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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 already listening on a phone, press "*1" to indicate that you have a question. If you are listening through your computer and want to call in with a question, dial 1-888-496-6261 and use the password "bioterrorism", then press "*1".

While asking your question on the air, please do not use a speakerphone or a cell phone to ask your question. If you are listening through your computer, it is important that you turn down the volume after speaking with the operator. There is a significant time delay between the Web and telephone audio.

If you want to send a question by the Internet, simply click the button marked "Q&A" on the event window on your computer screen. Type in your question and then click the "Send" button. One important thing, if you prefer not to use your name when you speak with us, that is fine, but we would like to know what State you are from and the name of your department or organization. So please provide those details regardless of whether your question comes in by phone or Internet.

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 series.

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 researchers.

We would certainly appreciate any feedback you have on this Web-assisted audio conference. At the end of today's broadcast, a brief evaluation form will appear on your screen. Easy to follow instructions are included on how to fill it out. Please be sure to take the time to complete the form. For those of you that have been listening by telephone only and not using your computer, 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 audio conference will provide us with a valuable tool in planning future events that better suit your needs.

Alternatively, please E-mail your comments to the AHRQ User Liaison Program at

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 tabletop drill.

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, hello.

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 experience.

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 effects.

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 problem.

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 to access.

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 grant program.

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 readiness.

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

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 planning?

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 help.

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 amongst themselves.

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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