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Planning and Practicing for a Disaster: Transcript of Webcast (continued)
Karen Migdail: Now I would like to move to Part II of the Webcast, where the
highlights and practical uses of AHRQ's Tool for Evaluating Core Elements of
Disaster Drills will be discussed. This tool was also released in 2008,
but it is an abridged version of the AHRQ tool, Evaluation of Hospital
Disaster Drills: A Module Based Approach, which was released in 2004. The
abridged tool includes instructions on how to use the document when planning
and executing the evaluation of hospital disaster drills and modules for
assessing the incident command, decontamination, triage, and treatment zones
during a hospital disaster drill.
Now I would like to introduce our next speaker, Mollie
Jenckes. Mollie is a Research Associate at Johns Hopkins University, and today
she will discuss the Tool for Evaluating Core Elements of Hospital Disaster
Mollie Jenckes: Thank you very much. Hi, everybody,
and thank you for being with us today as we bring to your attention to two of
AHRQ's tools and discuss how to protect your community in times of disasters. We
are very glad you are with us and hope we are giving you useful information.
I am talking about the Tool for Evaluating Core Elements
of Hospital Disaster Drills. It was developed by the Johns Hopkins University
Evidence-based Practice team. This is a group effort, and each individual brought
different expertise to the effort. In addition, we had a panel of outside
experts who reviewed the tools as they were in development, more than one time.
So who is this man? You have probably all heard of him. Chesley
B. Sullenberger, III. He is pictured here. He was the pilot of the U.S.
Airways jet, which is also pictured here. Based on his training and diligence,
he single-handedly saved up to 155 people on Friday, January 17, when he landed
his plane in the Hudson River. He is a pilot and an aviation safety expert,
and he has received a tremendous amount of training; the fact he later
highlighted the importance of after he was able to bring this event to a
Hospitals are complex institutions with multiple levels of
staff with a wide range of backgrounds and training. When disaster strikes, it
is vital that the tasks are pre-assigned and have been practiced through drills.
To make a difference, each drill must be evaluated. Where is the emergency
equipment kept? How do I use it? Where do I report? What are my
responsibilities? How do I keep myself and the patients safe? These questions
surface immediately in the minds of each hospital worker, maintenance
personnel, physician director, and administrator at the time of the emergency
notification. The photos on the right show a scenario you may be familiar with:
a structural collapse, which will end up with hospital admissions as the
wreckage is cleared. The photo on the lower right shows the emergency transport
of a critically injured patient. Hospitals are prepared for natural and
manmade disasters, earthquakes, structural collapse, transportation, but they
need to drill their employees in order to know how each one of them should
respond under the pressure of this emergency.
Why do hospitals hold disaster drills? To allow hands-on
training, to build knowledge and understanding, to identify strengths and
weaknesses, to build familiarity with infrequently used equipment (this is a
very important objective) and, of course, to fulfill requirements of the JCAHO
[Joint Commission for Accreditation of Healthcare Organizations]. I will also
note that beginning in September of 2008, the HPP [Hospital Preparedness
Program] at HHS will be requiring participating hospitals to file executive
summaries of all drills that have been completed.
So, today, we are talking about a tool that can assist you
in meeting these requirements. You are all familiar with continuous quality improvement
[CQI]. This process is applied in this case for disaster preparedness. Disaster
drills are one aspect of continuous effort to improve protocols, analyze the success
of a drill, and work towards improving total hospital disaster response. We
develop training, learn skills, analyze the response, reevaluate the training,
review and modify the disaster planning, and if necessary, re-entering the
cycle. Here is a figure on slide #40 showing the cycle. The evaluation allows
the hospital to identify the issues and target the improvements needed in
To build this Tool, the JHU EPC (that is a nickname for
Johns Hopkins University Evidence-based Practice Center) built a
multi-disciplinary team of experts for initial guidance and repeated feedback during
development of the modules. There were participants from Federal agencies, State
agencies, hospital administrators, disaster planning experts, and weapons of
mass destruction experts. Agencies at different political levels, as well as different
agencies within your Federal Government, State, and city have their own
perspectives, planning processes, and requirements, all of which impact your
hospital. In addition, the hospital-based administrators and care personnel,
they are the ones that know the capabilities of their institution. The JHU EPC
received input from a wide range of experts to develop, review, and strengthen
these assessments. Within the product, there are seven modules with a training
module that tells us about the use of the product. There is a pre-drill planning
module you can target to exactly what you want to perform under the drill. There
is a command center module, which for all of you familiar with HEICS [Hospital Emergency Incident Command System], you can relate to that. The module is based on the HEICS model.
There is a decontamination zone module, triage module, treatment module, and finally
a debriefing module. There are two addendums I will speak of in a moment. These
modules are designed to focus evaluation on the areas most likely to come into
play under a specific scenario. Each module is designed to stand alone. Each
can be used independently. Evaluators using the modules must first receive
training in their proper use.
Within each module, we will document the time points. By
that I mean: when did the drill begin, and did it begin on time? The zone description:
by that I mean approximately how many personnel in the area, the number of
beds. The zone operations: what that module is assessing is, it is designed to
accomplish the communications that assist in the information flow in and out of
that zone; the security arrangements for that zone, documentation and tracking
for the patients/the victims, their flow, the time they are in the zone, how
they come in, how they go out, delays. Personal protective equipment [PPE] and
safety; as we mentioned, the important part of the drill is to practice events
not often occurring during the normal work week, and personal protective
equipment and safety is certainly one of those areas. The equipment and
supplies: the rotation of staff, especially for an ongoing disaster, for
example, flu or anthrax where the victims can come over a great number of days,
weeks or even months, you need to think about rotating your staff. Finally,
zone disruption: what do you do if the zone is overcome by the disaster and you
still have patients in the unit?
Reviewing the details, the actions taken in each zone, the
EPC team identified the elements that required documentation in order to
properly evaluate the hospital response; that is, a summary of the difference
between the initial modules and the followup core modules. The core modules take
out the key points. The initial modules are comprehensive about almost every
activity that occurs. Most items in these modules have a check-off, and the
purpose is to quickly assess the response: did it happen, did it not? There
are also comment boxes scattered throughout the modules for more detailed
evaluations of what went right and what went wrong.
I mentioned addendums. In view of the rising threat of
biological and radiation incidents, the addendums cover the key points to
assess in these particular areas: types of exposure, prophylaxis, notification
of State and Federal agencies, and other issues. I will let you read slide #44
on your own. The field trial results, which we will hear more about in a
minute, indicate wide acceptance of the modules. Hospitals were able to document
activities occurring as they happened. Those of you that have been in the
field for many years know what a normal hot wash is—people get up and give their
specific perspectives but might miss something they did not see or was not
within their framework of attention. These modules allow you to document all
of the activities that occur under the drill, e.g. followup exercises,
hospitals requesting repeat use of the modules. Through distribution at HHS,
the modules have been used in different States across the country, as you can
see here on slide #45 in the right hand corner, with a mock patient being
treated. I bet a lot of you have probably seen that snapshot of activity at
the field trial.
To conclude, here on slide #46 are the products that are
available. Both of the modules were initially published and distributed
through AHRQ. The modules were printed each in a different color to facilitate
description, distribution, and collection of them during an evaluation. A
CD-ROM is included in the package, with a spreadsheet to document the
responses. In 2007, the EPC team was called back together to review the full modules
and produce an abridged edition. Working with input, again, from an Advisory
Committee of experts, the EPC team identified the most vital elements in each module,
resulting in the abridged volume. This is a reduced data collection set limited
to core items. The core items have the same look as the volume on the left
when you see the original volume. They can also be downloaded from your
computer. On the right, we showed you the different colors so you can quickly
identify the different units that that module should be sent to. Let me
underline, again, the importance of training and the use of these materials
before you start your drill. The full publication is available on the AHRQ Web
site and is packaged with the CD-ROM, as I mentioned. We encourage you to look
at the full module, to use it as far as possible, and as you follow up and become
more experienced, the core modules will reinforce the key points that need to
be taken into account. Thank you.
Karen Migdail: Thank you very much, Mollie. In a
moment you will see the final poll question on your screen. The question is:
are you interested in being contacted by AHRQ to receive more information about
the Tool for Evaluating Core Elements of Hospital Disaster Drills? Please
select either yes or no.
I'd like to introduce our final speaker, Cindy Notobartolo.
Cindy is the Corporate Director of Emergency Trauma, Safety and Security Service
at Suburban Hospital in Bethesda, Maryland. Today, she will give a user's view
of the Tool for Evaluating Core Elements of Hospital Disaster Drills. Cindy?
Cindy Notobartolo: Thank you, Karen. I feel
extremely fortunate for all of the hard work that has gone into these tools. To
Tom, Sally, and Mollie, it has been wonderful meeting you directly. I am a
grateful recipient. In October of 2008, as part of the National Capital Region,
we have normally held complex multi-casualty disaster exercises. We, being the
Bethesda Hospital Emergency Preparedness Partnership, which consists of the
National Naval Hospital, NIH Clinical Center, the National Library of Medicine,
and Suburban Hospital, where I work, we designed, planned, and participated in
a large-scale explosive event involving over 40 military, research, National, State,
county, and private entities. It was to include thousands of participants and
hundreds of casualties.
Historically, the evaluation tool that was created or
adapted was from existing templates. There was dissatisfaction with some of
these tools. I remembered a particular group of probably six to eight of us
that spent weeks upon weeks developing a tool only to be dissatisfied at the
end, in not being able to use it and it not being helpful in our evaluation. Then,
just before our October event, this large multi-casualty event, a colleague who
works at the National Library of Medicine e-mailed me and sent me the link to
the AHRQ Tool for Evaluating Core Elements of Hospital Disaster Drills. I
was unbelievably happy to see this tool. For me, especially, having been an emergency
manager and also being a nurse, it had a logical framework. The flow and the
sequence matched actual events. It had, as Mollie said, pre-populated fields,
places that you just circled for ease of use. It also had comment sections where
you could, additionally, add in things that would be important in the after-action
reports. It also prompted questions. There were many different prompts, as
Mollie said, that you would not necessarily think of unless you had such a
comprehensive tool in front of you. The other thing that I really liked was,
for artistic people in our midst or not so artistic, it had diagram sections
where you could draw out the particular area that you are evaluating. I will
mention a little bit more about how important that was for one of our triage
The nice thing is it is modular, as was stated before, and
it breaks into logical modules. You can select individual sections, you can
use other targeted evaluation tools, or you can use the complete tool from the
very beginning to the very end. It has the things like red zones, the incident
command center, and one that I particularly liked was the group debriefing module.
A lot of times after an event, you will sit in front of a very large group of
people and, in the hot wash or the debrief, you will say: What went well? What
did not go well? What about your area? What happened in your area? This had
such wonderful questions that you can ask to illicit information from
participants. Such as, did people have a good understanding of their roles as
defined in the disaster plan? Were there problems with information flow
throughout the hospital? Did the right individuals show up? Did they show up
Suburban Hospital was founded in 1943. It is a community-based,
not-for-profit hospital, which is the trauma center for Montgomery County, Maryland. It has affiliations with Johns Hopkins Medicine and the National Institutes of
Health [NIH], as well as being part of this unique partnership that I told you
about for emergency preparedness with the National Naval Medical Center,
National Institutes of Health's Clinical Center, and National Library of
Medicine, where we exercise as well as try to do research in emergency
preparedness. All of the hospitals in Montgomery County also have MOUs [Memorandums
of Understanding] along with public health to work as a unit in the event of an
I have attached a picture on slide #53 of our Incident Command Center, and in this picture I think that you can see that there are many
people working to achieve command and control of an incident, making the process
more effective through every exercise refines our ability when a real disaster
strikes. I used the Incident Command Module in this particular exercise. What
it did was, it prompted important time parameters, such as the beginning and
the ending, who arrived when, and did they arrive at the right time? It
allowed me to draw a picture of the zone set up. As you can imagine with all
of our partners, there were many communication devices. I drew up the Incident Command Center and had to see whether the communications equipment was placed in
the right area. Was there a natural flow in the Incident Command Center when there were dozens of people that could, potentially, be going through there? One
of the outside evaluators that was doing the triage determined it was much too
small an area for a large incident and drew another area that could accomplish
the triage in a much more effective fashion.
I have to tell you there is a definite ease of use and efficiency.
It is very important when you have a tool to complete it in a timely manner,
because you want to identify gaps and you also want to remember things as
succinctly as you possibly can. The sooner that you do it after your exercise,
the better the information is going to be.
As far as the future of the tool, I have been telling
everyone I know to use it. It has received enthusiastic feedback. People look
at the tools and say, "Oh my goodness, this makes so much sense." Groups are
sharing their user experiences, and I believe that there will be more
widespread use. Hopefully, you will pass it along to your colleagues. The
more we refine our plans as a health care community, the better we can meet our
community needs in the event that a real disaster occurs. Thanks.
Karen Migdail: Cindy, thank you very much. I would
like to thank our speakers, Mollie Jenckes and Cindy Notobartolo, for their
informative presentations. We will now start our second moderated Q&A
session. We will do our best to answer all questions that are posed to us. If
you'd like to send a question in, please type it into the Q&A panel and
select the send button.
Our first question is for either Cindy or Mollie or both of
you. What are you doing to increase awareness for the need for staff to be
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. It is called "know your role." It goes from
physician to clinician to environmental service workers. One, two, three, this
is what you 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 or the National Incident Management Training to give them a better
perspective of any emergency, what the platform is as far as command and control.
Mollie Jenckes: That is a good answer, and there are
similar activities going on at Johns Hopkins.
Karen Migdail: Here is another question directed to
either of you. The Joint Commission requires hospitals to monitor six critical
areas during disaster drills. The AHRQ revised Disaster Drills material do not
address these six critical areas. Do you have plans to address them?
Cindy Notobartolo: I think that was one of my
suggestions. AHRQ tools do have it embedded in them, things like security,
things like Incident Command, but the structure is not, actually, outlined in those
Mollie Jenckes: Incident command does stand alone as
a separate module. There is a security element in each of the seven modules. Security
Karen Migdail: Mollie, who is it that is requiring
that we file all disaster drills with them?
Mollie Jenckes: If you are referring to the comment
I made during the presentation? It is HHS who is asking the hospitals that
participate in their Hospital Preparedness Program to file an executive summary
of each drill with them in order to meet their requirements. That is what I
was referring to during the discussion.
Karen Migdail: Another question for Mollie. Can you
describe what the modular guide offers that is different from the new tool? When
would I use one over the other?
Mollie Jenckes: That is a very good question. The
complete guide should be at every hospital because that will give you a
complete review of the activities that need to be covered, and, again, is
modular. You can look at every part of the hospital that will be involved. The Tool for Evaluating Core Elements of Hospital Disaster Drills covers the
main points in less detail. Please comment too, Cindy. I would think that the
core would be for smaller hospitals with fewer designated personnel and fewer
specialized personnel, perhaps. It would also be for followup drills, where
you are looking to correct something that had not been done properly,
Cindy Notobartolo: I would say that you can use the tool
for targeted drills if you were looking at certain areas or certain processes. I
think the more detailed the evaluation tool, the better you are going to be
able to define your after-action report and improve your plan.
Karen Migdail: Thank you. We will return back to part
I of the Webcast and ask a question for Christy Music. What are the basic
requirements for a proposed system for people tracking? Are you taking
Christy Music: We certainly are taking suggestions. The
basic proposal is a very small number of demographic data, a unique identification
number, gender, name (if available). I am not sure of the particulars of that
question, but I would like to add, in case you have this in mind, we are not
only looking for a tracking system that is manual, but can upload information
almost instantaneously from drivers' licenses, passports, satellite
Karen Migdail: Great. Thank you. Mollie, is your tool
Homeland Security Exercise Evaluation Program [HSEEP] compliant? All hospitals
receiving ASPR [Office of the Assistant Secretary for Preparedness and
Response] funds are now required to use the HSEEP in exercise planning.
Mollie Jenckes: Yes, the tool has been evaluated by
the HSEEP. It is under evaluation. It will be completed soon.
Let me go back, if I can go back for a moment to the
complete modules versus the core; I think it can also be used as a training
device, not just an evaluation device, bringing your attention to all the small
details that might not preliminarily be noticed. Secondly, it is always
possible to block out certain areas of them. For example, if communication
devices are not an issue with this particular drill, you can draw a line
through those sections in the larger module, do you agree?
Cindy Notobartolo: I agree, but when she is talking
about communication devices, when I looked at that particular module, it is
amazing how it draws attention to all of the different communication devices
you should be looking at and, perhaps, have not been looking at. The complete
detail of it, I think, is important just to make sure that you have a really
Karen Migdail: The next question is for Tom Rich.
Does the Mass Transportation and Evacuation Model work with the local,
municipal EMS provider, the hospital-contracted provider, or both to estimate
the number of resources that would be needed and be available?
Tom Rich: I can only speak for our two pilot tests
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 inter-agency process to come up with these
Karen Migdail: Thank you. Mollie, do the hospital
disaster drill evaluation tools address specific consideration of sub-populations
that might need special provisions. For example, the evaluation and treatment
of large numbers of children, patients with language barriers, etc.?
Mollie Jenckes: 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.
Cindy Notobartolo: 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.
Karen Migdail: Cindy, does your hospital use internal
or external evaluators during drills?
Cindy Notobartolo: Both. It is very important to
Mollie Jenckes: That was a good question. 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.
Karen Migdail: Mollie, can you repeat the link for
the tool, please?
Mollie Jenckes: Can you go with another question
while I look that up?
Karen Migdail: Absolutely. We will turn to Christy,
and then we will come back to that. Christy, do the recommendations for patient
evacuation and tracking address how evacuees will be moved back to their homes.
Christy Music: Actually, yes, it does. Repatriation,
back to their homes, or to another final destination would be included in this
Karen Migdail: Great. Tom, does the Hospital
Surge Model take into consideration the potentially significant number of "worried
wells" that can overcome a hospital.
Tom Rich: Excellent question. It does not. That is,
obviously, something that hospitals need to consider.
Karen Migdail: Mollie, you are going to give us the
Mollie Jenckes: Yes. The names of the publications
are Evaluation of Hospital Disaster Drills: A Module-Based Approach (AHRQ
Publication No. 04-0032 April 2004) and the Tool for Evaluating Core
Elements of Hospital Disaster Drills (AHRQ Publication No. 08-0019 June
2008). The way I find it is I go to http://www.ahrq.gov/ and input the tool names into the search field and they all pop up. You can
see the complete and core both with their graphs; click on them and they will
come right up.
Karen Migdail: Great. Thank you very much. Tom,
you stated your model was suited for optimal care. Any plans to expand your model
for disaster or crisis standard of care?
Tom Rich: That is something that certainly could be
done and is something that has been talked about. Again, I want to emphasize
that we are assuming optimal level of care. We will see. Great suggestion,
Karen Migdail: Another question for you, Tom, and
Christy. In this patient tracking system, who or what do you consider to be
the data entry resources?
Christy Music: The data entry resources for the national
initiative would include fixed facilities such as hospitals, nursing homes, any
home registry the States hold in hand, such as Florida. It could also include
data entry at a collection point where patients show up at an airfield to be
loaded into aero-medical evacuation or other types of transportation, either by
ground or by sea. It could be a search and rescuer who finds someone who could
have a handheld device and could enter the data into the system that would be
uploaded into a main server. It could be through self-registration. 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 persons or resources that would be included in this initiative.
Karen Migdail: Thank you, very much. Tom, does your
travel-time model include variations by season and/or road closures?
Tom Rich: No, it does not get down to that level of
detail. Again, a good suggestion for possible enhancements.
Karen Migdail: Christy and/or Tom, are there any
plans to develop a universal patient tracking system that would be available to
all agencies. Current commercial systems do not talk to each other, nor do
most hospital-based systems.
Christy Music: That is a wonderful question, thank
you. The premise of this initiative is to take existing systems, including
commercial systems that are in use, and through Federal standards, encourage
them to participate in our initiative, so we would have existing systems
becoming, basically, the building blocks of this national initiative.
Karen Migdail: Great. Thank you. Our last question
is for Christy. You mentioned HIPAA. Would your system allow public health
officials to track individual patients who need close followup. The example
that this question uses is tuberculosis.
Christy Music: Remember that the business operations
of the systems need to be HIPAA-compliant. Authorized users, if that public
health official would be an authorized user, certainly could use that information
for epidemiological and contact tracing, for instance.
Karen Migdail: Thank you very much. Thank you for
all of the great questions. Our time is about up. Thank you for joining us
for this event. I'd like to thank all of our presenters, Tom Rich, Christy
Music, Mollie Jenckes, and Cindy Notobartolo, again for sharing their
As we conclude this Webcast, let me remind you that information
about other emergency preparedness tools and the slides from today's event,
which will be posted in a few weeks, are available at http://www.ahrq.gov/prep. We also are going to
post a selection of questions from this Webcast with answers. Unfortunately we
have so many good questions and we have no time remaining, so we will choose
those that we feel will be most beneficial for the audience and they will be posted
Finally, when you close your screen, you will receive a pop-up
feedback form. Please take a few minutes to complete it. Your feedback is
important for the development of future AHRQ emergency preparedness activities.
On behalf of the Agency and all of the speakers, I would
like to thank you for joining us today. Have a good afternoon.
Current as of May 2009