, Mass Fatality, Evacuation, etc.– Incident Response Guides (IRGs).– 96 Hour Capability

• Recovery– Return to Normal Operations– Event Evaluation

EOP – Critical Function Areas

• Staffing– Staff Roles & Responsibilities– Reporting Instructions– Training– Acceptance & Use of Staff from other

Healthcare Organizations– Acceptance & Use of Volunteers– Workforce Identification

Hazard Vulnerability Analysis

• Required Annually• Systematic Approach for Recognizing

Hazards• The Risks of each Hazard are Analyzed

– Prioritizes Planning, Mitigation, Response, & Recovery Activities.

• Serves as the “Needs Assessment” for the Emergency Management Program.

• Should Involve Community Partners.

HUMAN EVENTS - Anschutz Medical CampusEVENT PROBABILITY RISK PREPAREDNESS TOTAL

          HUMAN (IN OUR BUILDING)  

HOSPITAL

DISRUPTION

         

  HIGH MED LOW NONE DEATHHEALTH/SAFETY

NONE HIGH MOD LOW POOR FAIR GOOD  

SCORE 3 2 1 0 6 3 0 3 2 1 3 2 1  MASS CASUALTY INCIDENT (TRAUMA)

  X         X X       X   7

MASS CASUALTY INCIDENT (MEDICAL)

  X         X X       X   7

WMD (CHEMICAL)     X     X   X       X   9

WMD (BIOLOGICAL)

    X     X   X       X   9

WMD (NUCLEAR)     X     X   X       X   9

INFANT ABDUCTION

  X       X     X       X 8

CIVIL DISTURBANCE

    X       X   X     X   5

HOSTAGE SITUATION

    X     X   X     X     10

ACTIVE SHOOTER

  X   X     X     X     14

BOMB THREAT     X     X     X       X 7

ILLEGAL CHEMICAL LAB

  

X     X       X   X   7

VIOLENCE IN THE EMERGENCY DEPT.

X       X     X       X 9

WORK PLACE VIOLENCE

  X       X       X     X 7

Action Point determined to be 9 or above

MCI Hospital Response• ED empties of all noncritical patients

– Move into hospital all admission– D/C stable patients

• Critical patient flow should be unidirectional– ED, critical studies, ICU or OR

• Operate in minimalist mode– Defer tests not immediately mandatory

Individual Responsibilities

Response

• Have a pre-existing plan for family emergencies, medicines, child and pet care

• Respond When Requested or spontaneous?

• Establish a Location & Point of Contact– Hospitals need to pre-designate

ED Initial Response

• ED Organizes– Security!!

– Red (Immediate, Critical)

– Yellow (Intermediate, Delayed)

– Green (Minor, Ambulatory)

– Triage area set up

– Disaster Registration commences

– Form treatment teams for Red• Physician, nurse, ancillary

Hospital Admin Response

• Hospital Command Center Opens– Coordinate Response– Push out resources

• Labor Pool

• Supplies

– Family Center– Behavioral Health Area– Morgue

HCC Response

• Send staff and beds to ED

• Set up labor pool

– ICU and PACU personnel ideal

– Cross train

• Floor teams discharge all appropriate patients

– Use discharge holding area

MCI Hospital Phases: Chaos

• Duration: minutes to hours

• Poor communications

• Minimal and unreliable information

• Implement disaster plan, reorganize resources

• Staff checks on family well being

Casualty Receiving

• Duration: few hours

• Hospital resources limited to on hand only

• Operate in damage control mode, limited treatment of life and limb threatening injuries to maximize surge

Consolidation

• Duration: about 24 hours

• All casualties received

• Restock supplies

• Tally patients and prioritize surgeries

• Rotate staff

Phases continued

• Definitive Care: weeks– Further surgeries as needed

• Rehabilitation: months

IEDs

• Highest FBI ranked terrorist threat in USA• Easily made devices (recipes on the web)• Primary bombing

– Maximize casualties and PR impact– Closed spaces

• Secondary devices common– Aimed at first responders

• Hospitals targeted overseas

Hospital Trauma Capacity

• 1 critical patient/100 beds – normal operations

• 2-3 critical patients/100 beds – maximal response

• A hospital ramp up requires 30-60 minutes

How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis.Hirshberg A, Scott BG, Granchi T, Wall MJ Jr, Mattox KL, Stein M .J Trauma. 2005 Apr;58(4):686-93

How does casualty load affect trauma care in urban bombing incidents? A quantitative analysis.Hirshberg A, Scott BG, Granchi T, Wall MJ Jr, Mattox KL, Stein M .J Trauma. 2005 Apr;58(4):686-93

Conclusions

It is important to have a well developed EOP

Exercises are key!

Continued staff education and training is hard but necessary