EFFECTIVEEMERGENCYMANAGEMENTDRILLS ANDEXERCISES

Greater New York Hospital Association

EFFECTIVE EMERGENCYMANAGEMENT DRILLS ANDEXERCISES

FOREWORD

This booklet has been prepared as part of GNYHAs continuing efforts tohelp its members undertake effective and efficient drills and exercises,specifically for emergency preparedness and response. It also explains therationale for conducting emergency management drills and exercises.

The booklet is intended for health care professionals involved withemergency management and response activities at all levels.

GNYHA is committed to ensuring that its members are prepared torespond to the wide range of emergencies, disasters, and events thatmight take place in the areas where they are located. As part of thatcommitment, GNYHA has undertaken a variety of initiatives to assist itsmembers in implementing effective emergency management drills andexercises.

In the aftermath of September 11, 2001, GNYHA created its EmergencyPreparedness Coordinating Council (EPCC). The EPCC brings togetherrepresentatives of GNYHA members and other provider groups as well aslocal, state, and Federal public health officials and emergencymanagement agencies to encourage collaboration and communicationacross the region and, ultimately, to ensure a more integrated response toany future attacks or events.

GNYHA has also created a Workgroup on Emergency Management Drills,which consists of members of the EPCC (both GNYHA member andgovernmental representatives), as well as additional GNYHA members withspecific expertise in undertaking emergency management drills for theirinstitutions. Through this workgroup, GNYHA has designed a number ofworkshops consisting of didactic sessions and small group sessions with acurriculum tailored specifically to health care facilities to assist them inundertaking effective exercises. The materials from the workshops are

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available online in the Drills and Exercises section of the EmergencyPreparedness Resource Center on GNYHAs Web site, www.gnyha.org/eprc/general/drills_exercises.

Following actual emergency events (for instance, the regional poweroutage of August 2003), GNYHA has held debriefing sessions withmembers and governmental agencies to discuss lessons learned fromthose events. GNYHA staff has also coordinated the hospital componentfor numerous exercises organized by the New York State Department ofHealth, the New York City Department of Health and Mental Hygiene, theNew York City Office of Emergency Management (OEM), the WestchesterCounty Department of Emergency Services, and other governmentalagencies that have held regional emergency management exercises.Finally, GNYHA has organized two tabletop exercisesone in June 2003designed by the Naval War College, and the other designed by GNYHAsWorkgroup on Emergency Management Drills in June 2004as well asfour drills of the New York State Health Emergency Response Data System,known as HERDS, and drills of OEMs 800 MHz radio system.

ACKNOWLEDGMENTS

GNYHA would like to thank its Workgroup on Emergency ManagementDrills, and specifically Karen Biancolillo, R.N.; Kevin Brown, M.D.; KevinChason, D.O.; Andrew Chen; Jack Delaney; Dario Gonzalez, M.D.; MarkMarino; Frank Mineo; Brian ONeill; Steven H. Silber, D.O.; and JosephStevens.

This brochure was produced by GNYHA and funded by a generous grantfrom the Federal Health Resources and Services Administration to theNew York State Department of Health and Health Research, Inc., undergrant/contract number 6U3RMC000260203.

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THE FOUR PHASES OFEMERGENCY MANAGEMENT

Effective emergency management takes into account an all-hazardsapproach that includes the following four phases: mitigation,preparedness, response, and recovery.

Mitigation activities, according to the Joint Commission onAccreditation of Healthcare Organizations (JCAHO), are those that ahospital undertakes in attempting to lessen the severity and impact ofa potential emergency.1

Preparedness activities are those that a hospital undertakes to buildcapacity and identify resources that may be used if an emergencyoccurs.2

Response involves activating the plan (including the incidentcommand system, or ICS) and dealing with the actual event as itunfolds. In health care facilities, it usually involves treating victims ofthe emergency.

Recovery involves activities designed to help facilities resumeoperations after an emergency.

Drills and exercises should ideally test as many of the four phases ofemergency management as possible, although they may not necessarilytest them all at the same time.

PRELIMINARIES:THE HAZARDVULNERABILITY ANALYSIS

Before designing and undertaking drills and exercises, staff members whoare responsible for coordinating their facilitys emergency managementactivities (usually the emergency management committee) must developan emergency management plan. The staff designs the plans based on thefacilitys hazard vulnerability analysis (HVA). The purpose of the HVA is to

1. Joint Commission on Accreditation of Health Care Organizations, 2004 ComprehensiveAccreditation Manual for Hospitals, Environment of Care Standard 4.10 (Oakbrook Terrace,Ill., 2004).2. Ibid.

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identify potential emergencies that could affect the need for its [thehealth care facilitys] services or its ability to provide those services.3

Facilities that are accredited by the JCAHO are required to conduct anHVA.4 Facilities that are not JCAHO-accredited should also conduct one.

The purpose of the HVA is to enable a health care facility to identify, withinits emergency management plan, the possible emergencies that it mayneed to address and their probable impact if they were to occur.

When conducting an HVA, the facility staff should start by listing theemergencies that might affect the facility, including various factors inthe surrounding area. For example, is the area prone to floods? Is achemical plant located nearby?

The HVA should include internal events (such as fires) as well asexternal events (such as power outages).

The HVA should focus on the naturally occurring and man-madehazards that are most likely to have an impact on the facility and thesurrounding community (such as floods, HAZMAT incidents, terroristattacks).

The probability that those events will occur should then be considered.The analysis is based upon history as well as events that might nothave actually occurred but might be expected to occur.

Next, the staff should consider how each event will affect the facility(sometimes called the severity of an event). For example, will livesbe lost if the event occurs? Will the facility be damaged?

Finally, staff should review the extent to which the facility and thecommunity are prepared for each type of event. If an organization isnot well prepared for a certain type of incident, it might want todevote more resources to preparing for that type of incident. Similarly,if community resources would not be available to assist in addressingthe incident, then the facility would probably want to devote moreresources to addressing it.

An organization may undertake the HVA in a variety of ways. Theemergency management plan should reference the HVA in order todocument that it was undertaken. Several tools have been designed sothat health care organizations may undertake effective HVAs. Examples ofthese tools appear in Appendix 1 and on GNYHAs Web site,www.gnyha.org, in its Emergency Preparedness Resource Center.

3. Ibid.4. Ibid.

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DRILLS AND EXERCISESOnce an HVA has been completed, work can begin on making sure thatthe emergency management plan includes specific approaches topreparing for and responding to the emergencies that a health careorganization is likely to face. The plan should include the mitigation,preparedness, response, and recovery activities that will need to beundertaken in order to address the priorities identified in the HVA. Theapproaches can be rehearsed through various types of drills andexercises. Based on the outcome of those drills and exercises, theemergency management plan might be modified and improved.

TYPES OF DRILLS AND EXERCISES

Drills and exercises simulate or are based on possible real-life scenarios inorder to improve emergency management, and should be based on thevulnerabilities identified in each health care organizations HVA. There areseveral different types of drills and exercises.

Drill: A drill is a supervised activity with a limited focus to test a procedurethat is a component of the organizations overall emergency managementplan. That is, drills usually highlight and closely examine a limited portionof the overall emergency management plan. For example, an organizationmight conduct a drill for the use of a radio system with those responsiblefor communicating on it.

Tabletop Exercise: A tabletop exercise uses written and verbal scenarios toevaluate the effectiveness of an organizations emergency management planand procedures and to highlight issues of coordination and assignment ofresponsibilities. Tabletop exercises do not physically simulate specific events,do not utilize equipment, and do not deploy resources. In a tabletopexercise, a facilitator usually coordinates discussion.

Functional Exercise: A functional exercise simulates a disaster in the mostrealistic manner possible without moving real people or equipment to areal site. A functional exercise utilizes a carefully designed and scriptedscenario, with timed messages and communications between players andsimulators. The emergency operations center (EOC)the facility or areafrom which disaster response is coordinatedis usually activated during afunctional exercise and actual communications equipment may be used.

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Full-Scale Exercise, or Field Exercise: A full-scale exercise is often theculmination of previous drills and exercises. It tests the mobilization of allor as many as possible of the response components, takes place in realtime, employs real equipment, and tests several emergency functions. Inthe hospital context, a full-scale exercise often involves pre-hospital as wellas hospital response, and usually involves actors simulating patients andthe activation of the EOC. It may also include other health care facilities inorder to test mutual aid agreements. Controllers, who maintain orderand ensure that the exercise proceeds according to plan, are also usuallyused. Full-scale exercises are generally intended to evaluate the operationscapability of emergency management systems in a community and toevaluate interagency coordination.

RATIONALE FOR CONDUCTING DRILLS AND EXERCISES:ACCREDITATION AND REGULATORY STANDARDS

Hospitals that are accredited by JCAHO are required by JCAHOEnvironment of Care (E.C.) standard 4.20 to conduct drills regularly to testemergency management. Further, the elements of performance for E.C.4.20 include the following:5

Hospitals must test the response phase of their emergencymanagement plans twice a year, either in response to an actualemergency or in planned drills.

Drills that involve packages of information that simulate patients, theirfamilies, and the public are acceptable.

Hospitals must conduct drills at least four months apart and no morethan eight months apart.

Hospitals must conduct at least one drill a year that includes an influxof volunteers or simulated patients if the hospitals offer emergencyservices or are community-designated disaster receiving stations.For purposes of the influx of simulated patients requirement,tabletop exercises are not acceptable.

Hospitals must participate in at least one communitywide practice drilla year (where applicable) relevant to the priority emergenciesidentified in their HVAs. The drill must assess the communication,coordination, and effectiveness of the hospitals and communityscommand structures and may be conducted by means of a tabletop

5. Joint Commission on Accreditation of Health Care Organizations, 2004 ComprehensiveAccreditation Manual for Hospitals, Environment of Care Standard 4.20 (Oakbrook Terrace,Ill., 2004).

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exercise.Communitywide may range from a contiguousgeographic area served by the same health care providers to a largeborough, town, city, or region.

The drill involving the influx of volunteers may be separate,simultaneous, or combined with the communitywide practice drill.

Drills must be critiqued to identify deficiencies and opportunities forimprovement.

In addition, many state regulations require hospitals to conduct drills. Forexample, New York State regulations that apply to hospitals require eachhospital to have a written emergency and disaster preparedness planthat must be rehearsed and updated at least twice a year, withprocedures to be followed for the proper care of patients and personnel,including but not limited to the reception and treatment of mass casualtyvictims in the event of an internal or external emergency or disasterarising from certain events.6 The New Jersey Administrative Code requireseach hospital to conduct 1) at least one evacuation drill each year, eithersimulated or using selected patients, and 2) at least one drill a year inwhich a large influx of emergency patients is simulated.7 Under the NewJersey code, actual emergencies of each type are considered drills, if theyare documented. Even if they were not required, drills are a good way totest an emergency management plan.

GOALS AND OBJECTIVES OF DRILLS AND EXERCISES

Drills and exercises are an excellent means of determining whether a healthcare organization functions as anticipated in a disaster and, if not, as a way toidentify opportunities for improvement. They also provide an opportunity forstaff to practice their skills and to identify future areas for training. Whendesigning drills, the following objectives should be kept in mind:

Drills and exercises should be designed to clarify the roles andresponsibilities of those who are expected to respond to a disaster andto improve coordination among those responding.

The objectives of drills and exercises should state who should do what,under what circumstances, and according to what standard.

When designing drills and exercises, it is important to test theequipment that the staff will use during an actual emergency to ensurethat it functions correctly and that staff knows how to use it.

6. 10 New York Code, Rules and Regulations Section 405.24(g).7. New Jersey Administrative Code Section 8:43G-5.16(h),(i).

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EVALUATING DRILLS AND EXERCISES

Following an exercise, the evaluator (either someone from the health careorganization who is assigned that role, or an outside individual) shouldprepare a critique, also known as an after-action report. If otherorganizations (for example, Emergency Medical Services) haveparticipated, comments from those agencies should be requested as well.The use of external evaluatorsthat is, personnel who dont work for theinstitutionshould be considered, since they enhance objectivity and helpkeep staff out of difficult situations (such as evaluating supervisors).Outside evaluators may be from another hospital, an agency in thecommunity, or a party hired to help undertake the exercise.

An effective evaluation takes into account the observations of evaluators,players, controllers, and actors. Evaluation forms are usually used to recordthe observations. The person (or people) evaluating drills and exercisesshould observe the action, report on what goes well and what doesnt, notehow participants perform, and determine whether the goals and objectivesof the exercise are met.

In addition, the following approaches should be applied when evaluatingdrills and exercises:

An organizations emergency management committee, which ischarged with designing and reviewing the emergency managementplan, should also be charged with designing drills and exercises.

For an exercise to be effective, the players should be thoroughlyevaluated using measurable standards, such as the length of time ittakes them to decontaminate patients who have been exposed to atoxic chemical. Those standards should be specified in the exerciseobjectives.

An evaluation should also focus on the exercise itself. Was it welldesigned? Did it test what it was designed to test? A discussion (de-briefing) with actors and staff should also take place after the exercise,so they may share their experiences. The discussion should encouragecritical thinking and honest evaluation and should focus on thefollowing questions: What went right? What needs to be improved?How will improvements be made?

An effective evaluation should include suggestions for revising theemergency management plan, if necessary, and retraining after theexercise is completed in order to address specific problems that mighthave been identified.

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An example of an evaluation form appears in Appendix 2 and may befound at www.gnyha.org/eprc/general/presentations/Disaster_Eval_Tool.pdf. Additional evaluation tools developed by theJohns Hopkins Evidence-Based Practice Center for the Agency forHealthcare Research and Quality as well as by the U.S. Department ofHomeland Security can be found at www.ahrq.gov/research/hospdrills/index.html.

Federally Funded Drills and Exercises. Beginning in 2005, for drills andexercises that are undertaken using Federal funding (including hospitaldrills and exercises undertaken with Federal funding from the HealthResources and Services Administration), the Homeland Security Exerciseand Evaluation Program (HSEEP) will be the framework within which thosedrills and exercises will be initiated, implemented, and evaluated. Thepurpose of the program is twofold: 1) to evaluate performance on criticaltasks, and 2) to validate strengths and identify improvement opportunities,all with the goal of improved preparedness. Performance during drills andexercises will be analyzed at different levels, including task level, agency/discipline/function level, and mission level (within and across communities),and will be required to utilize both Homeland Security Exercise EvaluationGuides and HSEEPs After-Action Report template.

A link to HSEEP can be found at www.gnyha.org/eprc/general/drills_exercises/ under Design and Evaluation Tools.

DESIGNING A FUNCTIONAL EXERCISE: AN EXAMPLE

This example illustrates an approach to designing a functional exercise fora hospital. Please note that each hospital designing a similar exercisewould indicate specific symptoms for possible incoming patients.

Background. Hospital A is located near a subway station in New York City.In its HVA, Hospital A has identified the possibility of receiving patientswho have been contaminated as a result of a chemical terrorism event.Goals. The goals of the exercise are to test the hospitals emergencymanagement plan for mitigating the consequences of an event identifiedin its HVA (a chemical event, in this case), including decontamination, andto test the hospitals response, including the activation of the hospitalsincident command system.

Objectives. The exercise is intended to test the hospitals ability: to successfully prepare, within a specific period of time, for

decontaminating patients;

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to prepare staff on the decontamination team to be outfitted inpersonal protective equipment (PPE) within a specific period of time;

to prevent contaminated patients from entering the emergencydepartment without being decontaminated; and

to successfully decontaminate ambulatory and non-ambulatorypatients within a certain period of time after their arrival at theemergency department.

Measures. The exercise can be evaluated using the following measures: How long did it take the hospital to get its decontamination

equipment ready? How long did it take staff to be outfitted in PPE? Were patients stopped before entering the emergency department? How long did it take to decontaminate patients?

TIPS FOR DESIGNING EFFECTIVEDRILLS AND EXERCISES If you want to test your staffs ability to recall the emergency management plan and

respond accordingly, an unannounced exercise should be conducted. If you wantto motivate staff to review the emergency management plan (when they wouldnthave otherwise) and test their ability to get equipment ready, an announcedexercise is helpful.

Drills and exercises should be conducted to test or practice only what staff havebeen taught. Asking staff to undergo a drill or exercise before they have beentrained is like asking students to take a final exam before attending the course.

Allow several months to design the drill or exercise. Drills and exercises should be based on the real hazards that a health care facility

facesthat is, threats identified in its HVA and addressed in its emergencymanagement plan.

Maintain a limited focus. Dont try to test too many things at once. When undertaking a full-scale exercise, make sure that real patients continue to

receive care. For example, if the exercise is taking place in the emergencydepartment, make sure that staff continue to treat patients. Have a mechanism inplace for terminating the exercise if necessaryfor example, if the exercise iscausing harm to volunteers.

Consider conducting an exercise that addresses multiple facets of an emergency atone time (for example, preparing for a large influx of patients while experiencing apower loss).

When paper patients (sheets of paper or index cards with symptoms and otherinformation written on them) are used, they should be triaged, put on stretchers orin wheelchairs, and transported through the hospital as if they were real patients.

Remember to conduct drills and exercises during all shiftsday, evening, night,and weekendto test responses with various staffing levels. Use realistic staffingpatterns in exercises.

Remember to revise your emergency management plan based on what you learnfrom the drill or exercise.

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SUMMARY ANDCONCLUSION

One of the keys to successful emergency preparedness and response is aneffective emergency management planand in order to have an effectiveplan, it is critical to conduct well-designed drills and exercises before theplan is actually needed. This booklet provides you with some guidelines fordesigning and conducting drills and exercises.

The steps a health care facility must take to prepare for potentialemergencies and disasters that are specific to its geographic region are:

1. Conduct a hazard vulnerability analysis (HVA) to identify facility-specificthreats.

2. Prepare an emergency management plan based on the hazards andthreats identified in the HVA.

3. Design and conduct appropriate drills and exercises, taking intoaccount the hazards identified in the HVA and addressed in theemergency management plan.

4. Evaluate the outcome of the drills and exercises.5. Modify the emergency management plan as needed based on the

evaluation of the drills and exercises.6. Train staff in the modifications that have been made to the plan.

For additional information on drills and exercises, visit theDrills and Exercises section of the Emergency Preparedness ResourceCenter on GNYHAs Web site at www.gnyha.org/eprc/general/drills_exercises.

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APPENDIX 1

SAMPLE HAZARD ANDVULNERABLILTY ANALYSIS

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Hazard Assessment KP.xls

This document is a sample Hazard Vulnerability Analysis tool. It is not a

INSTRUCTIONS:

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Natural Hazards: Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Technological Hazards - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Human Hazards - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Hazardous Materials - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Hazard Assessment KP.xls Summary

APPENDIX 2

SAMPLE EVALUATION FORMFOR EMERGENCYMANAGEMENT DRILLS ANDEXERCISES

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Greater New York Hospital Association555 West 57th Street, 15th FloorNew York, New York 10019212.246.7100 / FAX 212.262.6350www.gnyha.org