exercise operation prep overview

Operation PREPOperation PREPNovember 15November 15thth, 2006, 2006

New England Center for Emergency PreparednessNew England Center for Emergency Preparedness

Dartmouth Medical SchoolDartmouth Medical School

OverviewOverview

Introduction and BackgroundIntroduction and Background Exercise ObjectivesExercise Objectives Activities and Observations Activities and Observations Reactions and Lessons LearnedReactions and Lessons Learned RecommendationsRecommendations Conclusions, future directionsConclusions, future directions

Introduction and Introduction and BackgroundBackground

Cooperation of multiple organizations is Cooperation of multiple organizations is key to a successful disaster response. key to a successful disaster response.

In a disaster, organizations that don’t often In a disaster, organizations that don’t often work together will have to.work together will have to.

Practice will ensure this collaboration and Practice will ensure this collaboration and cooperation are effectivecooperation are effective

Hanover/Lebanon Region, Wednesday, Hanover/Lebanon Region, Wednesday, November 15November 15thth, 2006: Functional exercise , 2006: Functional exercise to practice cooperation of multiple partnersto practice cooperation of multiple partners

PartnersPartners

Town of HanoverTown of Hanover City of LebanonCity of Lebanon Dartmouth-Hitchcock Dartmouth-Hitchcock

Medical Center (DHMC)Medical Center (DHMC) Dartmouth CollegeDartmouth College Northern New England Northern New England

Metropolitan Medical Metropolitan Medical Response System Response System (NNE MMRS)(NNE MMRS)

New England Center for New England Center for Emergency Emergency Preparedness (NECEP)Preparedness (NECEP)

Hospital ObjectivesHospital Objectives

Demonstrate:Demonstrate: Ability to respond to an infectious respiratory Ability to respond to an infectious respiratory

disease epidemicdisease epidemic Critical ICS sections Critical ICS sections Ability to communicate both internally and Ability to communicate both internally and

externally externally Ability to coordinate with senior leadership at Ability to coordinate with senior leadership at

DHMC DHMC Ability to secure the facility set up external Ability to secure the facility set up external

triage at the Emergency Department triage at the Emergency Department

Hospital ObjectivesHospital Objectives

Demonstrate:Demonstrate: Ability to track patients using Ability to track patients using HC StandardHC Standard Decision-making process for requesting Decision-making process for requesting

community ACCcommunity ACC Ability to identify patients to discharge or transfer Ability to identify patients to discharge or transfer

to ACC in order to create hospital surge capacity to ACC in order to create hospital surge capacity Decision-making process for transfer of 25 patients Decision-making process for transfer of 25 patients

to community ACC to community ACC Ability to vaccinate health care workers to allow Ability to vaccinate health care workers to allow

continuity of care in an infectious disease outbreak continuity of care in an infectious disease outbreak situationsituation

Community ObjectivesCommunity Objectives

Practice:Practice: Setting up an Emergency Operations Center Setting up an Emergency Operations Center

and implementing Incident Command Structureand implementing Incident Command Structure Communicating with hospitals and State Communicating with hospitals and State

agenciesagencies Setting up an Acute Care Center (ACC)Setting up an Acute Care Center (ACC) Admitting 50 patients to the ACCAdmitting 50 patients to the ACC Tracking these 50 patients using new software: Tracking these 50 patients using new software:

Health Care Standard (HCS) for patient Health Care Standard (HCS) for patient tracking and Athenahealth for Electronic tracking and Athenahealth for Electronic Medical RecordsMedical Records

Activities and ObservationsActivities and Observations

Tested implementation and Tested implementation and functionality of the Epidemic functionality of the Epidemic Respiratory Infection Respiratory Infection Readiness Plan. Readiness Plan.

An All Hazards plan should An All Hazards plan should be developed to fit all events. be developed to fit all events.

Individual department plans Individual department plans exist, but are not collated into exist, but are not collated into an all-hazards planan all-hazards plan

ICS staff should be flexible ICS staff should be flexible about how they use the about how they use the plans.plans.

Hospital Objective: Demonstrate ability to respond to an infectious respiratory disease epidemic


First time DHMC has used ICS in functional exercise.First time DHMC has used ICS in functional exercise. Majority of staff in the EOC felt they understood the chain of Majority of staff in the EOC felt they understood the chain of

command, and felt confident in their ability to fulfill their role. command, and felt confident in their ability to fulfill their role. Excellent staff turnout at the EOCExcellent staff turnout at the EOC For effective decision-making in the EOC, only key staff For effective decision-making in the EOC, only key staff

should participate in conversations with the IC. should participate in conversations with the IC.

Hospital Objective: Demonstrate critical ICS sections

Diagram Source: www.fema.govDiagram Source: www.fema.gov


Phone lines in the EOC were functionalPhone lines in the EOC were functional Cell phones were not always operationalCell phones were not always operational Email was used extensively for internal Email was used extensively for internal

communication.communication. HANs had to be redistributed as only one HANs had to be redistributed as only one

member of staff was registered to receive member of staff was registered to receive themthem

Patient tracking software worked well for Patient tracking software worked well for internal and external communications. internal and external communications.

DHMC needs to incorporate a centralized DHMC needs to incorporate a centralized emergency communications plan in their emergency communications plan in their EOP.EOP.

Hospital Objective: Demonstrate ability to communicate both internally and externally; ability to coordinate with hospital senior leadership


ED staff assigned by the EOC ED staff assigned by the EOC went outside to assess and went outside to assess and triage the patients on the bus. triage the patients on the bus.

Patients were not allowed into Patients were not allowed into the building in order to avoid the building in order to avoid potential contamination.potential contamination.

Identified need for specific Identified need for specific instructions and protocol for instructions and protocol for establishing an external triage establishing an external triage area during an infectious area during an infectious disease outbreak. disease outbreak.

Hospital Objective: Demonstrate ability to secure the facility and establish external triage at Emergency Department


Entering the patients into the Entering the patients into the patient tracking system patient tracking system paralleled assessment of paralleled assessment of patients in the triage area. patients in the triage area.

HC StandardHC Standard and current and current patient admitting system patient admitting system would need to be linked to would need to be linked to avoid duplication of effort and avoid duplication of effort and be effective in a real event. be effective in a real event.

It did not appear that the It did not appear that the patient tracking system would patient tracking system would severely interfere with the severely interfere with the flow of patients. flow of patients.

athenahealthathenahealth was not tested was not tested at DHMC triage location as at DHMC triage location as planned. planned.

Hospital Objective: Demonstrate ability to track patients


Discussion of how to best utilize this facility Discussion of how to best utilize this facility Decided to transfer all infectious Morbus patients to Decided to transfer all infectious Morbus patients to

the ACC as a temporary isolation facility for further the ACC as a temporary isolation facility for further observationobservation Goal: cohort and observe these patients until it could be Goal: cohort and observe these patients until it could be

determined if they were sufficiently ill to require critical care, determined if they were sufficiently ill to require critical care, and minimize exposure of staff and other patients.and minimize exposure of staff and other patients.

Decision-making process in this area was efficient, Decision-making process in this area was efficient, sound and very effective. sound and very effective.

The IC discussed the possibility of using another The IC discussed the possibility of using another facility as a clean facility for transferring non-infectious facility as a clean facility for transferring non-infectious inpatients to create additional hospital surge capacity.inpatients to create additional hospital surge capacity.

Protocol for requesting community assistance for Protocol for requesting community assistance for medical surge is not included in hospital emergency medical surge is not included in hospital emergency response plans at this time response plans at this time

Hospital Objective: Demonstrate decision-making process for requesting an Acute Care Center (ACC)


Identified more than 60 inpatients for immediate Identified more than 60 inpatients for immediate discharge discharge

Established a discharge center to immediately open Established a discharge center to immediately open necessary bedsnecessary beds

Incident Commander cancelled elective procedures Incident Commander cancelled elective procedures for the day; procedures scheduled for the following for the day; procedures scheduled for the following day were put on hold until further notice day were put on hold until further notice

Hesitant to cancel all procedures due to financial Hesitant to cancel all procedures due to financial implications implications

All patients in one inpatient unit were moved to other All patients in one inpatient unit were moved to other areas of the hospital so that this unit could become areas of the hospital so that this unit could become an internal cohort unit if necessary an internal cohort unit if necessary

Hospital Objective: Demonstrate ability to identify patients to discharge or transfer to ACC in order to create hospital surge capacity


Physical transfer was not tested.Physical transfer was not tested. Discussion about how to transfer them to the ACC, including the Discussion about how to transfer them to the ACC, including the

possibility of instructing patients to drive themselves there. possibility of instructing patients to drive themselves there. Led to an in-depth discussion of liability on the part of the Led to an in-depth discussion of liability on the part of the

hospital and the need to treat and stabilize arriving patients. hospital and the need to treat and stabilize arriving patients. Incident Commander did not want to tie up the ambulances Incident Commander did not want to tie up the ambulances

transferring stable, non-critical patients. transferring stable, non-critical patients. Decided to stop running local transportation company shuttles Decided to stop running local transportation company shuttles

and use those busses to transfer Morbus patients to the ACC. and use those busses to transfer Morbus patients to the ACC. Patients would be accompanied by staff members from Security Patients would be accompanied by staff members from Security

and the Emergency Department. All staff on the bus, including and the Emergency Department. All staff on the bus, including the driver, were instructed to wear appropriate personal the driver, were instructed to wear appropriate personal protective equipment (PPE). protective equipment (PPE).

Hospital Objective: Demonstrate ability to transport 25 patients to community ACC


Three 12-hour vaccination clinics Three 12-hour vaccination clinics where employees were provided where employees were provided the seasonal flu vaccine at no costthe seasonal flu vaccine at no cost

Advertised to staff via the intranet Advertised to staff via the intranet Participation was encouraged by Participation was encouraged by

department directors. department directors. Clinics were patterned after the Clinics were patterned after the

New Hampshire POD planning New Hampshire POD planning guidance. guidance.

2,890 employees were vaccinated 2,890 employees were vaccinated Average wait time of one minute. Average wait time of one minute. A much larger number of A much larger number of

employees could have been employees could have been managed with the same level of managed with the same level of staffing if necessary.staffing if necessary.

Hospital Objective: Demonstrate ability to vaccinate health care workers to allow continuity of care in an infectious disease outbreak situation.

Results and Reactions - Results and Reactions - HospitalHospital

DHMC exercise participants demonstrated the capability to:DHMC exercise participants demonstrated the capability to: Initiate specialty teams within the ICS that were able to think Initiate specialty teams within the ICS that were able to think

and act independently, helping to address organization and and act independently, helping to address organization and community response.community response.

Communicate with the NH DHHS on the phone, with hospital Communicate with the NH DHHS on the phone, with hospital senior leadership through in-person briefings, and with hospital senior leadership through in-person briefings, and with hospital employees through email. employees through email.

Create hospital surge capacity by transferring and discharging Create hospital surge capacity by transferring and discharging stable patients.stable patients.

Utilize community medical surge capacity resources to Utilize community medical surge capacity resources to maintain hospital capacity for critically ill patients.maintain hospital capacity for critically ill patients.

Identify local transportation resources which could be used to Identify local transportation resources which could be used to move large numbers of patients in a safe and efficient manner.move large numbers of patients in a safe and efficient manner.

Vaccinate large numbers of health care workers to maintain Vaccinate large numbers of health care workers to maintain continuity of operations in an infectious disease outbreak.continuity of operations in an infectious disease outbreak.

Results and Reactions - Results and Reactions - HospitalHospital

Major areas for improvement:Major areas for improvement: Further training in ICS would be beneficialFurther training in ICS would be beneficial

Desire to be collaborative will impede decision-Desire to be collaborative will impede decision-making process in real eventmaking process in real event

Newly released HICS IVNewly released HICS IV Emergency response plans need to be refined Emergency response plans need to be refined

for flexibility, completenessfor flexibility, completeness Useful in all emergency situationsUseful in all emergency situations Cover all bases: communication, transportation, Cover all bases: communication, transportation,

surge capacitysurge capacity


Hanover emergency Hanover emergency planners set up EOC in new planners set up EOC in new location – what to bring?location – what to bring?

Practice with ICS – not all Practice with ICS – not all familiar with chain of familiar with chain of commandcommand

Job Action Sheets and Job Action Sheets and diagram assisted ICS set-updiagram assisted ICS set-up

Communication: cell Communication: cell phones, landlines, internet – phones, landlines, internet – did not test radiosdid not test radios

Community Objectives: Practice setting up Emergency Operations Center and implementing Incident Command Structure. Practice communicating with hospital and State.


SNS resource tracking SNS resource tracking requirementrequirement

Efficiency: <1 minute per Efficiency: <1 minute per patientpatient

Accountability: full record for Accountability: full record for each patienteach patient

Community Objectives: Practice ability to track 50 patients in a POD


Multiple organizations: NNE Multiple organizations: NNE MMRS NH Strike Team, HFDMMRS NH Strike Team, HFD

Besides Hanover FD, none of Besides Hanover FD, none of these people had ever worked these people had ever worked together beforetogether before

Determine ICS – Job Action Determine ICS – Job Action Sheets and diagram helpfulSheets and diagram helpful

Physical set up of Cabela’s Physical set up of Cabela’s cots – Supplied by Hanovercots – Supplied by Hanover

Receiving and unloading of Receiving and unloading of medical supplies from DHMCmedical supplies from DHMC

Secure facilitySecure facility

Community Objectives: Practice setting up an Acute Care Center

Leverone Field HouseLeverone Field House


Local High School and Local High School and Dartmouth students Dartmouth students volunteered as “patients”volunteered as “patients”

No acting – each received a No acting – each received a patient card with a patient card with a description of symptomsdescription of symptoms

Strike team admitted Strike team admitted patients patients

No patient care givenNo patient care given Written orders to track Written orders to track

activities, use of staff and activities, use of staff and suppliessupplies

Community Objectives: Practice admitting 50 patients to ACC


Patients given tag with bar Patients given tag with bar code at triage (ED, NEHC)code at triage (ED, NEHC)

Scanned at every point of Scanned at every point of contact – discharge facility, contact – discharge facility, transfer, receivingtransfer, receiving

Handheld scanners (HCS) Handheld scanners (HCS) are multipurpose toolare multipurpose tool

HCS linked to WebEOC, HCS linked to WebEOC, monitors anything and monitors anything and everythingeverything

Athena tracks care given, Athena tracks care given, resources usedresources used

Community Objectives: Practice tracking 50 patients in ACC using patient tracking and electronic medical records software

Results and Reactions - Results and Reactions - CommunityCommunity

Strike team worked well together, especially Strike team worked well together, especially considering they have never done so before considering they have never done so before this exercise! this exercise!

Need some non-medical personnel at the Need some non-medical personnel at the ACC to handle administrative and custodial ACC to handle administrative and custodial duties duties

Need simple instructions on how to set up an Need simple instructions on how to set up an ACC; very few people know exactly how to ACC; very few people know exactly how to do it! do it!


Supplies are a big issue: how do we get the Supplies are a big issue: how do we get the supplies to the people who need them?supplies to the people who need them?

DHMC coordinated the supplies they sent with DHMC coordinated the supplies they sent with the Logistics Trailer inventory the Logistics Trailer inventory

State Logistics Trailer was unavailable for the State Logistics Trailer was unavailable for the exerciseexercise

Pre-printed admission and discharge formsPre-printed admission and discharge forms


Clear lines of communication between State, Clear lines of communication between State, local and hospital EOC’s, and ACC are a mustlocal and hospital EOC’s, and ACC are a must

Not always clear who should call which Not always clear who should call which organization for what informationorganization for what information

Periodic practice and training in ICS and review Periodic practice and training in ICS and review of emergency response plans will make this of emergency response plans will make this process more familiar and comfortable during process more familiar and comfortable during an actual incidentan actual incident

Recommendations Recommendations

PlanningPlanning DHMC should review current emergency response DHMC should review current emergency response

plans, and ensure they are flexible enough to be plans, and ensure they are flexible enough to be useful during a public health emergency.useful during a public health emergency.

DHMC should develop annexes to this plan, DHMC should develop annexes to this plan, including an emergency communications plan, and including an emergency communications plan, and mass transportation.mass transportation.

DHMC should review medical surge capacity plans DHMC should review medical surge capacity plans and protocol for requesting assistance from the and protocol for requesting assistance from the community.community.

NNE MMRS should review the ACC Concept of NNE MMRS should review the ACC Concept of Operations document in relation to NIMS and HICS Operations document in relation to NIMS and HICS guidance to ensure compatibility.guidance to ensure compatibility.

RecommendationsRecommendations

OperationalOperational Additional education and practice in ICS is Additional education and practice in ICS is

needed by both DHMC staff and the NH needed by both DHMC staff and the NH Medical Strike Team.Medical Strike Team.

Before any IT systems are used, staff will Before any IT systems are used, staff will require extensive training in them. Just-in-require extensive training in them. Just-in-time training should be created where time training should be created where appropriate.appropriate.


Training and Education Training and Education NNE MMRS should continue to educate NNE MMRS should continue to educate

medical strike team members on ICS and medical strike team members on ICS and procedures for opening and operating an procedures for opening and operating an ACC.ACC.

DHMC should continue to education staff on DHMC should continue to education staff on ICS, emphasizing new HICS IV guidanceICS, emphasizing new HICS IV guidance


Future ExercisesFuture Exercises Additional exercises should exercise other Additional exercises should exercise other

components of hospital and community components of hospital and community surge capacity, including staff shortages, surge capacity, including staff shortages, and supply use.and supply use.

Incorporate additional partners and Incorporate additional partners and stakeholders in future exercises, including stakeholders in future exercises, including those from neighboring states.those from neighboring states.

ConclusionConclusion

Collaboration is key to successCollaboration is key to success Fire, police, emergency managers, hospital, EMS, Fire, police, emergency managers, hospital, EMS,

local physicians and nurses, nursing home local physicians and nurses, nursing home facilities, Visiting Nurses Association, schools, facilities, Visiting Nurses Association, schools, businessesbusinesses

SuppliesSupplies What do you have? What do you have? What do you need? What do you need? How can you get it? (Hint: be creative)How can you get it? (Hint: be creative)

Practice makes perfect! Practice makes perfect!

ResourcesResources NNE MMRS: NNE MMRS: www.nnemmrs.orgwww.nnemmrs.org

Guidance for planning exercises and drills, medical surge capacity Guidance for planning exercises and drills, medical surge capacity documents, including documents, including ACC Concept of OperationsACC Concept of Operations

NECEP: NECEP: http://http://dms.dartmouth.edu/necepdms.dartmouth.edu/necep Department of Homeland Security: Department of Homeland Security: www.dhs.govwww.dhs.gov Centers for Disease Control: Centers for Disease Control: www.cdc.govwww.cdc.gov Department of Health and Human Services: Department of Health and Human Services: www.dhhs.govwww.dhhs.gov Contact: Contact:

Reiley Lewis MPHReiley Lewis MPHNew England Center for Emergency PreparednessNew England Center for Emergency Preparedness

Colburn Hill, HB 7462Colburn Hill, HB 7462One Medical Center DriveOne Medical Center Drive

Lebanon, NH 03756Lebanon, NH 03756Office: (603) 653-1189Office: (603) 653-1189

[email protected]@Dartmouth.edu

exercise operation prep overview

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