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Disaster Planning Drills and Readiness Assessment (continued)
Cindy DiBiasi: You mentioned HEICS. What is that?
Mary Massey: HEICS is Hospital Emergency Incident Command System that was
developed in California and is based on fire scopes, the incident command system
used by the fire department. It is a system that helps hospitals deal with
emergencies. The prioritized job action sheets that go along with the (unclear)
uses a common nomenclature that helps us work and communicate with other agencies.
For example, you have an incident commander and under him are four chiefs,
logistics, operations, planning and finance. My logistics chief can call up
the fire department logistics chief and we know they will be on the same page.
It is a flexible plan that can be adjusted to whatever the event is. Suppose
you have a five-car collision that overwhelms your emergency department. That
requires a much smaller activation than if you have like a 9/11 scenario that
may go on for weeks or months.
Cindy DiBiasi: What other pointers would you give others who are planning
and conducting drills?
Mary Massey: We really do need to learn to work together. Weakness in one
is a weakness for all of us. The stronger we are, the better the community
response we will have. It is OK to make mistakes. Trust me, we have made more
than our share of them. That is where your learning goes on. We can go ahead
and make a perfect drill with maybe five or six people that know all of the
rules, but that isn't going to teach us anything. We need to throw the
people into the loop who aren't on the planning commission. The ones
that are on the front line, maybe they are working weekends or nights when
these scenarios can possibly happen. So don't just tabletop with the
key players. Get some real people out there working on real victims. An alternate
to the smart patients Gary was talking about earlier is we get into the community
and get them involved as victim volunteers. When you are done, make sure you
bring everybody together. Do a hot wash critique meeting or debriefing. Get
the information from them. Find out what you need to change for next time.
Cindy DiBiasi: Are there any standardized forms or processes that you would
recommend using in planning and evaluating drills?
Mary Massey: I would start with the HEICS form. You can get those online for
free. We are always looking for something that won't cost us any more.
It is nice to have a form that the whole community is using. JCAHO approved
these and they have been used over and over in real and drill scenarios. The
other positive point to having a standardized form is that it helps reduce
training times when you have employees that work at different hospitals. I
recommend using a universal critique form. Once you have identified what your
objectives are, if you write down your universal critique, you will all be
measuring the same thing.
Cindy DiBiasi: You know, Mary, with so many hospitals walking that fine economic
line to just meet the demands of day-to-day patient care needs, how are you
supposed to find the time or money to pay for a community-wide drill?
Mary Massey: I wish I had the magic answer to that one. We are all in the
same boat. Remember, I am from California; we are like a lot of the country,
we are in the middle of a little budget crisis. The entire HEICS system is
available online for free at the California Website. We have also learned to
be very creative and to share. When one group comes up with a new policy, we
share it. Problems and needs are shared at group meetings and often we find
a solution. Our disaster vests were sewn by our Guild members and the command
post cart is made from an old med cart. I am not saying there aren't
many things I would do with a bigger budget. I am just saying there are a lot
of things you can do with a little creativity and some elbow grease.
We also know there is HRSA funding. Hung up at the State level right now in
California, but I understand it will be coming through soon. And MMRS has been
great help for our first responders.
Cindy DiBiasi: Any final words of wisdom?
Mary Massey: I think you need to make sure you identify what you want to do,
what your objectives are. Make sure you have a way of measuring them and then
practice as much as you can. The more you practice, the more prepared you will
be when a real event comes.
Cindy DiBiasi: Like so many things in life. Thank you, Mary.
In a moment, we will open up the discussion for questions from our listening
audience. But first let me tell you how to communicate with us. There are two
ways you can send in your questions. The first is by telephone. If you are
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As you are formulating your questions or queuing up on the phone lines, I
would like to say a few words about our sponsors today. The mission of AHRQ
is to support and conduct health services research designed to improve the
outcomes and quality of healthcare, reduces cost, address patient safety and
medical errors and broaden access to effective services.
A few of AHRQ's operating components helped to produce this series
of audio conferences. First, AHRQ's User Liaison Program serves as a
bridge between researchers and State and local policymakers. ULP not only brings
research-based information to policymakers so you are better informed, we also
take your questions back to AHRQ researchers so they are aware of the priorities
at the State and local levels. Hundreds of State and local officials participate
in ULP workshops every year.
Secondly, AHRQ's Center for Primary Care Research provides expertise
and leadership on primary care practice and research both within AHRQ and throughout
the Department of Health and Human Services. The Center supports extramural
and intramural research that informs a wide range of issues related to primary
care practice and policy.
I would like to take a quick moment to thank Dr. Sally Phillips, director
of AHRQ's Bioterrorism Preparedness Research Program in the Center for
Primary Care Research. She has been instrumental in helping to produce this
ULP and the Center for Primary Care Research hope that today's Web-assisted
audio conference and the three remaining events in this series will provide
a forum for a productive discussion between our audience of policymakers and
We would certainly appreciate any feedback you have on this Web-assisted audio
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we ask that you stay on the line. The operator will ask you to respond to the
same evaluation questions using your telephone keypad. Your comments on this
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that better suit your needs.
Alternatively, please E-mail your comments to the AHRQ User Liaison Program
Now let's go to the questions from our audience. Let's go back
to a question that we actually touched upon. What is unique about bioterrorism
preparedness or bioterrorism drills separate from, if there is any such thing
as a run-of-the-mill disaster drill, a more common disaster drill?
Dr. Howard Levitan: I will say one thing. What makes bioterrorism unique is
let's look at other disasters. When you look at manmade disasters, bombings,
earthquakes, I mean natural disasters, a small percentage of patients are actually
admitted to the hospital so the vast majority of the victims come to the emergency
department, are treated and released. Typically about 15% of the patients are
actually admitted to the hospital.
What makes bioterrorism unique is now we are talking about patients that are
sick. So now we are basically impacting the entire healthcare system above
the emergency department. That is the real challenge there. I actually (unclear)
for the drill.
Mary Massey: I think the other problem that we look at with bioterrorism is
the fear factor. Anthrax never made it to the west coast, but I can guarantee
that almost every household was affected in how they handled their everyday
life. So we felt the effects of it in our entire country. So I think fear has
to be dealt with.
Cindy DiBiasi: And how do you manage that because that is such a nebulous
thing to try to get your arms around?
Mary Massey: We found that the more we can communicate with the same information,
we looked to our local EMS and public health department and CDC to make sure
that we are not only giving the same information but it is worded the same.
Because we found information worded differently is perceived differently so
we try to have a uniform front.
Cindy DiBiasi: We are going to go to the phones now where Sonya Shepherd from
Georgia is standing by. Hello Sonya. Hello, are you there?
Sonya Shepherd: Hello. Can you hear me?
Cindy DiBiasi: Yes. Do you have a question?
Sonya Shepherd: Yes. I am the emergency preparedness and bioterrorism exercise
coordinator here in Georgia and I heard you speak to drills and tabletops.
Coming from an emergency management community where there is standardized terminology
for exercises, I was wondering have you had any experience or what is your
experience in orientation, functional and full-scale exercises?
Cindy DiBiasi: Gary, I believe that is addressed to you.
Dr. Gary Green: My understanding of your question is that you are asking about
the difference in experience between a fully operationalized drill versus a
Sonya Shepherd: Well, actually I understand the drills, but I didn't
hear much about functional exercises and full-scale exercises and orientation
exercises which are all also types of exercises. I am hearing a lot on drills
and tabletops and I was wondering what are your experiences in the other types
of exercises that can be used?
Dr. Gary Green: I think what we found in our review of the literature as well
as just in experience in various parts of the U.S. as well as in various other
countries is that there is a lot of confusion about the nomenclature of different
training techniques. So when we are referring, when I refer to tabletop drills
I am including all the various kinds of drills or exercises short of physically
operationalizing the movement of mock patients and actually taking care, trying
to simulate taking care of the patients in a physical way. I know in different
regions of the country they use different terms to describe different other
types of exercises. A tabletop drill could be anything from a bunch of disaster
planners sitting in one room to a very large regional simulation with different
people and different institutions coordinating with each other in various locations
as well as some varying degrees of physical movement.
The tabletop drill is also sometimes referring to literally a scale model
sitting on a tabletop where people actually move around models of equipment,
almost like a little game. So I am not sure of the various terminologies that
you are using and what those specific terms are referring to because I think
different regions use different terms to describe different exercises.
Cindy DiBiasi: Mary?
Mary Massey: I found tabletops very helpful in helping us develop policies,
like how to deal with a smallpox patient, how to handle mass-casualty decon.
It is when we go into the exercises or the full-functional exercises where
we can test those policies and find out, oops, that didn't work. Or yes,
this works very well and maybe we will expand it farther. You can have these
beautiful policies developed, but until you actually walk it through and put
someone through and see how much water goes into that drain? Does it overflow?
Is that radiation badge actually in radiology that you thought you could pick
up when you go? Make it as realistic as possible; you will find yourself a
lot more prepared.
Sonya Shepherd: Thank you.
Cindy DiBiasi: Thank you. Now we are going to Sherri Isert from Colorado.
Sherri Isert: Sherri Isert at Denver Health. I have a question I think for
any four of you all, although Mary I know that, I think Mary Massey has dealt
with the exercises. In Gary Green's presentation he had mentioned that
there are no measures that have been established to determine how prepared
a community or a region is. I was wondering Mary, or if anyone else who has
been involved in exercises, whether any measures have attempted to be developed
or if there has been an aggregate score developed on how prepared a certain
group was through a drill?
Mary Massey: We don't have a regionalized critique. What we have used
is within our net; within our county we use the same one. You can develop it
unique to what your drill is, what you are trying to prepare yourself for.
I think you really do need to do that before you sit down to do a drill. Because
going through the motions is just going through the motions. You need to know
what you are trying to achieve first. I am not sure, did that answer the question?
Cindy DiBiasi: Gary is going to add to it and then we will see.
Dr. Gary Green: In terms of evaluation, one of the other things that our group
at Hopkins as part of our AHRQ sponsor work is doing is working on developing
a collective set of data collection instruments for assessment of possible
base disaster drills. That work is not completed yet, but in a few months after
the work is completed and been piloted, these evaluation methods and they are
released, hospital disaster planners can all access those and sort of add them
to a tool box.
I have also had experience working with an NGO called Emergency International
and we have developed a series of evaluation methods and tools to evaluate
disaster drills, both for pre-hospital disaster drills as well as in-hospital
disaster drills. There is a publication coming out next month in Annals of
Emergency Medicine that is describing evaluation methods and piloting those
messages actually in a disaster drill in Guatemala.
Cindy DiBiasi: Does that answer your question?
Sherri Isert: Just one follow up. And so do your measures vary by type of
disaster drill or do you have real broad measures that are used?
Dr. Gary Green: The measures that we are designing in those cases, we are
attempting to design them to be as flexible as possible. So there is a little
bit of a modular approach to them in that there are different components that
can be pulled out to be used, depending on the specific goals of the specific
drill. So if there is a regional drill and people wanted to assess both pre-hospital
and in-hospital they would pull those components out. If what the drill planners
were only interested in was incident command system, there is components for
that. If you are interested in actually monitoring performance of individual
providers and the medical care given, there are modules to pull out that can
be applied for that. Each set of instruments has basically instructions or
methods to use them as well as a plan to analyze and report that data so that
you have got it.
Sherri Isert: Well great. I look forward to seeing your report.
Cindy DiBiasi: Next we are going to Peter Brown from the New York State Office
of Mental Health. Hello Peter.
Peter Brown: Hi there. Thank you very much.
Cindy DiBiasi: Thank you for calling.
Peter Brown: My pleasure. Actually I am hoping you may help me. Very briefly
you began to discuss the fear factor and I am curious to know whether you have
any specifics with regard to how you would anticipate our systems would deal
with the psychological impact of a terrorist event? I think our experience
has shown us that the psychological impact of a major terrorist action like
the one that occurred in the attack on the World Trade Center gives us several
orders of magnitude greater psychological difficulty and behavioral issues
than we have with any of the sorts of disasters with which we are usually having
Cindy DiBiasi: I am assuming coming from the New York State Office of Mental
Health you have first-hand experience with that.
Peter Brown: Oh yes. As a matter of fact I have some. There are really two
stages of response. There is the immediate response upon the actual occurrence
of an event like this. Then a few weeks later there is the more measured and
equally important intervention to avoid post-traumatic stress and other continuing
The second stage we have had some very explicit experience and we also have
some experience to draw upon in other areas. But the first stage that is the
immediate response, is one I have been unable to find much in the way of examples.
So I am anxious to know what, if any, part of the planning processes that you
folks have participated in might be addressing this aspect of the event. Clearly
should something major happen, I think as you pointed out, we can anticipate
some pretty sizeable public reactions that aren't the actual physical
Cindy DiBiasi: Howard, would you like to take that?
Dr. Howard Levitan: It is a complicated question because you are actually
talking about multiple different scenarios. I think the response to a chemical
event, we learned a lot of data from Tokyo and how people responded both initially
and later in long term, three or four years out in terms of psychological impact.
You talk about the event that happened at the World Trade Center in New York
as a whole other event. If we look at bioterrorism, it is even another event
and how to handle that. I think it would be very interesting actually. We learned
some very interesting things from the anthrax event in terms of panic. The
problem when comprehensive, competent information was not being provided to
people, people took actions that we may consider to be panic. I think we are
going to learn a tremendous amount with the SARS event in terms of how people
are responding. Looking at Hong Kong and looking at China where people, and
that sort of shows people aren't really panicking but they are following
good advice by wearing masks.
So actually by protecting, by giving resources to people, I am concerned about
the issues of panic or how people respond in the hospital. If an infectious
agent comes into a hospital, how will our healthcare providers respond? We
learned from the SARS event that many of the people actually becoming ill were
healthcare providers. So how do we circumvent that? Do we have plans in place
to make sure that we are following universal precautions? Do we have plans
in place that hospitals have sufficient supplies of N-95 masks to give to their
staff? Do we have plans in place to educate our staff about that?
There was an interesting article in the New York Times yesterday looking at,
talking to a physician in Hong Kong about where he had been unable to have
any physical contact with his family. He goes home but he sits in a completely
different room for dinner. He wears a mask because he has fear of spreading
this illness to his family. So I think if we look at bio, we are going to learn
a lot from the recent SARS.
Panic and response by individuals I think is going to vary event by event.
Cindy DiBiasi: The thing you are talking about really is empowering people
by giving them some control, by giving them some tools to manage it themselves.
Dr. Howard Levitan: Absolutely. I don't believe there is any panic at
all. People look at the anthrax event and people panicked every time they saw
white powder, but I think they did the appropriate thing. They were told that
white powder was anthrax. So they called the health department. They found
out the people were sick when they saw white powder at the mail postal service
and they needed to be treated. They went to their doctors. I don't consider
that panic. But if we want to have better control over the way people respond,
we have to realize that people in our community, these are intelligent people,
if we provide them with good information and good resources they will do appropriate
things. We just have to have some impact on giving them the appropriate information.
Cindy DiBiasi: OK. On the phone also we have Kasem Irimdari. I hope I have
that pronounced right, from the Houston Department of Health and Human Services.
Kasem Irimdari: How are you?
Cindy DiBiasi: Fine. How are you?
Kasem Irimdari: All right. I have two quick questions. I keep hearing you
guys using the word "next slide" and sort of stuff. How do we have
access to those materials? Because we are on just the phone and if we have
any kind of pamphlets or slides that would be useful for us.
Cindy DiBiasi: Yes. You will be able to get more information I believe after
the Webcast that they will be clueing you in on information after we sign off
that will help the people who are just getting this by phone, access the slides.
Kasem Irimdari: The second question I have, I didn't get the correct
name of that form or download system, H-I-C-S?
Cindy DiBiasi: Oh, HEICS. Mary?
Mary Massey: Hospital Emergency Incident Command System.
Kasem Irimdari: Thank you very much.
Mary Massey: The Website will be in the information that you will be able
Kasem Irimdari: Thank you.
Cindy DiBiasi: OK. Thank you. We have actually been asked to clear up a couple
of acronyms that were in the presenters' presentations. I am going to
start with Sue. HRSA, if you could tell us what that stands for.
Sue Skidmore: HRSA is one of the Department of Health and Human Services Agencies
and it stands for the Health Resources and Services Administration. They are
the agency responsible for administering the hospital bioterrorism preparedness
Cindy DiBiasi: Mary, you mentioned MMRS.
Mary Massey: Metropolitan Medical Response System, it is high-target cities
within the United States that the government has been trying to educate and
train how to handle bioterrorism events.
Cindy DiBiasi: OK. Thank you both. A question from Christian Phillips. Are
there Federal funds available to assist hospitals in communities with the cost
of drills? Mary, were you able to tap into anything?
Mary Massey: There are HRSA funds that are probably at your State level right
now but should be coming through. Those were for last year. There is an additional
block of HRSA funds that are going to be sent to the hospitals. I am not sure
how those will be distributed yet.
Sue Skidmore: This is Sue Skidmore. The mechanism is that the State applied
for the HRSA grants and through the State public health department and the
hospitals in each State, depending on their needs analysis, will receive a
percentage of those funds. So they do trickle down through the State health
departments, the HRSA funds do. So each hospital, depending on their needs,
should receive some of that funding. It can be used for disaster drills from
what I understand.
Cindy DiBiasi: And are there any additional resources for rural communities?
Sue Skidmore: The HEICS Hospital Emergency Incident Command System is available
for free. That is one additional.
Cindy DiBiasi: OK. A question from Donald Gordon. Howard, what are the twelve
areas that you are piloting in June with your evaluation questionnaire?
Dr. Howard Levitan: Well, we are looking at a number of things. We are looking
at regional linkages; bioterrorism planning and structure; training and exercise;
triage diagnosis and treatment; infection control; decontamination as it applies
to a bio event in isolation; public health surveillance; surge capacity and
space utilization; laboratories; pharmacies; mass immunization; safety and
psychiatric support along with information systems.
Cindy DiBiasi: Howard, how are your questionnaires an objective measure of
preparedness contribute to improve hospital readiness? Maybe Sue I should ask
you that question.
Sue Skidmore: Well, we are attempting to standardize the definitions of preparedness
and capacity, which make planning more focused and objective. We are offering
peer-reviewed readiness milestones that will help guide hospitals and hospital
systems towards a reasonable level of preparedness. We are thinking of it in
terms of a preparedness continuum. These objective measures we are calling
Readiness Milestones will not only measure our benchmark hospital readiness,
but will also measure hospital and hospital systems progress over time in achieving
Information from the questionnaire can be used in computer simulation models
that may be out there to learn how critical preparedness factors relate to
each other and which factors become more important in determining a successful
response and can be used for analyzing system capacity and flow.
Finally, basing hospital readiness on the national and regional norm will
provide a standard method for gauging process, which is critical for continued
funding as well as improved research and evaluation in this arena.
Cindy DiBiasi: I should mention, for more information about the first phase
of the AHRQ-sponsored project and a copy of the original questionnaire which
is entitled Bioterrorism: Emergency Planning and Preparedness Questionnaire
for Healthcare Facilities, you can visit www.AHRQ.gov/prep/.
A question now from Marjory Powery. Isn't it likely that a bioterrorism
event or natural disaster such as SARS will continue over a long period of
time, weeks or months, and how do you build this factor into your disaster
Dr. Howard Levitan: That is exactly what a bioterrorism event would be like,
or SARS or pandemic influenza. As I said earlier, that is the real difference.
We are now challenging all the resources within the hospitals. We have to look
at staffing, increasing inpatient capacity, increasing outpatient capacity,
healthcare protections; there is a number of issues that are to be looked at.
But they are all very unique to bioterrorism and that is what we are addressing
in our questionnaire on developing preparedness criteria, to try to help them
in this process.
Cindy DiBiasi: Mary, a question from Jan Petrolli from the Vermont Veteran's
Home in Burlington. Is it better to start small with the tabletop and then
build to a community drill so that you create your drill in increments and
also do you build in a critical incident stress debriefing piece at the end
of the drill for the staff, much like it would be used in real incidents so
the staff is then oriented to this piece?
Mary Massey: Yes to all of those. If you start small and just keep building
up. At first I said when we discussed having a tabletop helps you develop your
policies; you have to have policies to work from. Then put those into play
and you might even start just drilling on an individual department and then
you can include more departments, then do your hospital-wide, then you can
get your community involved. You can just build from there.
Cindy DiBiasi: Well, we have a question from Malta. Dennis Velatino. He says, "I
come from a small island, Malta, with a low incidence of major incidents. Obviously,
this does not imply that there are no risks. Obviously this remoteness leads
to some degree an inertia from higher authorities to organize matters in a
professional way. Any hints on how to convince politicians and senior administrators
to change their attitudes before an incident really occurs with the consequent
crisis management and the high mortality?"
Dr. Gary Green: I can handle that one. Working with Emergency International,
we work quite a bit in developing countries and Central America and Asia and
other areas. We found that it is very key to work directly with the policymakers
and the Ministry of Health, but you also have to educate the public. You have
to recruit the public and the physicians and nurses and pre-hospital care workers
to partner with you to convince the policymakers that this is a high priority
area. It really is a team effort that takes a lot of coordination.
Cindy DiBiasi: Mary, did you find it difficult to convince the higher-ups
to buy into this?
Mary Massey: You do have to have buy-in from the top on down. If you don't,
you are fighting a losing battle. So you need to have compelling evidence to
show them what is going on and convince them first. If you educate people at
the lower levels first, if they have questions, the people above them won't
be able to answer them so I do believe in educating from the top on down.
Cindy DiBiasi: OK. A question for you, Mary. To what extent do you include
Federal agencies in your disaster planning and exercise drills? In particular
do you include the National Guard and/or the Department of Defense?
Mary Massey: It depends on the drill, but the last several years we have been
involving them in many of our drills. We did a seren gas attack at Edison Field
that we involved National Guard. We had Los Alamitos Air Base there. FBI, we
found working with the FBI was a big help when September 11th hit because then
we knew our local people. We knew who the Orange County rep was, who the CIA
agent for LA County was. We could just call them on the phone. They knew who
we were ahead of time. So if you build these relationships, it really does
Cindy DiBiasi: Can anyone tell me where I can find examples of standardized
exercise critique forms?
Mary Massey: If you go online to the HEICS Web site, they have whole drilling
segments to the Website that will help you do critiques, lesson plans, scenarios
that you can use.
Cindy DiBiasi: Do you want to repeat the URL for that? She is looking. We
will come right back to you on that one.
In the meantime, Sue, you can answer a question. From Andrea Kernack from
the Institute of Medicine here in Washington. What venues or processes have
States and local areas used to share information on lessons learned and best
practices related to bioterrorism readiness assessment?
Sue Skidmore: Most recently the States have been participating in the LISTSERV®
that is mediated by HRSA. It is the Bioterrorism Hospital Preparedness Program
LISTSERV®. That is a big method in which they exchange information and talk
In addition, there is a local sort of a grassroots network. The bioterrorism
community was small. It is starting to expand more now since the fall of 2001,
but there are a lot of people who know each other within the community. We
just network around so if I get a question that I don't know I trip it
to Howard and he might trip it to someone else. So there is both an informal
network and a formal network provided by the HRSA listers.
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