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Hospital Readiness Assessment 1 st National Health Emergency Preparedness Conference Preparing Your Hospital for Disaster H. Roslyn Devlin May 29, 2006 Slide 2 Ready: A Definition Prepared mentally or physically for some experience or action Prepared for immediate use Willingly disposed Likely to do something indicated Immediately available Slide 3 Readiness Assessment Tools OSHA Best Practice for Hospital-Based First Receivers of Victims Centers for Disease Control and Prevention. Local Public Health Preparedness and Response Capacity Inventory. December 2002; Version 1.1 Bioterrorism and Other Public Health Emergencies Tools and Models for Planning and Preparedness Evaluation of Hospital Disaster Drills: A Module-Based Approach Bioterrorism Emergency Planning and Preparedness Questionnaire for Healthcare Facilities. Booz-Allen and Hamilton Mass Casualty Disaster Plan Checklist: a Template for Healthcare Facilities. American Practitioners in Infection Control. http://www.apic.org/bioterror/checklist.doc Slide 4 CEEP Readiness Assessment Tools General readiness checklist: A template for healthcare facilities 24 Sections CBRNE plan checklist: A template for healthcare facilities 8 Sections Reviewed by individuals with expertise in Emergency Medicine, Emergency Management and Public Health Slide 5 Assumptions Disasters/emergencies may occur inside or outside the organization Healthcare facilities will be expected to respond to these emergencies in a coherent fashion Checklists provide a Gap Analysis Primary target are traditional (short stay) hospitals Yes mean Yes No can have many meanings Slide 6 Process Identification of the need 2003 Literature review. 2004 First draft 2004 Second literature review 2005 Panel review and edit of initial tool 2006 Trial of tool at test sites Incorporation of feedback Release of final document. Slide 7 General Readiness Checklist I Definitions General Facility Information Where do patients go and who cares for them Foundational Considerations Does a disaster plan exist How is it managed Is it integrated with other disaster plans Identification of Authorized Personnel Who is in charge Who does what Slide 8 General Readiness Checklist II Plan Activation and Response Human resources Supplies Inter-facility/agency agreements Departmental plans Chain of custody Morgue facilities Back-up plans Slide 9 General Readiness Checklist III Incident Command System Security and Access External traffic control Internal Traffic and Control Tracking of patients, staff, volunteers, media Communications Organized runner system Contact directory Slide 10 General Readiness Checklist IV Visitor Management Release of patient information Identification of visitors Designated spokesperson Media Location Spokesperson Release of information policy Integrated community response Slide 11 General Readiness Checklist V Reception of Casualties Temporary patient tracking Tracking of patient belongings Field Communications Notification to stand down Regular updates TV, radio and other sources of information Redirection of Hospital Operations IT Concerns Ability to process patients in non-standard locations Inter Agency Agreements Slide 12 Evacuation Procedures Relocation of Patients and Staff Satellite locations Evacuation routes Transportation requirements Bad weather plans Inter Agency Agreements Discharge Routine Patient tracking Medical records Slide 13 Stand Alone Procedures Auxiliary Power Food and Water Waste and Garbage Disposal Rest and Rotation of Staff Medication and Supplies Slide 14 General Readiness Checklist VI Diagnostic Capabilities Information Technology Critical Incident Stress Management Post Disaster Recovery How much did it cost? Education and Training Slide 15 CBRNE Checklist Assumptions Victims will arrive with little or no warning Information about the hazardous agent will not be immediately available A large number of victims will be self-referred Victims will not necessarily have been decontaminated prior to arriving at the facility Many people arriving at the facility will have had little or no actual exposure Most victims will go to the healthcare facility closest to the site where the emergency occurred Victims will attempt to use other entrances in addition to the Emergency Department Slide 16 CBRNE Checklist Foundational Considerations Is there a plan/planner/planning committee Inter-Agency collaboration Internal and external disasters External and internal facility Requirements Training and Awareness Signs and symptoms of a CBRNE event Roles and responsibilities Chain of custody Wheres the equipment? Role of ER team and content specialists Slide 17 CBRNE Procedures I Communication With and without PPE Baseline Syndromic Surveillance Numbers Decontamination Equipment Heating Containment of water run-off Triage and Segregation of Patients Ventilation Controls Security Arrangements Slide 18 CBRNE Procedures II Standard Orders Antidotes and Therapy Dosage requirements Drug administration equipment Who Accepts Deliveries from the National Pharmaceutical Stockpile Regulatory Requirements for PPE Slide 19 Biological Incident Module I Category A Agents Anthrax Plague Smallpox Botulism Viral Hemorrhagic Fevers Tularemia Characteristics Easily disseminated High mortality rates Cause public panic Require special action for preparedness Slide 20 Biological Incident Module II Clinical Presentation Laboratory Diagnosis Infection Control Procedures Treatment Stockpiles: Local, Municipal, Provincial, National Prophylaxis Vaccination Public Health Requirements Slide 21 Biological Incident Module III Internal/External Surveillance When Does the ER call Infection Control? Can Your Facility Test for Biologic Agents 24/7 Processing/referral of Class A Agents Chain of Custody Issues Pharmacy Surveillance of drug use 24/7 coverage Slide 22 Chemical Incident Module I Nerve Gases Sarin, Tabun, Soman VX Pesticides Blood Agents Cyanides Vesicants Sulfur Mustard, Lewisite, Phosgene Pulmonary Agents Chlorine, Phosgene, Diphosgene, Ammonia Riot Control Agents Tear gas, Vomiting gas, Pepper Spray Slide 23 Chemical Incident Module II Atropine Pralidoxime Diazepam Tropicamide Pyridostigmine Cyanide antidote kit Amyl nitrite, Sodium nitrite, and Sodium thiosulfate Dimercaprol Acetylcysteine aerosol Slide 24 Chemical Incident Module III Safe Storage of Inventories Rapid stockpile Access Tracking Antidote Inventories Expiry dates Maintaining Antidote Inventories Plan for Both External and Internal Event Internal response team Role of Hazmat Slide 25 Chemical Incident Module IV Decontamination Protocol Containment and Remediation Monitoring of Chemical Contamination Decontamination of Pregnant Patients Chemically Resistant/Vapour Tight Plastic Bags/Containers for Waste Air Exclusion Policy Handling of Deceased People Slide 26 Chemical PPE Appropriate PPE Respiratory Protection Program Fit Testing Tracking of PPE Appropriate Size Distribution Regularly Checked Staff Training/Certification Frequency of staff training/certification Slide 27 Radiological/Nuclear Incident Module Radiation Safety Officer Contact List for Radiation Experts Radiation Safety Officer Nuclear Medicine Specialist/Radiologists Radiation Oncology Staff External Experts Internal and External Events Exclusion of Pregnant HCWs Irradiated Victims vs. those Contaminated with a Radioactive Material Decontamination Facilities Slide 28 Radiation Detection Appropriate Instrumentation Use of instrumentation and interpretation of data Documentation of the radiation monitoring results Dosimeters for Staff Program to monitor dosimeters Appropriate PPE Mitigation of a Procedure Breach Slide 29 Treatment of Victims Anti-emetics Anti-diarrheal agents Potassium iodide Fluid and Electrolyte Balance 24 hour Urine Collections Measurement of Faecal Radioactivity Safe Transportation of Specimens Specimen Analysis Slide 30 Contaminated Personal Property and Waste Lead Lined/Concrete Room for Storage Plastic Bags and Containers for Waste Slide 31 Health Care Workers Ability and Willingness to Report to Duty 47 Health Care Facilities in NYC 31 hospitals, 11 LTCFs, 3 CHCs 6 Scenarios Weather emergency Bioterrorism Chemical terrorism Mass casualty incident Environmental disaster Radiation terrorism Untreatable infectious diseases outbreak 2 Categories Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 32 Employee Demographics 88% fulltime 69.4% female 42.7% > 45 years 26.2% nurses 24.8% support staff 19.3% administrators 10% physicians 11% others Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 33 Personal Safety Concerns Level of Concern Biological Event Chemical Event High/moderate3,298 (54.7%)3,168 (52.5%) Slight/Low2,736 (45.3%)2,870 (47.5%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 34 Ability to Respond to an Emergency Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 35 Willingness to Respond to an Emergency Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 36 Barriers to Ability to Respond to an Emergency Transportation (33.4%) Childcare (29.1%) Personal Health Concerns (14.9%) Eldercare Responsibilities (10.7%) Pet Care (7.8%) Second Job (2.5%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 37 Barriers to Willingness to Respond to an Emergency Fear and Concern for Family (47.1) Fear and Concern for Self (31.1%) Personal Health Problems (13.5%) Child/Eldercare Issues (1.4%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005 Slide 38 Response to Barriers Car Pools Use of EMS/Police to Transport Staff Emergency Childcare/eldercare pools Medication on site for some staff Pet Care Arrangements Appropriate PPE Appropriate Education Slide 39 Process Failure Mode & Effect Analysis (FMEA) FMEA: Determine the probability of the potential cause or risk Design a system to absorb errors - Simulation of application and removal of the Personal Protective Equipment, Code Blue Special and Operating Rooms scenarios Standardize procedures Reduce variation, eliminate the exposure risk to unknown contaminants Training & re-training Competency assessments of the education program Create a safe caring environment where staff and patients both feel protected Survey of staff satisfaction and confidence when providing care Slide 40 Precautions for High risk Procedures Slide 41 Process Hospital-Wide Module Train the trainer model 2-4 trainers were designated for each area Trainers work with Infection Control Practitioner in scheduled sessions Group 1 -6 hours Group 2 -4 hours Group 3 -3 hours Return demonstrations appropriate to designated area Slide 42 Competency Checklist Application and Removal of N95 Respirator NAME: _____________________________UNIT: _____________________ REVIEWED BY:______________________DATE: _____________________ In order to be approved for this advanced clinical competency you must demonstrate the knowledge, skill and judgement in the following: KNOWLEDGE: Outline proper technique for the application and removal of N95 respirator State importance of fit testing Describe proper method for completing seal check State indications for changing respirator State rationale for not touching mask with hands once applied State indications for use of surgical/N95 masks for different isolation types SKILL: Wash hands or use waterless hand rinse Cup the respirator in hand with nose piece at fingertips Position respirator under chin with nose piece up Pull top strap over head resting strap at crown of head Pull bottom strap to position that ensures proper fit Pinch nose piece using two fingers from each hand Perform seal check and adjust straps accordingly Cup hands over respirator and exhale Adjust nose piece and straps to ensure complete seal Proper removal of mask: Grasp lower strap and then upper strap at sides Carefully pull straps back and over head ensuring respirator remains positioned on face Using straps carefully allow respirator to move very slowly away from face Discard respirator into biohazard waste COMMENTS Slide 43 Educational Module by Hospital Area GroupBSP Review Environmental Cleaning Central Processing Department Protocol Patient Transport Policy Revised Oxygen Therapy Guidelines Code Blue Special RCP*RCPE * T4 Stryker* 1 Critical Care Areas Diagnostic Imaging Emergency Department Peri-operative services Respiratory Therapy Special Procedure Units Ward areas with negative pressure rooms 2 Central Housekeeping Clinical support staff and labs Community practice clinics Morgue attendants Security 3 Out-patient clinics Ward areas without negative pressure rooms All administrative staff Slide 44 Physicians Specific Module Self learning educational packages with a CD containing video demonstration of appropriate use of PPE. A return demonstration, one hour workshop for certification purposes. A questionnaire to review at the workshop. This module was applied to all staff and in house physicians in addition to midwifes, family physicians and fellows. Slide 45 Survey of staff As of Aug 31/2005, a number of 4364 staff has been certified 400 Physicians, Fellows and Midwifes Ongoing sessions still scheduled once a month for each level of certification A survey of staff demonstrated the following results Slide 46 Evaluations 151 responses were received. 4 did not indicate any type of education, therefore were removed of the study. Questions were related to their level of confidence in their Infection Control related Practices, their level of knowledge about the guidelines and their comfort level in educating family members on infection control issues. The strength of the association was measured by using the RxC statistical analysis table. A statistical significance was noticed between the two study groups with a p value of (p