In addition to the latest Marathon bombings in Boston, Massachusetts and the Industrial explosion in West, Texas, America has experienced many other terrorist attacks, major hurricanes, tornados and floods over the past decade. Many healthcare organizations have suffered catastrophic consequences in association with these events. One would think with the variety and scale of disasters America has faced, we would be getting very good at Emergency Management. The reality points to the fact that instead of learning lessons from past disasters, we are stuck in the past practice of writing plans for accreditation purposes instead of taking an “Operational Readiness Approach” to Healthcare Emergency Management. A suggested paradigm shift described in this paper will build support systems strong enough and deep enough to sustain healthcare functions during and after major disasters. There is a silver lining to the future of Healthcare Disaster Readiness if we grasp it.
There is a real opportunity for Healthcare organizational leaders to encourage a new generation of Healthcare Disaster Readiness professionals to become pioneers in building a “Whole Community” organic response and recovery system to bolster Healthcare Disaster Readiness for future disasters. The new framework will concentrate on building strong, resilient systems, capable of standing up to long-term, large-scale disasters. Those leaders who encourage and champion the new breed of Disaster Readiness leader will reap much more than Medical Readiness. As Healthcare systems, and even stand alone hospitals increase their Disaster Readiness profile, they will discover ways to save money, save time, improve procedures and systems, enhance the quality and safety of healthcare and increase community trust and commitment to its healthcare organization.
These ten steps will go a very long way to ensuring healthcare organizations have the systems depth and resiliency in place to successfully manage a major disaster and more quickly return to normal operations.
1. Emergency Operations Plan. Over the years, all manner of Emergency Management Plans /Disaster Preparedness Plans and now the Emergency Operations Plans (EOP) have been meticulously developed and distributed in health care organizations. A major problem with the plans is that many have been so complex and laborious that often healthcare workers didn’t read them. The key to a readable EOP is to open with the CEO statement of the importance of Emergency Management in maintaining hospital operations during and after any future disaster. There should be an overview of how the healthcare response will work, using the Hospital Incident Command System (HICS) and how the Hospital Command Center (HCC) will be ramped up in a graduated way as well as the positions represented in the HCC. Finally the CEO should direct operational leaders to the annexes pertaining to their departments, teams and responsibilities. Each director, unit manager and supervisor is responsible for training their respective teams on specific duties and how the team interfaces/supports ongoing disaster functionality of the healthcare organization during disasters. Each annex leader should brief their individual annex at Directors’ meetings and explain how their annex builds resiliency and how it supports the overall EOP.
2. Facility services. A good facility support annex bolsters the facility against the 3-5 disaster planning scenarios outlined in the jurisdiction’s Hazard Vulnerability Assessment (HVA). Simply put, the jurisdiction Emergency Management Agency needs to advise the healthcare organization on the disasters most likely to occur in that region. The healthcare organization then develops an in-house HVA and develops mitigation efforts to address the top 3-5 jurisdictional planning scenarios. The in-house HVA can add other facility-specific disaster planning scenarios such as active shooter, bomb threat or other relevant scenarios.
The following discussion outlines the goods, services and systems needed to maintain and bolster healthcare facility disaster operations. The facility engineer should work closely with the Materials Manager (Supply Chain Manager) to establish solid contracts with emergency support clauses with providers of facility supplies, equipment and services (for example, Grainger, Home Depot. Lowes, Environmental Services companies, fuel, food and medicinal gas providers), All vendors should be required to provide the Materials Manager with their rapid resupply plans for redeploying stock and staff from unaffected regional centers into local outlets during and after disasters. There should also be concrete plans for the corporate organization’s assets in unaffected areas to redeploy to the corporation’s affected healthcare organization (s) in the disaster area. The facility engineer should work closely with the Chief Financial Officer to ensure hospital insurance policies are appropriate for the potential losses associated with the top 3-5 planning scenarios and that cash reserves are adequate to support disaster activities. If there is no formal Medical & Non-Medical Equipment Management Office, the CFO should be able to provide a list of in-use equipment from financial amortization files. The organization needs a current in-use equipment inventory and pictures to make post disaster claims to insurers and to FEMA for Public Assistance (PA) grants much easier, more accurate and less stressful.
3. Staffing. The Human Resources (HR) Officer should develop a list of employees in the Corporation designated as “Mission Essential” and those who agree to deploy during disasters to assist affected healthcare organizations within the corporation. Part of the change in mindset for the organization must include enhanced staffing. The HR officer should think outside the four walls and look to the community for reinforcements in the form of either volunteers or “Extra Hires.” In addition, each State (or Territory) has an “Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) Program” which allows for advanced registration and credentialing of Health Professionals. HR will also need to develop procedures to badge volunteers and extra hires, add language to HR regulations on their pay and insurance coverage, privileging, team assignments and ensure these folks receive training with their assigned team. For Private, Non-Profit (PNP) healthcare organizations, the Emergency Manager should request an Emergency Management Agency (EMA) or FEMA representative brief C-Suite and HR on how to establish “Extra Hire” procedures in order to understand which costs associated with disaster related activities may be reimbursed via FEMA’s Public Assistance (PA) post disaster grants. FEMA administrative policies can change. Thus, periodic reviews and regularly scheduled EMA/FEMA representative briefings are wise.
In any long-term disaster, the staff must be certain that their family members are safe, cared for and close by, or they may not report for duty as planned. It is wise to establish brainstorming sessions with all “Mission Essential” employees and augmentees to explore the types of services for family members that will enable staff to remain in service to the healthcare organization during and after disasters. Healthcare Systems can contract with community child care centers to relocate near hospitals to care for the family members of hospital staff. To keep the staff nearby, healthcare procurement officials can negotiate room rates and emergency availability processes with local hotels. Insurance providers and EMA/FEMA representatives can offer guidance on eligibility for reimbursing the costs associated with sheltering and caring for families of mission essential medical staff during emergencies for PNP Healthcare organizations. “For Profit” healthcare organizations will need to address disaster related costs and potential damage / replacement costs and activities with their insurance providers. The differentiation between Private-Non-Profit and For Profit healthcare organizations is prescribed by law in The Stafford Act.
4. Medical Materials. The current “Just-In-Time” model of managing pharmaceuticals, medical supplies and equipment is inadequate to provide the required quantities of medical materials during large-scale or long-duration disasters. We have recommended a solution to the Federal Drug Administration (FDA) that would mitigate current persistent shortages of pharmaceuticals and other medical items as well as suggesting the FDA establish Federal Reserve Inventories (FRI) for use in disasters. Currently the Strategic National Stockpile (SNS) contains some medical items for use during disasters, but these inventories were never designed to sustain Healthcare organizations during disasters. Short of building reserve inventories at the federal level, Materials Managers need to develop very robust and very deep supplier contracts (Prime Vendor and ancillary suppliers). These plans should include contract stipulations that suppliers provide plans to redeploy supplies and equipment from the unaffected regions of America into distribution centers supporting hospitals in the affected community (or communities). Besides pharmaceuticals and treatment supplies these contracts should also address medicinal gases, food, durable medical equipment (DME), ventilators and associated supplies and special needs items. Materials Managers must own the materials sustainment mission and must ensure the continuous flow of goods and services throughout the response and recovery phases of a disaster or public health emergency.
5. Management of Medical Surges of casualties and fatalities. The jurisdiction’s HVA may point to disaster planning scenarios capable of generating thousands of casualties and even more fatalities. Your Emergency Management Agency should provide both planning scenarios and the estimated numbers of casualties and fatalities for each planning scenario. Most healthcare planners understand that hospitals may be overwhelmed and patient gridlock may result in many patients dying of treatable injuries or exposures. An innovative, combat proven system that hospitals and Emergency Medical Services (EMS) organizations should be adopted to optimize patients’ “Golden Hour” and thus, save many more lives than current mass casualty management systems. The 4-Echelon Mass Casualty Management System optimizes the saving of lives through stabilization of injuries or exposures in health care facilities close to the disaster, followed by rapid transportation to hospitals and specialty centers with the appropriate capabilities in outlying, less affected jurisdictions.
Please see http://www.jvrhr.com/Adapting-a-Battlefield-Medicine-System.php for a discussion on how the 4-Echelon Mass Casualty Management System works in managing casualties and fatalities. This system also mitigates staff burnout and resource depletion in the disaster location and enables a more timely healthcare recovery. The 4-Echelon concept requires a robust Electronic Medical Record (EMR) and patient tracking system as well as redundant medical communications systems for all participating hospitals and specialty centers.
6. Non-Governmental Organizations (NGOs). Thinking outside the healthcare campus into the community is an excellent staff-multiplier approach to adding depth and resilience to the healthcare organization. This requires serious coordination and staff work, but is well worth the time and effort. Future disasters or public health emergencies will truly require a “Whole Community” approach to supporting the healthcare organizations. Emergency Managers should coordinate with the American Red Cross for sheltering, food as well as blood & tissue products. Religious congregations are excellent resources for social services, caring for the homebound and dying, last rites etc. Community Service Groups (LIONS Clubs, Rotary Clubs; Moose Lodges etc.) can be a great resource as security augmentees, for extra security, staffing day care centers for hospital staff’s, family and they may also be able to provide guest housing for medical staff deploying to support your hospital. The American Red Cross should be a part of all community-wide disaster drills. A blood drive during each jurisdiction-wide exercise will help the community to get accustomed to donating blood during disasters and knowing where donation centers are located. The American Red Cross can also use planned blood drives to help level America’s blood supply. The Red Cross can also be instrumental in planning scenarios involving large numbers of burn patients, in order to coordinate the supply of blood products and skin grafting tissue.
7. Communications. Healthcare organizations have done a good job in developing redundant communications, much of which was supported by grants from HHS’ Hospital Preparedness Program (HPP). Still, Emergency Management Agencies need to provide mobile communications systems, including portable cell towers and satellite systems to communities as an extra layer of support to Healthcare Organizations and EMS providers for adding communications infrastructure during disasters. Social Media has benefits, but “bad guys” can use Social Media to set traps for responders and to confound response and recovery operations through misinformation. Reliable, redundant and secure jurisdiction-wide communications systems are a must.
8. Contract Services. Healthcare organizations should establish contingency contracts for supplemental security and Environmental Services support along with pharmaceutical and medical surgical suppliers along with suppliers of medicinal gasses and water for drinking, washing/bathing, toilets and chillers. This will help keep the facility operational and aseptic during the response phase of a disaster and until normalcy returns. Update contracts with emergency clauses for generator fuel deliveries, per diem staffing agencies, food and nutritional products, DME and medical equipment rental companies, etc. Consider contingency contracts with commercial generator vendors to further back-up the facility’s auxiliary power supply. If the healthcare organization does not treat its regulated medical waste (RMW) on site, service for the transportation of RMW may not be available until the recovery phase of the disaster due to traffic disruptions. In these cases, Emergency Managers and Facility Engineers will need to establish a RMW storage area approved by the appropriate jurisdictional regulatory agencies.
9. Jurisdiction Services. This is where the new mindset change is most difficult. Jurisdiction leaders usually think about healthcare representation in the jurisdiction’s Emergency Operations Center (EOC). However, when the Emergency Management Agency is asked if they can provide the mobile communications systems (like mobile cell towers or satellite linkups) or the rapid response /mobile high output generator systems that a health care organization may need for disaster response, the answer may surprise you. Likewise, inquiring about funeral services and a grave registry for mass fatalities, emergency medical waste treatment systems, mobile water purification and sanitation services for Public Health etc., the responses may be very mixed and in some cases, incredulous. Similarly, when the jurisdiction’s Public Health Officer is asked what public health services will be available to the Public, the poor and special needs persons or persons requiring lifesaving chronic medications such as insulin during and after emergencies or disasters, the responses may be mixed as well. This is why a “Whole Community” approach to emergency management is necessary and will entail the Whole Community coming together to form an “Organic Emergency Response and Recovery System.” There is much work and tireless coordination required to bring this notional concept to full fruition. While individual communities’ needs vary, we recommend a “Whole Community Disaster Resiliency Prototype” be supported by the Federal Government to help all jurisdictions benefit from a fully developed “Whole Community” emergency response model.
10. Exercises. For many years, exercises have been confined to patient decontamination (as needed), patient triage and receiving and the “Immediate,” “Delayed,” “Minimal” and “Expectant” treatment stations or areas. During accreditation surveys, we rolled out the Emergency Operations Plan, exercise documentation, an “after action report” and a “lessons learned” paper along with documentation that a retest of the problem areas had resolved noted problems.
Future exercises must include a brutally honest evaluation of the steps outlined above to offer a true “Operational Readiness Assessment” of a healthcare organization’s Emergency Operations Plan. By so doing, healthcare organizations will achieve accreditation but will also remain fully functional and sustainable during the types of “Large Scale/Long Term” disasters that America is facing in the 21st Century.
Healthcare leaders will notice that the 10-steps to Healthcare Disaster Readiness outlined above do not involve large outlays of funds. They do require hard work and an unshakable determination to remain in service to their communities during the worst of times.
It is definitely worth the effort.
