Operation PREP November 15th, 2006

1
Operation PREPNovember 15th, 2006

• New England Center for Emergency Preparedness
• Dartmouth Medical School

2
Overview

• Introduction and Background
• Exercise Objectives
• Activities and Observations
• Reactions and Lessons Learned
• Recommendations
• Conclusions, future directions

3
Introduction and Background

• Cooperation of multiple organizations is key to a
  successful disaster response.
  
• In a disaster, organizations that dont often
  work together will have to.
  
• Practice will ensure this collaboration and
  cooperation are effective
  
• Hanover/Lebanon Region, Wednesday, November 15th,
  2006 Functional exercise to practice cooperation
  of multiple partners
  

4
Partners

• Town of Hanover
• City of Lebanon
• Dartmouth-Hitchcock Medical Center (DHMC)
• Dartmouth College
• Northern New England Metropolitan Medical
  Response System (NNE MMRS)
  
• New England Center for Emergency Preparedness
  (NECEP)

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Hospital Objectives

• Demonstrate
• Ability to respond to an infectious respiratory
  disease epidemic
  
• Critical ICS sections
• Ability to communicate both internally and
  externally
  
• Ability to coordinate with senior leadership at
  DHMC
  
• Ability to secure the facility set up external
  triage at the Emergency Department

6
Hospital Objectives

• Demonstrate
• Ability to track patients using HC Standard
• Decision-making process for requesting community
  ACC
  
• Ability to identify patients to discharge or
  transfer to ACC in order to create hospital surge
  capacity
  
• Decision-making process for transfer of 25
  patients to community ACC
  
• Ability to vaccinate health care workers to allow
  continuity of care in an infectious disease
  outbreak situation
  

7
Community Objectives

• Practice
• Setting up an Emergency Operations Center and
  implementing Incident Command Structure
  
• Communicating with hospitals and State agencies
• Setting up an Acute Care Center (ACC)
• Admitting 50 patients to the ACC
• Tracking these 50 patients using new software
  Health Care Standard (HCS) for patient tracking
  and Athenahealth for Electronic Medical Records

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Activities and Observations
Hospital Objective Demonstrate ability to
respond to an infectious respiratory disease
epidemic

• Tested implementation and functionality of the
  Epidemic Respiratory Infection Readiness Plan.
  
• An All Hazards plan should be developed to fit
  all events.
  
• Individual department plans exist, but are not
  collated into an all-hazards plan
  
• ICS staff should be flexible about how they use
  the plans.

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Activities and Observations
Hospital Objective Demonstrate critical ICS
sections

• First time DHMC has used ICS in functional
  exercise.
  
• Majority of staff in the EOC felt they understood
  the chain of command, and felt confident in their
  ability to fulfill their role.
  
• Excellent staff turnout at the EOC
• For effective decision-making in the EOC, only
  key staff should participate in conversations
  with the IC.

Diagram Source www.fema.gov
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Activities and Observations
Hospital Objective Demonstrate ability to
communicate both internally and externally
ability to coordinate with hospital senior
leadership

• Phone lines in the EOC were functional
• Cell phones were not always operational
• Email was used extensively for internal
  communication.
  
• HANs had to be redistributed as only one member
  of staff was registered to receive them
  
• Patient tracking software worked well for
  internal and external communications.
  
• DHMC needs to incorporate a centralized emergency
  communications plan in their EOP.

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Activities and Observations
Hospital Objective Demonstrate ability to secure
the facility and establish external triage at
Emergency Department

• ED staff assigned by the EOC went outside to
  assess and triage the patients on the bus.
  
• Patients were not allowed into the building in
  order to avoid potential contamination.
  
• Identified need for specific instructions and
  protocol for establishing an external triage area
  during an infectious disease outbreak.

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Activities and Observations
Hospital Objective Demonstrate ability to track
patients

• Entering the patients into the patient tracking
  system paralleled assessment of patients in the
  triage area.
  
• HC Standard and current patient admitting system
  would need to be linked to avoid duplication of
  effort and be effective in a real event.
  
• It did not appear that the patient tracking
  system would severely interfere with the flow of
  patients.
  
• athenahealth was not tested at DHMC triage
  location as planned.

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Activities and Observations
Hospital Objective Demonstrate decision-making
process for requesting an Acute Care Center (ACC)

• Discussion of how to best utilize this facility
  
  
• Decided to transfer all infectious Morbus
  patients to the ACC as a temporary isolation
  facility for further observation
  
• Goal cohort and observe these patients until it
  could be determined if they were sufficiently ill
  to require critical care, and minimize exposure
  of staff and other patients.
• Decision-making process in this area was
  efficient, sound and very effective.
  
• The IC discussed the possibility of using another
  facility as a clean facility for transferring
  non-infectious inpatients to create additional
  hospital surge capacity.
• Protocol for requesting community assistance for
  medical surge is not included in hospital
  emergency response plans at this time

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Activities and Observations
Hospital Objective Demonstrate ability to
identify patients to discharge or transfer to ACC
in order to create hospital surge capacity

• Identified more than 60 inpatients for immediate
  discharge
  
• Established a discharge center to immediately
  open necessary beds
  
• Incident Commander cancelled elective procedures
  for the day procedures scheduled for the
  following day were put on hold until further
  notice
• Hesitant to cancel all procedures due to
  financial implications
  
• All patients in one inpatient unit were moved to
  other areas of the hospital so that this unit
  could become an internal cohort unit if necessary

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Activities and Observations
Hospital Objective Demonstrate ability to
transport 25 patients to community ACC

• Physical transfer was not tested.
• Discussion about how to transfer them to the ACC,
  including the possibility of instructing patients
  to drive themselves there.
  
• Led to an in-depth discussion of liability on the
  part of the hospital and the need to treat and
  stabilize arriving patients.
  
• Incident Commander did not want to tie up the
  ambulances transferring stable, non-critical
  patients.
  
• Decided to stop running local transportation
  company shuttles and use those busses to transfer
  Morbus patients to the ACC.
  
• Patients would be accompanied by staff members
  from Security and the Emergency Department. All
  staff on the bus, including the driver, were
  instructed to wear appropriate personal
  protective equipment (PPE).

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Activities and Observations
Hospital Objective Demonstrate ability to
vaccinate health care workers to allow continuity
of care in an infectious disease outbreak
situation.

• Three 12-hour vaccination clinics where employees
  were provided the seasonal flu vaccine at no
  cost
  
• Advertised to staff via the intranet
• Participation was encouraged by department
  directors.
  
• Clinics were patterned after the New Hampshire
  POD planning guidance.
  
• 2,890 employees were vaccinated
• Average wait time of one minute.
• A much larger number of employees could have been
  managed with the same level of staffing if
  necessary.

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Results and Reactions - Hospital

• DHMC exercise participants demonstrated the
  capability to
  
• Initiate specialty teams within the ICS that were
  able to think and act independently, helping to
  address organization and community response.
  
• Communicate with the NH DHHS on the phone, with
  hospital senior leadership through in-person
  briefings, and with hospital employees through
  email.
• Create hospital surge capacity by transferring
  and discharging stable patients.
  
• Utilize community medical surge capacity
  resources to maintain hospital capacity for
  critically ill patients.
  
• Identify local transportation resources which
  could be used to move large numbers of patients
  in a safe and efficient manner.
  
• Vaccinate large numbers of health care workers to
  maintain continuity of operations in an
  infectious disease outbreak.

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Results and Reactions - Hospital

• Major areas for improvement
• Further training in ICS would be beneficial
• Desire to be collaborative will impede
  decision-making process in real event
  
• Newly released HICS IV
• Emergency response plans need to be refined for
  flexibility, completeness
  
• Useful in all emergency situations
• Cover all bases communication, transportation,
  surge capacity
  

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Activities and Observations
Community Objectives Practice setting up
Emergency Operations Center and implementing
Incident Command Structure. Practice
communicating with hospital and State.

• Hanover emergency planners set up EOC in new
  location what to bring?
  
• Practice with ICS not all familiar with chain
  of command
  
• Job Action Sheets and diagram assisted ICS
  set-up
  
• Communication cell phones, landlines, internet
  did not test radios

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Activities and Observations
Community Objectives Practice ability to track
50 patients in a POD

• SNS resource tracking requirement
• Efficiency
• Accountability full record for each patient

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Activities and Observations
Community Objectives Practice setting up an
Acute Care Center

• Multiple organizations NNE MMRS NH Strike Team,
  HFD
  
• Besides Hanover FD, none of these people had ever
  worked together before
  
• Determine ICS Job Action Sheets and diagram
  helpful
  
• Physical set up of Cabelas cots Supplied by
  Hanover
  
• Receiving and unloading of medical supplies from
  DHMC
  
• Secure facility

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Leverone Field House
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Activities and Observations
Community Objectives Practice admitting 50
patients to ACC

• Local High School and Dartmouth students
  volunteered as patients
  
• No acting each received a patient card with a
  description of symptoms
  
• Strike team admitted patients
• No patient care given
• Written orders to track activities, use of staff
  and supplies

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Activities and Observations
Community Objectives Practice tracking 50
patients in ACC using patient tracking and
electronic medical records software

• Patients given tag with bar code at triage (ED,
  NEHC)
  
• Scanned at every point of contact discharge
  facility, transfer, receiving
  
• Handheld scanners (HCS) are multipurpose tool
• HCS linked to WebEOC, monitors anything and
  everything
  
• Athena tracks care given, resources used

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Results and Reactions - Community

• Strike team worked well together, especially
  considering they have never done so before this
  exercise!
  
• Need some non-medical personnel at the ACC to
  handle administrative and custodial duties
  
• Need simple instructions on how to set up an ACC
  very few people know exactly how to do it!

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Results and Reactions - Community

• Supplies are a big issue how do we get the
  supplies to the people who need them?
  
• DHMC coordinated the supplies they sent with the
  Logistics Trailer inventory
  
• State Logistics Trailer was unavailable for the
  exercise
  
• Pre-printed admission and discharge forms

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Results and Reactions - Community

• Clear lines of communication between State, local
  and hospital EOCs, and ACC are a must
  
• Not always clear who should call which
  organization for what information
  
• Periodic practice and training in ICS and review
  of emergency response plans will make this
  process more familiar and comfortable during an
  actual incident

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Recommendations

• Planning
• DHMC should review current emergency response
  plans, and ensure they are flexible enough to be
  useful during a public health emergency.
  
• DHMC should develop annexes to this plan,
  including an emergency communications plan, and
  mass transportation.
  
• DHMC should review medical surge capacity plans
  and protocol for requesting assistance from the
  community.
  
• NNE MMRS should review the ACC Concept of
  Operations document in relation to NIMS and HICS
  guidance to ensure compatibility.

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Recommendations

• Operational
• Additional education and practice in ICS is
  needed by both DHMC staff and the NH Medical
  Strike Team.
  
• Before any IT systems are used, staff will
  require extensive training in them. Just-in-time
  training should be created where appropriate.
  

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Recommendations

• Training and Education
• NNE MMRS should continue to educate medical
  strike team members on ICS and procedures for
  opening and operating an ACC.
  
• DHMC should continue to education staff on ICS,
  emphasizing new HICS IV guidance
  

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Recommendations

• Future Exercises
• Additional exercises should exercise other
  components of hospital and community surge
  capacity, including staff shortages, and supply
  use.
• Incorporate additional partners and stakeholders
  in future exercises, including those from
  neighboring states.
  

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Conclusion

• Collaboration is key to success
• Fire, police, emergency managers, hospital, EMS,
  local physicians and nurses, nursing home
  facilities, Visiting Nurses Association, schools,
  businesses
• Supplies
• What do you have?
• What do you need?
• How can you get it? (Hint be creative)
• Practice makes perfect!

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Resources

• NNE MMRS www.nnemmrs.org
• Guidance for planning exercises and drills,
  medical surge capacity documents, including ACC
  Concept of Operations
  
• NECEP http//dms.dartmouth.edu/necep
• Department of Homeland Security www.dhs.gov
• Centers for Disease Control www.cdc.gov
• Department of Health and Human Services
  www.dhhs.gov
  
• Contact
• Reiley Lewis MPH
• New England Center for Emergency Preparedness
• Colburn Hill, HB 7462
• One Medical Center Drive
• Lebanon, NH 03756
• Office [phone]
• Reiley.S.Lewis_at_Dartmouth.edu