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Lessons Learned From the Field of Emergency Preparedness

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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Cindy DiBiasi: Thank you, Nancie. In a moment you will see the second poll question pop up on your screen. This poll asks, "What are your community's current priorities for emergency preparedness? Please choose all answers that apply to your community: Emergency Health Care, Primary Health Care/Continuity of Care, Home Health Care Services, Palliative Care, Surge Capacity, Resource Allocation, Staffing, Transportation, Alternate Care Sites, Disease Surveillance, and Communication.

Please take a moment to fill out your response.

I would now like to introduce Christian Feller. Chris is the Safety Officer with the Aultman Health Foundation based in Canton, Ohio. Chris is also the Chair of a multi-county coalition in Ohio that is working to assemble and inventory critical emergency preparedness resources using AHRQ's Emergency Preparedness Resource Inventory tool (EPRI). Chris, you're our last speaker, let's hear from you now.

Chris Feller: Thank you Cindy. I want to begin my presentation by informing you a little about AHRQ's EPRI (Emergency Preparedness and Resources Inventory) tool and how it operates so you have a little background going through this presentation. EPRI is an Internet-based tool that enables our community first responders, public and private entities, and other individuals wishing to share their resources the ability to share resources through an Internet-based system. It maintains a flexible inventory system and allows people to collaborate on a regular basis. It gives you the ability to present emergency requests (how we get through those requests and how we get them out to the public), as well as it generates reports on quantity, location, discipline, and the availability of the resources you may need during a time of disaster. It currently meets ASPR [Assistant Secretary for Preparedness and Response] guidelines for tracking of grant-funded purchases across the health care continuum.

So how did we implement EPRI as a region? Well, the first thing that we had to identify was work that needed to be accomplished. Our region is a 13-county region established in northeast Ohio in the Northeast Ohio Emergency Planning Consortium. We thought that we were great at sharing information, giving reports, and listening to guest speakers, but we weren't generating any work. It was at that time we took the opportunity as a committee to look at what opportunities for growth were out there. One of those opportunities for growth or improvement was that of resource management. During a disaster, we felt comfortable with resource management within our individual counties but didn't feel we could adequately pursue it at a regional level. So we put together a very small multidisciplinary team that consisted of various regional coordinators from both health care and public health, Emergency Management Agency representation, and public health and hospital representation. We took a nine-month period to evaluate various resource tools that would let us track these emergency preparedness resources and also enable us with response. There were several tools that were brought to the table, but overall, we felt EPRI was the best option, and in a few minutes, I'll explain to you why this was our best choice. All the tools we evaluated were evaluated on the following criteria: Affordability—what do we do when our regional grants run out? How do we continue to sustain such an opportunity for growth? Does the tool have the ability to be customized, how does it meet our regions need, and how can we make it reach the needs in the future? Is it Internet-based? How do we make it accessible for everyone who is a major player within emergency response? Is there security involved? This tool is going to be used during an emergency, and it is going to be used to track some very critical resources within the community. How do we make sure that remains secure? Customer support—with this tool being Web-based and not having a true owner, what do we do to get support we need in a time of emergency when things aren't functioning the way they should? And finally, ease of use. There's a great turnover within health care and emergency first responders. We wanted to make sure that no matter who stepped up to the plate within these organizations that this tool would be easy to use and something that would be readily available to staff.

So we identified EPRI as our emergency tool of choice based on a couple of different things. First and foremost was cost. There is no cost. Currently, AHRQ is working with several agencies and several organizations across the country to ensure that EPRI meets the needs of the customers while not costing the customers anything. All the cost at this time is accrued by AHRQ. In the event that grants don't work out, there's a very small nominal hosting charge that would be involved with having an Internet-based tool. The second was ease of use. This tool is Microsoft Windows-based. Most organizations are very familiar with Windows-based tools, and we thought it was easier to use a Windows-based operation instead of teaching a new method of computing format. We wanted something that was remote hosted; something that was easily accessible to all players no matter where they are, whether it be out in the field, in the county's Emergency Operations Center, or within the health care institutions themselves. We wanted the ability to back up the information. In the event of every emergency, whatever can go wrong will go wrong. That is why we wanted the ability to have redundancy; we have that through the ability to send reports out in CSV format, Microsoft Excel, and Microsoft Word format. We wanted something that was password protected; something that prevented just anyone who stumbled onto our regional site to be able to gain access and see what valuable resources we had in a time of emergency. We wanted something with strong reporting capabilities, something we would use in a time of emergency, and something that would help us locate these resources, how we get to them, and how we transfer them. We wanted something that was NIMS [National Incident Management System]-compliant, this was a very big sticking point with out EMA's [Emergency Management Agencies] as they are very NIMS-compliant. A lot of health care does not embrace NIMS compliance at this point, but in order to get the buy-in from public health and emergency management, this was very important. We wanted something that was customizable, something that would meet the needs of our region now and moving forward, and something that has some sort of open-ended infrastructure. Currently, our fire and police agencies across the State of Ohio use the State's Response Plan and Protocol. We wanted to be able to aggregate data from the State plan or provide the State plan with additional data as we move forward with this project. We also wanted free tech support. As I mentioned before, we wanted something that provided organizations the ability to reach out for help when things weren't functioning as they should.

So what did we do moving forward? We've identified EPRI. The first thing we needed to do was present our findings to the Regional Steering Committee because we needed their buy in. One thing that you need to remember is that, with a lot of these regional planning consortiums, this is in addition to other people's own work. This is something we needed to have their buy-in in something we could get them away from their organizations and work exclusively on this project with. We identified workgroups within each specific discipline to identify the resources that we wanted to track. This is much easier said than done, as everybody had different examples of what they wanted to utilize. Some people wanted to get down to pencils and clipboards, and others wanted to track helicopters, boats, and trains. So from a health care standpoint, we identified that we wanted to track all of our ASPR grant purchases valued over $250 at the time of purchase. From public health, they identified that they wanted to use any equipment that was purchased through their CDC grants, also at a value of $250 or more. Reason being the Ohio Department of Health requires a tracking method for any of these purchases over $250. This really killed two birds with one stone. EMA's wanted to track all NIMS-compliant resources and anything they could bring to the Steering Committee that might be found valuable at the time of an emergency. We then worked with Abt Associates, who is under contract by AHRQ, to develop training modules and user manuals. We felt this was important so we had a way to reach out to these organizations and their large turnover and keep this project running smoothly. We developed region-specific standard operating procedures, guidelines, and policies. How do we implement the security? How do we make sure the system is being used appropriately? How do we make sure organizations are buying in to the program itself? We then continued to work with Abt Associates to load initial data such as demographics, contacts, and purchases into the system. This was over the past 7 or 8 years of Federal grant spending, so we already had a very large paper-based or Microsoft Excel-based database that we wanted to upload very quickly.

We then identified a couple of pilot test groups. We wanted these pilot test groups to reach out over a one-month period and use EPRI. We wanted them to use it on a regular basis. We wanted them to use it during disaster drills, whether they be full-scale, functional, and/or tabletop, and we wanted them to identify areas for improvement. This was volunteer-based. It took a very large group of people to put this system together, but we wanted to drill it down to the individual agency level. Our pilot test group consisted of three hospitals, two health departments, and two emergency management agencies. The pilot groups are currently going on right now and identifying opportunity for improvement within the EPRI system. They will be doing this process through December 1st of this year, at which time they'll be writing a full report to our Regional Steering Committee on how we can improve this process. Once this has been handled and we go through the process improvement, we'll begin a full media campaign the first of the year to really look at how we branch out with this. How do we get the involvement of all hospitals, all of our 13 county EMA's, our health departments, police, fire, EMS, and also some of the private entities that we use such as large corporations and other agencies like the Red Cross?

So what are our future plans moving forward? Well the first quarter of 2009, we want all 33 regional hospitals to be on board with EPRI. One of the ways in which we are doing this is we're tying it back to their Federal grants. We want to take the Federal grant and provide this as a benchmark or deliverable to force the hospitals to use the process and get the engagement we want right off the bat. We're then going to have public health online by midsummer of 2009. They are currently aggregating their systems from previous systems they put together and, once they get these resources in line, they're going to continue to load them moving forward. We are then going to bring EMAs online, or emergency management agencies, as the demand exists for them. Right now, several of the emergency management agencies use several large high-dollar systems to track resources, while other emergency management systems within our county or region do not track resources at all. So, as we see the demand from these agencies to come on board, we're going to bring them on board. We want to use EPRI effectively during our 2009 regional exercise. At this time, planning has already started for a pandemic flu exercise. We want to take this opportunity to use EPRI and identify any further deficiencies that may need correcting moving forward. We want to provide EPRI to all the county emergency management operations centers within the region. This is important because it's a resource management tool that our emergency management agencies need to be able to get their hands onto if needed. We want to continue to work with regional fire and police entities to provide data or pull data from the State of Ohio's system, as this system is already used by all fire and police agencies in the State of Ohio, we want to make sure we can use EPRI's open-ended architecture to merge with these systems to get the pertinent data where it needs to go. We want to provide implementation assistance to other Ohio regions. We've already had a large level of interest across other regions within the State of Ohio to implement this with them, as well, and then share our resources across regional lines. We want to work collaboratively with adjacent State regions to develop a multi-State EPRI tool. We have had interest from States such as Michigan, Pennsylvania, Indiana, and Kentucky on how we can continue to share resources without worrying about State boundary lines. Then we want to continue to promote the implementation and usage of EPRI to all interested parties through avenues such as this.

What are some of the challenges we've had through this process? Well, the biggest challenge we've seen so far has been what I like to call resource silos. Public response agencies are very reluctant to share what resources they have and share the quantities associated with them. So we've had a very hard time getting around that, but we are moving forward through people using this system. We don't want to overstep the emergency management agencies' boundaries. In the State of Ohio, the EMAs are seen as a resource inventory location or place where you can go for additional resources. We don't want to step on their toes, and we want to make sure they are still an integral part of emergency response work output at the regional levels. As I have said before, region interaction is on a voluntary basis. All the people within these regions have jobs elsewhere, so it has been difficult to bring people to the table for one more project. Elimination of grant funding—as our grant funding continues to dwindle, how do we operate this system in the event that we no longer receive our ASPR or HHS [Department of Health and Human Services] funding moving forward? Then system ownership—when this grant system is no longer in place or when we lose our regional collaboration, who owns this system and where do we go moving forward with the ownership portion?

So what have been some of our strategies to correct these deficiencies? We are continuing to provide a secure method of data input. We are continuing to keep the organizations that are involved engaged; we've done that through scheduling data uploads, scheduling Webinars, things like that. We want to stress the importance of EPRI being used as a tool to assist EMAs and not stepping on their toes because this is simply for resource identification. We're still going to rely on our emergency management agencies for resource acquisition. We want to continue to engage regional participants through projects that benefit individual entities. As many of the health care institutions on the line know, right now the Joint Commission is very gung-ho with resource management. This helps met your Joint Commission requirements. Long term, we want to think about other regional-based tools and how they will be funded. Finally, we want to provide key contacts and system owners moving forward that will be able to manage and facilitate this system across State and regional lines. Thank you very much. I'm going to turn this back over to Cindy.

Cindy DiBiasi: Thank you, Chris. In a moment you will see the final poll question pop up on your screen. The question is: "Would you like to be notified when the new version of the Emergency Preparedness Resource Inventory (EPRI) is released?" Please check "yes" or "no."

I would like to thank our speakers, Terri Gill, Nancie McAnaugh, and Chris Feller, for these informative presentations. Now we will start the Q&A portion of the Webcast. If you would like to pose a question to our panel, please type your question into the Q&A panel, then click the send button. We are already under an avalanche of questions here, so I am going to get started right away and ask our panelists to keep their answers short so that we can get to as many as possible.

Our first question is for Terri: Where is the staff going to come from to work in the ACSs [alternate care sites] if we assume that all health care providers are going to be needed to report to work in traditional hospitals or health care facilities?

Terri Gill: That is a great question, and it is one that we really struggled with in the Alternate Care Site Group. The way that we looked at it was that the alternate care sites would be a part of our emergency management organization. They would be plugged in to the operations section of the unified command in the area, and they would be activated at the request of the local government. Therefore, requests for staffing would first go through the emergency management system and then attempts would be made to find the appropriate staffing via various mechanisms. We have the California Medical Volunteers Database, which health care professionals throughout the State register in, and they can be actively deployed. Their credentials are checked on a routine basis so that we can verify they are still active and moved to the necessary locations. We then looked at alternate types of providers that would be available—people with licenses that had lapsed and things of that sort—and looked at ways that those could be activated in a medical surge and establish protocols whereby we could do that. We also gave, in our Alternate Care Site Manual, recommendations for staffing ratios and the types of clinical staff you would want to have on board, as well as ancillary and support staff and various places one can acquire that staff. For example, we have Calnet teams that can be requested though the emergency management organization. Of course, you have your CERT teams and the DMAT teams that could be requested through the emergency management organization. Ultimately, the request will go through the emergency management organizations that are in the community and then that emergency management organization will tap into a variety of resources. Of course, what resources are available depends on the event; if you're talking a pandemic it's going be in a short supply for everybody, but if you are talking about a localized earthquake, they will tap into resources throughout the State and, of course, the Feds to make sure we can activate those alternate care sites at an appropriate level.

Cindy DiBiasi: Nancie, with the cross-departmental statutes and regulations workgroup, is this related to liability or to something else?

Nancie McAnaugh: No. It's actually related to—for example, Missouri licenses hospitals. Not all States do. While all of us are going to have an issue as far as CMS guidelines and regulations that will need to be modified should we have a mass casualty event, we have some statutes and State-based regulations that we needed to take a look at waiving in a mass casualty event both in our Department as well as the Department of Mental Health. That really is what the cross-departmental group is looking to do is to pre-identify those regulations and statutes we feel need to be waived, so that when the Governor issues his executive order allowing for altered standards, those regulations and statutes are attached to that executive order, so everybody knows what they're operating under. Then this group will also be pre-identifying, pre-informing all the health care system on exactly what the expectations will be so there's not a surprise when we have a mass casualty event.

Cindy DiBiasi: Chris, a very practical question, how would EPRI work if Internet access were lost during a disaster event?

Chris Feller: One of the great things about the Internet is that it was developed by the military several years ago, quite a few years ago, not to fail. Being this is an Internet-based tool, the hosting company that AHRQ and Abt Associates has decided to use has over 50 redundant sites across the United States. In the event that we lose Internet access within our own organizations, we've all had the opportunity, through Federal grant funding, to purchase equipment such as satellite phones that we could tether to our laptops and provide us with the Internet access needed. Also, through our regional coordinators both public health, health care, and law enforcement, fire, police, EMS, and EMAs on a monthly or quarterly basis were also taking the redundancy part of the EPRI tool and printing off a paper copy of what resources are available. That is then housed in the county emergency management agencies for usage later.

Cindy DiBiasi: Terri, did you look at home care and community care centers for those that can't stay in their homes as important linkages to government-authorized ACSs, and how do you see this linkage being supported?

Terri Gill: We looked at home care as an option, but not necessarily attached to an alternate care site. It would be in the communications that could go out to the public prior to a patient presenting either at a hospital or an alternate care site giving them the information about when you would not present and therefore relieving that burden on the health care system. We are looking further down the road for how the home health care community fits in this surge model and that's part of what we're looking at now, but it was outside of the alternate care site. We did look at family members providing care in the alternate care site with some just-in-time training to take vital signs and that sort, but not necessarily moving patients from the alternate care site to a home health agency or vice versa.

Cindy DiBiasi: Nancie, don't the local emergency planning communities deal mainly with hazardous materials incidents?

Nancie McAnaugh: No. In Missouri, we and our State Emergency Management Agency have strongly encouraged our local emergency planning groups to embrace health care readiness, as well. It is a systems perspective, and they are the natural conduit at the local level to be doing this kind of planning. It is taking place in every State, better in some parts of the State than others, but that would be the ultimate goal is that your local emergency planning committees would be stepping up and really taking responsibility for global planning efforts, not just response to hazardous material incidents.

Cindy DiBiasi: Chris, is EPRI for use by regions or can it be used statewide?

Chris Feller: EPRI can be used statewide. Obviously, you are going to have a much larger project in collaborating resources and making sure you have various entities on board, but EPRI can be used at the individual institution level and go all the way to the State level.

Cindy DiBiasi: Now, I have a question for all of you, but I'm going to start with Nancie. Do any of you allow public access to these plans that you discussed and, if so, where?

Nancie McAnaugh: Our Ventilator Allocation Protocol currently is still in a draft format. We will be publishing it online and having focus groups around the State once we finalize it. Currently, since we're still working on the draft, it's not published anywhere on the Web site, although all our mass casualty meetings are open meetings that anybody can attend.

Chris Feller: From a resource standpoint, we try to keep a lock and key on where our resources are, how much of our resources are available, and how soon we can get them. We're certainly able to talk with other communities and other organizations across the State and country to implement a similar program.

Cindy DiBiasi: You have been talking to these people?

Chris Feller: Yes. We talked to several different groups. We've talked to people from the State of Michigan, Florida, and California.

Cindy DiBiasi: Terri, how did you establish temporary statutes to govern the ACSs since you didn't use existing statutes?

Terri Gill: Let me step back just a minute and answer the previous question. You can access all of our materials at our Be Prepared California Web site. It's Right now, we have posted the hospital volume, the alternate care site volume, our foundational knowledge, and the payer volumes, as well as the supporting tools. We will be coming out with long term care facilities, licensed health care clinics, and a licensed health care professionals' volume, as well. Those will be coming out sometime soon here.

Your other question—the liability issue—when you look at liability, you are looking at two different issues. What we found in our study is that many of these liability factors were already addressed in California statute. First is facility liability and under California, let me look at the code number for you so you can use it as an example. Under California Civil Code section 1714.5, any facility that is used as an alternate care site has liability protection. Then you are talking about professional liability. Because we're doing government-authorized alternate care sites, when a person is tasked to perform services at an alternate care site they become a disaster service worker and as such they are afforded certain immunities, as well as other parts of our law. Of course we have executive orders, which can suspend certain parts of law, as well. Barring anything other than a willful omission, basically liability issues are covered under existing statutes in California.

Cindy DiBiasi: Nancie, was there a reason why specialty care like dialysis was not on your list of pre-hospital, hospital, ACS, and palliative care?

Nancie McAnaugh: No. There wasn't because it's definitely something we've been looking at. When you talk about earthquake planning obviously dialysis is a huge part of that. So there was no reason why it was not done.

Cindy DiBiasi: Chris, our region is already using a bed-tracking system, what additional resources does EPRI track?

Chris Feller: EPRI tracks any resource you can put on paper. Being in NIMS compliance, it will track everything from a bulldozer to a rescue boat to an airplane. We really got away from individual bed tracking within this system, as we have another system in the State of Ohio that handles our bed tracking. With this having open-ended architecture, anything you could want to track you have the ability to track in EPRI.

Cindy DiBiasi: Nancie, what process was used to establish the topic areas for emergency preparedness planning? Was there a prioritization system that was used?

Nancie McAnaugh: I'm not quite sure I fully understand the question. On the one slide that talked about the Mass Casualty Care Plan, those were actually just chapters that were contained within the Mass Medical Care With Scarce Resources document, so that's why the prehospital, hospital, AFC, that's why those were listed. Those are individual chapters within that document.

Cindy DiBiasi: Terri, this cache of goods for an ACS—is this something you'll have on hand prior to an outbreak of disease or pandemic, or would you try to acquire the goods after the outbreak has occurred?

Terri Gill: We actually have them now. They're stored in various places throughout the State. We actually deployed one of our caches during the 2007 fire storms in San Diego, so those are located in various parts of the State as we speak and can be deployed at a moment's notice.

Cindy DiBiasi: And in your cache planning, you mentioned IV fluids. What provisions have been made for access to other pharmaceuticals in an ACS environment?

Terri Gill: We'll draw upon the various resources. We have resources in the alternate care site cache, and if you go to our Be Prepared California Web site, you'll see the list of those and then, of course, we can access the Strategic National Stockpile and various other things. As a State, we stockpiled certain pharmaceuticals ourselves for pandemic influenza and such. So all of those are being stored in a variety of places in California. We also have Chem packs, and those can be deployed throughout our Emergency Management system as needed.

Cindy DiBiasi: I have a question for all of you, and Terri, I promise not to forget you this time. Have any of you tried to involve physician or medical staff offices in your emergency preparedness planning?

Chris Feller: We have tried to do both and have actually done it somewhat successfully. From a physician standpoint, we wanted to make sure we were tracking the appropriate medical supplies that they would need or would want to use in a time of a disaster. So that has actually worked very well for us. Through our ASPR funding, we also do in Ohio what is called tier two planning. Our tier two planning is where we engage our nursing homes, acute care facilities, doctor's offices, physician's offices, things like that, into emergency planning. We certainly left the door open to them if they want to be part of the EPRI tool. We'll be more than welcome to involve them, but now we've started bringing them into emergency planning as a whole.

Cindy DiBiasi: Nancie?

Nancie McAnaugh: We do have about seven physicians that currently sit on our Altered Standards of Care Committee and our Scarce Resource Allocation Committee. We invited a couple of larger physician groups in the Central Missouri area to participate and have not been successful in getting representation, and we will continue to try to involve physician groups. At the local level, our local public health agencies have been engaging physician's offices and long term care facilities, nursing homes, residential care facilities, in the planning process. So there has been a broader effort to involve physicians in these discussions.

Cindy DiBiasi: Terri.

Terri Gill: We actually involved a lot of clinicians in our Surge Standards and Guidelines Project throughout. As a matter of fact, the project is kind of morphing in to our new Crisis Standards of Care Project, which is the clinical application of the move from individual-based care to population-based care. The physicians are critical in that component. So we are actively engaging the clinicians in a variety of ways, and we couldn't do this without them.

Cindy DiBiasi: To Nancie, I am the Director of Nursing at a facility for the intellectually disabled and developmentally disabled in New York State. We provide residential and day treatment services. There's been very little planning addressing the population we serve. Any way to address this?

Nancie McAnaugh: I think we're kind of fortunate in Missouri because we actually fund in our State Department of Mental Health a couple of disaster preparedness positions, and it really is their job to be working statewide with both public and privately based mental health facilities to develop response plans for pandemic influenza, as well as mass casualty events. I guess my recommendation to you would be to contact whatever the equivalent of the Department of Mental Health would be in the State of New York and have the discussion with them about emergency preparedness, and see if you can't get a group started in the area to address some of these issues.

Cindy DiBiasi: Terri, before I ask you the next question, we have had a lot of requests for you to repeat the Web site.

Terri Gill: Ok. It is If you look under health care providers you will see a link to Surge Standards and Guidelines. I did check this morning, if you go to Yahoo and put in bepreparedcalifornia, it will lead you to that link.

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