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Planning and Practicing for a Disaster

This resource was developed by AHRQ as part of its Public Health Emergency Preparedness program, which was discontinued on June 30, 2011. Many of AHRQ's PHEP materials and activities will be supported by other Federal agencies. Notice of transfer to another agency will be posted on this site.

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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 lag?

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?

Answer:

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 suggestion.

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 available?

Answer:

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?

Answer:

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?

Answer:

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?

Answer:

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?

Answer:

Tom Rich: Yes. You can specify any number of evacuating hospitals and any number of receiving hospitals.

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.?

Answer:

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 information.

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?

Answer:

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?

Answer:

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 these patients.

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?

Answer:

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 Model.

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 System Initiative? Specifically, is it still moving ahead? How can we get HAvBED to be used in our communities?

Answer:

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.

Answer:

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?

Answer:

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 (e.g. HIPAA).

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?

Answer:

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?

Answer:

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?

Answer:

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?

Answer:

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.?

Answers:

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 subcategories.

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? 

Answers:

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 Exit Disclaimer (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? 

Answer:

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.

Answer:

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?

Answer:

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?

Answer:

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?

Answer:

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? 

Answers:

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?

Answers:

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.?

Answer:

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

The information on this page is archived and provided for reference purposes only.

 

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