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Frequently Asked Questions
The following is a transcript of the questions and answers portion of a Webcast titled Planning and Practicing for a Disaster that took place on February 9, 2009.
Select to access a transcript of the Web Conference.
Part I: Hospital Surge Model, Mass Evacuation
Transportation Model, National Mass Patient and Evacuee Movement, Regulating,
and Tracking System
Question 1. The Mass
Evacuation Transportation Model uses an ED time of one day, yet
most resources are only required for 2-4 hours. Is 2-4 hours an
"accurate" triage time, or are you including a 20-hour wait/treatment
For example, in Florida,
unfortunately, as we are prone to hurricanes, we have developed a Web-based
evacuation tool and drill annually—using the Mass Evacuation
Transportation Model it appears it takes a very long time to evacuate a
150 hospital and there is much more to this process other than the patients.
Our Web-based program allows us to evacuate one of our hospitals in
approximately 2-4 hours whereas the AHRQ Model illustrates days?
Tom Rich (Tool Developer, Abt
Associates Inc.): We do not consider time increments of under one day. The
model's accuracy could be improved by doing an hour-by-hour modeling. We don't
do that right now, but that is certainly a way to improve things. Good
Question 2. Did
the Mass Evacuation Transportation Model work with the
local municipal EMS provider, the hospital contracted provider or both to
estimate the numbers of resources that would be needed and may/would be
Tom Rich: I can only speak regarding
our two pilot test sites in New York City and Los Angeles. Essentially, the New
York City Office of Emergency Management went through a process to figure out
what percent of their vehicle fleet would be available to assist in the
evacuation. The same process was done in Los Angeles. This was an issue for a
lot of agencies to get together and discuss. It was an interagency process to
come up with these assumptions.
Question 3. Has
the use of aircraft been addressed in the Mass
Evacuation Transportation Model? What about air evacuation?
Tom Rich: The model
includes an "overflow facility" where patients are transported in the event
that there isn't capacity available at the designated receiving facilities.
The overflow facility could be thought of as an airport for air evacuation, but
the model does not allow you to specify where those air-evacuated patients
would be transported.
Question 4. How
was load time determined in the Mass Evacuation Transportation Model?
Are the pre-loaded per patient load times based on previous experience or
observations in an exercise?
Tom Rich: You have the
ability to specify them. So, if you did an exercise and know how long it
takes, then you should, certainly, specify that. In the user guide, we did
indicate what times were assumed in our pilot tests in New York City and Los Angeles. If you have done an exercise, you could certainly use the values obtained
from the exercise.
Question 5. Can
you discuss the process by which the travel time estimate is arrived at in the Mass
Evacuation Transportation Model? In addition to distance, what
other features are taken into consideration?
Tom Rich: We struggled with
that because, on the one hand, we thought maybe we should just have users
specify the travel time they want to use. If you are running this tool in a
big city, evacuating 20 hospitals and sending them to 40 others, that is an
awful lot of travel times to specify. Instead, we developed a sub-model within
the Model for estimating travel time. It takes into account the latitude and
longitude of the facilities, so those inputs are required. To develop the
sub-model, we obtained point-to-point drive time information from 40 major
metropolitan areas in the country from a third-party vendor. The details of
this sub-model are described in the Model Description document. I do want to
add that there is an input for indicating that the travel time is twice as fast
or slow or twice as long, so there is the ability to scale that in the Model.
Question 6. What
about multiple hospital evacuations in a region? Can that be modeled on the Mass
Evacuation Transportation Model?
Tom Rich: Yes. You can
specify any number of evacuating hospitals and any number of receiving
Question 7. Can
you discuss the 'time to overflow facility' input in the Mass
Evacuation Transportation Model? I am unclear what its purpose
is, how best to use it, etc.?
Tom Rich: Basically,
through the inputs, you specify how much space is available in the receiving
hospitals. Part of that is surge capacity. If there is still not room for the
patients to be evacuated, they go to what is called the overflow facility. In
real life, that might correspond to an airport where they may be flown out of
town. So, you specify how long it takes to get there. Again, I would
encourage you to go to the user manual and the Model description for more
Question 8. The Hospital Surge Model has, as a premise, an understanding of how many patients will be coming. Is it
your sense that this information is readily available?
Tom Rich: The Model is
essentially asking you to decide how many patients you want to assume your
hospital will be treating. That is, obviously, a difficult thing to do. The
Model will not tell you how many to expect. I did mention the
password-protected AHRQ Surge Model. If the person asking that question
is from a State or Federal Agency, you can request access to the
password-protected Model, which will estimate how many casualties there will be
from attacks. That model is not publicly available, but States can request
passwords from AHRQ.
Question 9. Are
any of the panelists familiar with whether these or any model can be used in
developing an emergency plan for local health departments with regard to
special needs populations, such as the elderly? If so, how and where can such a
model(s) be accessed?
Tom Rich: You can
incorporate special considerations for the elderly or other special needs
populations into the model in a variety of ways - for example, by adjusting the
transport vehicle requirements for the patients (a very small percentage would
be transported via bus), by lengthening the loading and unloading times, and
perhaps by indicating that certain facilities would not be able to receive
Question 10. Are there any plans for
incorporating staff and resource volume into the Hospital Surge Model or
the Mass Evacuation
Transportation Model for a more realistic picture in a disaster
situation? Have you done a drill to test working when 30% of one staff type can
now work—such as during a pandemic?
Tom Rich: There are a whole
bunch of staff resources in the Hospital Surge Model; ten or twenty
different personnel resources. That is a great suggestion for the Mass
Evacuation Transportation Model. Right now, that is not in there. Certainly,
it is critical to have the appropriate persons on the ambulances and other
places when patients are evacuated. That would be a great way to enhance the
Question 11. Could you provide a brief
update about the status of the HAvBED project, which was mentioned in as part
of the National Mass Patient and Evacuee Movement, Regulating, and Tracking
Specifically, is it still moving ahead? How can we get HAvBED to be used in our
Christy Music (National
Mass Patient and Evacuee Movement, Regulating, and Tracking System Initiative Developer, Office
of the Assistant Secretary of Defense for Homeland Defense & Americas'
Security Affairs, Department of Defense): The Agency for Healthcare
Research and Quality, along with Federal, State, local, and private industry
representatives, designed the HAvBED system. The Department of Health and
Human Services (HHS) now holds/has the HAvBED information system. I understand
that HHS intends to use it (or may be using it) to collect available hospital
bed data, in aggregate form, during a national emergency from hospitals that
received HHS grant funds. The HAvBED system was also designed to serve as a
regulating tool and could reserve a hospital bed within specific categories
(e.g. burn, medical/surgical, pediatric, critical care, etc.) for a patient. It
can also be expanded to accommodate nursing homes, rehabilitation centers, and
other fixed facilities. You should contact HHS, the Office of the Assistant
Secretary for Preparedness and Response (ASPR) within HHS, if you would like
your community to use the HAvBED system.
Question 12. What is the time-frame for
actually having an operational National Mass Patient and Evacuee Movement,
Regulating, and Tracking System? When will the recommendations be
published? How can I receive a copy? Where can I obtain the standards for
tracking since we are close to implementing our own state patient tracking
system? Are there any plans to develop universal patient tracking system that
would be available to all agencies? Current commercial systems do not talk to
each other or most hospital based systems.
Christy Music: We are
looking at an estimated three-to-five year completion date for the National
System, depending upon the availability of Federal funds. The recommendations
are included in the Report that was released in February 2009. (Its title is Recommendations
for a National Mass patient and Evacuee Movement, Regulating, and Tracking
System. You will be able to find the Report on the AHRQ Web site at http://www.ahrq.gov/prep/natlsystem/).
The Federal Government is currently developing standards for information
systems' architecture and data; however, the final Report does includes
information related to data that could be collected: general population/patient
unique identifier, and if available, name, gender, date of birth, etc.
Apparently, these demographic data are being adopted by commercial firms that
develop tracking information systems. This initiative proposes the creation of
a "universal" system that could be used by local, State, tribal, and Federal
agencies, as well as by private industry (to include medical and non-medical
establishments), during a large-scale event, or optionally, for routine use.
Existing information systems would be interoperable, so that data could be
shared among authorized users. Operational functions, such as regulating and
movement (matching and reserving general population evacuee or patient's
requirements, such as transportation requirements (e.g. bus, ambulance,
aero-medical evacuation, medical crews, equipment) to a receiving location
(e.g. shelter cot, hospital bed, nursing home bed), would be added to the
system. We envision local communities and tribal agencies using the System
first, in a mass casualty event or pre-event (e.g. expected natural disaster
such as a hurricane), followed by States, and lastly, by Federal authorized
users. The System would ultimately be able to tell where a person is located,
what their special needs are, and where they have been (essentially an audit
trail of their previous locations) in near-real time. We understand that some
people may not want to be entered into the System, and some agencies would not
want their evacuees included in the System. Entry into the System certainly is
voluntary. However, there are many who would want their family or friends to
know where they were if they had to evacuate, or be evacuated. I would also
like to emphasize that only authorized users would be able to review the
collected data, and HIPAA compliance, Federal regulations, and other
requirements would be met by the System. The beauty of this proposal is that it
would leverage off existing information systems—daily use systems already in
place. It could also serve as a System where someone could self-register, if
they cared to do so. And, one of the recommendations was that the System be
funded by the Federal Government, and made available to the other national
sectors (local, State and tribal sectors, private industry, etc.). This may
encourage various communities to use the System during a large event. The
System would also be available for routine, daily use, if communities decided
to use it regularly.
Question 13. What are the basic requirements
of the National Mass Patient and Evacuee Movement, Regulating, and Tracking
System? Are you taking suggestions?
Christy Music: We certainly are taking suggestions.
The basic proposal has a very small number of demographic data that would be
collected: a unique identifier, such as a unique number, and if available,
name, gender, and date of birth. A person's special needs could be included in
the system, such as equipment they have with them (e.g., wheelchair), or
medication they need but don't have when being evacuated. The System could be
enhanced with medical information through an electronic medical record format
that could inform receiving health care providers about the patient being
transported to them for care. The regulating and movement functions would help
ensure appropriate transportation resources are available, and that appropriate
and available receiving locations for general population evacuees and patients
are reserved. These functions will also deconflict reservations from two or
more responding agencies, counting on using the same hospital (bed) for
different patients, for example. Other requirements of the System include the
following: it must be based upon existing information systems, include rapid
scanning of a unique identifier (e.g. barcode on a bracelet, passport, driver's
licenses, military ID card), and be able to receive manually entered data. The
System would be able to accept and share aggregate data (e.g. total numbers of
general population evacuees that may be going to a shelter), be able to accept
and share individual data, incorporate current or planned "feeder" tracking
systems (jurisdictional, commercial, and agency-specific systems), incorporate
feeder institutional records systems, be accessible to authorized users (e.g.
emergency responders, planners), use technology for easy use (e.g. scanners, Web-based,
satellite transmission, manual back-up system with download when power is
restored, etc.). As mentioned in response to earlier questions, architectural
and data standards would be incorporated, and regulations would be adhered to
Question 14. In the National Mass
Patient and Evacuee Movement, Regulating, and Tracking System, who or what
do you consider to be the data entry resources?
Christy Music: There are many data entry sources for
the national initiative. These would include fixed medical and non-medical facilities
such as hospitals, nursing homes, schools, etc., that may have institutional
records that could be downloaded into the System. Another source for data
entry could be through State or county agencies with population registries,
such as home-bound elderly members of the community. Data entry could also take
place at a collection point, where general population evacuees and/or patients are
taken, such as an airfield, to be loaded into aero-medical evacuation or other
types of transportation. Data entry could take place at a transportation
center, such as a bus or train station, or at evacuation centers, overnight
facilities, shelters, nursing homes, hospitals, or alternate care facilities.
Data entry could also take place at a point of injury, by a search and rescue
team, or a medical response team, through a hand-held device that would
transmit basic registration data to the larger System. Another recommendation
within this initiative included possible self-registration by the public, in
case they wanted to enter themselves into the System to keep family or friends
informed of their location. (If I were a general population evacuee, I would
certainly want to notify my family members or have a way for them to know where
I would be going.) There are many different data entry sources that would be
included in this Initiative.
Question 15. Do the National Mass
Patient and Evacuee Movement, Regulating, and Tracking System Recommendations address how the patients will be moved back to their home regions?
Christy Music: Actually, yes, it does. Repatriation
back to their homes, or to another final destination, and the movement,
regulating, and tracking operations involved in getting the person back to
their home regions, would be included in this initiative. One of the premises
of this proposal, is that the person could be tracked from the first time they
are entered into the System, through intermediate locations (such as a
hospital, then a nursing home), to their final location (such as their home).
Question 16. How does this National
Mass Patient and Evacuee Movement, Regulating, and Tracking System work
with HIPAA laws?
Christy Music: The business
operations/practices of the National System would be HIPAA-compliant. Only authorized
users would be able to view the data and enter data. Medical data could
potentially be used for epidemiological studies and contact tracing, as they
are now used, following HIPAA regulations.
Question 17. One problem identified in
Gustav evacuation was the inability of the sending facility to get follow-up
information with regard to status and/or location of the patients they sent.
Will the National Mass Patient and Evacuee Movement, Regulating, and
Tracking System resolve this problem?
Christy Music: Yes, and I
appreciate that question. What we are proposing is that fixed facilities that
enter their patients' or general population evacuees' data into the System would
be able to receive or view information on their patients' or evacuees'
location, as they move through transportation and care. Authorized users from
within the fixed facility could know the evacuee's current location, and may
have access to an audit trail of their previous locations.
Part II: Tool for Evaluating Core Elements of
Hospital Disaster Drills
Question 18. Does the Tool
for Evaluating Core Elements of Hospital Disaster Drills address specific considerations for subpopulations which might need special
provisions e.g. evaluation and treatment of large numbers of children, patients
with language barriers, elderly etc.?
Cindy Notobartolo (Tool User
from Suburban Hospital, Bethesda, MD): They draw your attention to the fact
that these populations might be in your hospital, but they do not give
specifics about how to manage those sub-populations. You need to call in
experts, most likely, to oversee that. That is where your comments section and
other things come in. You can put those down under those categories, when you
become aware of them, such as your behavioral health populations and other
Mollie Jenckes (Tool Developer, Johns Hopkins University (JHU) Evidence-based Practice Center (EPC)): The evaluation tools allow the user to identify the subpopulations
that may need special provisions, e.g., children, elderly. From there it is
necessary to refer to your hospital's policies in dealing with that specific
group. As an example, children are particularly vulnerable during an attack
for multiple reasons, including their generally smaller stature, placing them
closer to the ground where gases may accumulate at high density during a
chemical attack, or their immature physical development, which includes
increased abdominal organ vulnerability. Being aware that children are
involved as victims allows the officials in the drills to both draw on hospital
policies to protect children and to contact pediatric experts who have the awareness
to respond to the additional threats relevant to this sub-population.
The tools do not provide guidance
on direct care for any specific sub-population; rather they do provide a format
in which to document the steps taken to treat and protect victims of all ages
and conditions, as well as staff. Any needed care not specifically identified
in the evaluation steps can be noted in the comment sections. On receiving
these notes, it is recommended to review your disaster plan to discern that the
provisions in the plan cover these individuals and contingencies, and revise
the plan as appropriate.
Question 19. The Joint Commission
requires hospitals to monitor six critical areas during disaster drills. Does
the AHRQ revised tool address these six critical areas?
Cindy Notobartolo: AHRQ
tools do have it embedded in them, things like security, things like Incident
Command, but the structure is not, actually, organized into those six
categories. This is a suggestion for AHRQ in the future.
Mollie Jenckes: The AHRQ
tools address five of the six areas: internal and external communications;
adequacy and appropriateness of supplies; safety and security enabling hospital
operations to continue; staff roles and responsibilities within HICS; and
maintaining clinical activities. These areas are addressed through evaluating
the capability to deliver in each of these. Items to accomplish this are
included in each of the zone modules, i.e., decontamination, triage, treatment,
etc. Utilities to enable self sufficiency for 96 hours is not addressed
explicitly, although some areas evaluated are related to this area. To learn
more about The Joint Commission's six critical areas please refer to: http://www.disasterpreparation.net/resources.html (last accessed 3/22/09).
Question 20. Is the Tool
for Evaluating Core Elements of Hospital Disaster Drills Homeland Security Exercise Evaluation Program (HSEEP) compliant?
AHRQ: The Department of
Homeland Security (DHS), Office for Health Affairs is pleased to report that
they support the use of the AHRQ publication Tool for Evaluating Core
Elements of Hospital Disaster Drills. This document has undergone review
through their internal processes and has been found to be in concurrence with
DHS efforts. Federal Emergency Management Agency (FEMA) reviewers stated it is
a well developed/written tool to assist evaluators that encompasses unique
components of hospital evaluation, such as those required for Joint Commission
certification, and complies with the National Incident Management System (NIMS)
since it includes an evaluation of an Incident Command System. The tool
provides a certain level of detail of actual results, and along with
appropriate EEGs and well-documented exercise timeline, each module provides a
good tool to evaluate hospital exercises. Equally important, the modules serve
as a valuable tool to develop specific and measurable exercise objectives.
Question 21. Can one use the Tool
for Evaluating Core Elements of Hospital Disaster Drills to
evaluate how the hospital works with outside partners? Has it been used that
way and was it helpful to improve cross sector planning and coordination.
Mollie Jenckes: The tools
can be used to assess inter-hospital coordination in two ways: Firstly, in a
multi-hospital drill, with all hospitals using the tool to evaluate activities,
each hospital's responses can be compared to identify strengths and areas that
need additional support in each hospital. Those hospitals with strengths in an
area not matched by other hospitals can provide guidance as to how to
strengthen that particular response in the partner hospital. Secondly, the
evaluations will identify any weaknesses in coordinated response between, for
example, emergency services; local, State, or Federal health officers;
laboratories; supply depots, or other shared resources. The Tool has been used
in multi-hospital drills.
Question 22. Has the Tool
for Evaluating Core Elements of Hospital Disaster Drills been
used by a critical access hospital with attached long term care? If so, what
has been the feedback on the ease of use?
Mollie Jenckes: As the
tools have been available for several years, and have been widely distributed
by DHHS, and are in use in multiple States, this may be the case; however, as
far as I know, we do not have a complete list of the instances where the tools
have been used to evaluate drills. This is a good suggestion for DHHS or AHRQ,
to request feedback from States on what hospitals have utilized the Modules,
whether the complete modules or the Core Elements were used, and in what
areas of patient care each was used. The agencies could then develop a contact
repository of users as the tools come into even wider use.
Question 23. Can you describe what the
modular guide offers different from the new Tool
for Evaluating Core Elements of Hospital Disaster Drills? When
would I use the other?
Mollie Jenckes: The initial
publication: Evaluation of Hospital Disaster Drills: A Module-Based
Approach should be at every hospital. This document gives a complete
review of the activities that need to be evaluated during a drill, and, again,
is modular. As you plan your drill and choose to target specific zones (e.g.,
Incident Command, Decontamination, Triage, Treatment, etc.), you can select the
modules you require to evaluate the activities you plan. In a drill where all
hospital operations are targeted, all modules may be used.
The Tool for Evaluating Core
Elements of Hospital Disaster Drills covers the main points in notably less
detail. Here is a brief example: To identify time points for a drill in the
Triage zone, the original toolkit has five time points identified: *Time drill
began; *time hospital disaster plan initiated in this zone; *time this zone
ready to accept victims; *time this zone notified the Incident Command was
operational; *time 1st victim arrived in this zone. This allows a
complete picture of the readiness of the zone. In contrast, the Core
Elements tool has a single time point: *Did the drill start on time?
This single piece of information
may be adequate in some cases; however, a lot of detail is lost and it is
difficult to identify the true readiness of the Triage zone. The JHU-EPC Team
believes that the more detailed information is needed to more fully understand
the hospital response, especially for initial drills. The Core Elements modules can be used for follow up with a specific target. Let me also note
that modules from each of the two sets can be selected from during one drill,
e.g., the Core Elements for areas that have been more heavily drilled
and are participating as support areas, and the complete modules for areas for
an initial drill or to identify specific problem areas or bottlenecks. Both
publications are designed to be flexible and it is possible to void a section
if that area is not a part of a specific drill, i.e., if supplies are not
relevant to a drill focused on communications, the drill leaders can simply "X"
out the supplies section. This is the case for wither of the module sets.
Question 24. Does Suburban Hospital use internal or external evaluators during the drills?
Cindy Notobartolo: Both.
It is very important to use both. Do not forget the training for all the
evaluators; even the inside evaluators may come from another unit and may not
be familiar with the area they are evaluating. Guidance for training is in the How to Use this tool: Introduction section of the complete tool, and in Chapter
3 of the abridged tool.
Question 25. Do you feel that you have
the buy-in from hospital management when it comes to Emergency Preparedness?
Cindy Notobartolo: Absolutely.
All of management has been trained in the National Incident Management model
and have had to take on different roles during exercises and real events. The executive
level has to participate. We give an annual review of incident management to
the executive and administrative team.
Mollie Jenckes: At our
hospital, the Emergency Management Team is positioned in the senior management,
and is accepted as a valued member of the Senior Management Team providing for
the health and safety of patients and employees. For example, this year there
are institution-wide seminars offered every other month which focus on a
variety of disaster preparedness issues. Disaster response is included in the
hospital business plan, which identifies steps to limit business losses and
regain stability as soon as possible. Buy-in from management can be dependent
on where in the institution the Emergency Preparedness officials are positioned
and to whom they report. These issues are important to analyze as a part of
the overall preparedness effort.
Question 26. Is there any particular
strategy to attract physicians to participate in drills?
Cindy Notobartolo: Availability
seems to be the biggest problem. If they get enough notice, they do participate
and take it seriously.
Mollie Jenckes: Two salient
points: Physicians have leadership roles in the Emergency Preparedness effort,
and physicians are credited with time spent at the drills as a part of their
workweek. To have physicians participate, it is necessary that they share the
responsibility for the outcomes, including the drills and the management of the
hospital under an emergency.
Question 27. What are you doing to
increase awareness for the need for hospital staff to be personally prepared
during a disaster? How do you train your staff? Have you had any difficulty
training hospital staff as far as getting them to understand ICS, NIMS, etc.?
Cindy Notobartolo: At Suburban Hospital what we do is distill it to a very understandable, easy-to-absorb, easy-to-remember,
basic list of one, two, three steps. It is called "know your role." It includes
all levels of workers, i.e., physicians and other clinicians, administrators,
environmental service workers. These are steps you need to do to know your role
in the event of an emergency. It works very effectively. The other thing we
have done is we have sent all of our staff through NIMS online training to give
them a better perspective of any emergency, and to understand the platform as
far as ICS command and control. Developing Job Action sheets, patterned after
the Hospital Incidents Command System (HICS) Job Action sheets, for different
cadres of workers provides clear guidance and simplifies training.
Current as of May 2009