Integration of Emergency Management

into Healthcare

Paul D. Biddinger, M.D. F.A.C.E.P.

MGH Endowed Chair in Emergency Preparedness

Director, Center for Disaster Medicine and Vice Chairman for Emergency Preparedness,

Department of Emergency Medicine, Massachusetts General Hospital

Medical Director for Emergency Preparedness, MGH and Partners HealthcareDirector, Harvard T.H. Chan School of Public Health Emergency Preparedness Research, Evaluation and Practice

(EPREP) Program

Overview

• Review of disaster epidemiology

• Benefits of an emergency management

approach

• Key components of a hospital-based emergency

management program

@MGHDisasterMed 2

Disaster Events are Increasing

Source: The Economist https://www.economist.com/blogs/graphicdetail/2017/08/daily-chart-19

Global Terrorism

4Source: Global Terrorism Index 2015

Active Shooter Events

Source: FBI

Emerging Infectious Diseases - 1984

Anthony Fauci Testimony to Congress 1984

Emerging Infectious Diseases - 2004

The challenge of emerging and re-emerging infectious diseasesDavid M. Morens, Gregory K. Folkers & Anthony S. FauciNature 430, 242-249(8 July 2004)

Factors Driving Disaster Impacts

• Population is:– Growing

– Increasingly urban

– Increasingly coastal

• 1B people live in coastal areas at risk of flooding

• Climate change

• Violent conflicts

• Global travel

• Changes in animal farming

• Others….

Hugo Ahlenius, UNEP/GRID-Arendalhttp://www.grida.no/graphicslib/detail/human-impact-in-the-coastal-zones_80d7

Healthcare Sector Emergency

Preparedness

• Essential for preservation of life and health

• Differs substantially from traditional first responder preparedness and response– Public health infrastructure tremendously varied in the

US

– Health care is delivered in many very different venues (acute hospitals, clinics, rehabs, nursing homes, etc.)

– Nearly all hospitals are private entities

– Little or no intrinsic coordination of entities

– System is at (or beyond) capacity on a daily basis

Healthcare Sector Emergency

Preparedness

• Increasing in visibility and importance

– Study of previous events more rigorous

– Demonstration of differences in outcomes

– Public demand for accountability

Why Utilize an Emergency

Management Approach?

• Improved incident recognition

• Improved mobilization of resources

• Standardized planning and response

• Improved situational awareness

• Enhanced coordination

• Faster recovery

@MGHDisasterMed 11

Healthcare Emergency

Preparedness Capabilities

• Capability 1: Foundation for Health Care and Medical Readiness – Health care organizations have strong relationships, identify hazards and

risks, and prioritize and address gaps through planning, training, exercising, and managing resources.

• Capability 2: Health Care and Medical Response Coordination – Health care organizations plan and collaborate to share and analyze

information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events.

• Capability 3: Continuity of Health Care Service Delivery – Health care organizations provide uninterrupted, optimal medical care to all

populations in the face of damaged or disabled health care infrastructure. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations.

• Capability 4: Medical Surge – Health care organizations deliver timely and efficient care to their patients

even when the demand for health care services exceeds available supply.

November, 2016 ASPR Healthcare Preparedness Program Capabilities

CMS Requirements

• Effective as of 2017, CMS now has Emergency

Preparedness requirements for Medicare- and

Medicaid-participating providers and suppliers

• The rule establishes national emergency

preparedness requirements to plan adequately

for both natural and man-made disasters, and

coordinate with federal, state, tribal, regional,

and local emergency preparedness systems

13

CMS’ EP Rule

• Applies to 17 provider and supplier types who must meet four core elements:1. Emergency plan – Must have a detailed plan based on a

risk assessment and use “all-hazards” approach

2. Policies and procedures - Must develop and implement policies and procedures based on the emergency plan and risk assessment that are reviewed and updated at least annually.

3. Communication plan - Must maintain an emergency preparedness communication plan that coordinates communications within the facility, across healthcare providers, with state and local public health departments and emergency management systems

4. Training and testing program – Must be able to demonstrate that staff have knowledge of emergency procedures and receive training at least annually. Must conduct drills and exercises to test the emergency plan or participate in an actual incident that tests the plan

14

Affected Providers and Suppliers

15Source: ASPR Tracie (www.asprtracie.hhs.gov) November 2, 2016

The Disaster Management

Cycle

• Mitigation

• Preparation (planning)

• Response

• Recovery

Risk Assessment

• Effective emergency management depends on an a

hospital’s Hazard Vulnerability Analysis (HVA):

• A systematic approach to recognizing hazards that may

affect demand for the hospital’s services or its ability to

provide those services.

Probability Consequence Preparedness Risk

The Need for Evidence-Based

Planning

• Historically, disaster planning has often focused more

on “myths” and how we would like disasters to happen

rather than how they actually happen

– Auf der Heide, E. The Importance of Evidence-Based Disaster

Planning Annals of Emergency Medicine 2006 (47) 34-49

• When tragic events occur, lessons are often “learned”,

re-learned, and re-re-learned because they planners

were unaware of the science

Response

• By definition, disaster events start by overwhelming

capabilities and with chaos

• An ideal disaster response brings order to the chaos as

quickly as possible to make the best possible use of limited

capabilities

• To do this, a hospital needs:

1. A management system that best supports command

and control

2. Systems and technologies to support optimal situational

awareness

3. Efficient and interoperable mechanisms to integrate with

key partners in the response

The Incident Command

System

Incident Commander

Public Information Officer

Safety Officer

Liaison Officer

Medical Officer

Compliance OfficerChiefs of

Services

Biological Agent

Supervisor

Nuclear Agent

Supervisor

Chemical Agent

Supervisor

Optimum Care

Committee Consult

Logistics Section

Chief

Deputy

Logistics Sec.

Chief-Support

Deputy

Logistics Sec.

Chief-Service

Material

Supplies Unit

Leader

Information

Systems/

Technology

Unit Leader

Nutrition and

Food Services

Unit Leader

Planning Section

Chief

Workforce Unit

Leader

Nursing/Allied Health

Staff Emergency

Credentialing Manager

Physician Staff

Emergency

Credentialing

Manager

Situation Status

Unit Leader

Patient Tracking/

Capacity

Monitoring Unit

Leader

Finance Section

Chief

Time Unit

Leader

Compensation/

Claims Unit

Leader

Cost/

Procurement

Unit Leader

Inpatient Units

Division

Supervisor

Peri-Op Area

Division

Supervisor

ED Division

Supervisor

Psychological

Support Group

Supervisor

Ancillary

Services Group

Supervisor

Deputy Ops.

Sec. Chief-

Research

Adult Unit

Leader

Obstetrics Unit

Leader

Psych Unit

Leader

Critical Unit

Leader

Case

Management

Unit Leader

Operating

Room Unit

Leader

Post-

Anesthesia

Care Unit

Leader

Central Sterile

Processing Unit

Leader

ED Triage Unit

Leader

HazMat Unit

Leader

ED Minor Unit

Leader

ED Urgent Unit

Leader

ED Critical Unit

Leader

Respiratory

Care Unit

Leader

Pharmacy Unit

Leader

Radiology Unit

Leader

Laboratory Unit

Leader

Patient Support

Unit Leader

Family Support

Unit Leader

Police and

Security Unit

Leader

Biomedical

Engineering

Unit Leader

Security Advisor

Recovery/

Demobilization

Unit Leader

Infection

Control Unit

Leader

Staff Support

Unit Leader

Telecom Unit

Leader

Senior EM Advisor

Environmental

Services Unit

Leader

Outpatient

Adult Unit

Leader

Outpatient

Pediatric Unit

Leader

Offsite Unit

Leader

Outpatient

Procedural Unit

Leader

Cancer Center

& Procedural

Unit Leader

Operations

Section Chief

Employee

Services Group

Supervisor

Labor Pool

Manager

Volunteer/

Interpreter Services

Manager

Pediatric Unit

Leader

Facility Unit

Leader

Damage

Assessment

Manager

Facilities

Engineering

Manager

Transportation

Manager

Deputy Ops.

Sec. Chief-

Ambulatory

Outpatient

Psych Unit

Leader

Subject Matter Expert(s)

Documentation

Manager

Morgue Unit

Leader

Periop Services

Facilities Unit

Leader

Periop Services

MM Unit

Leader

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Planning

• “…Plans are worthless, but planning is

everything. There is a very great distinction

because when you are planning for an

emergency you must start with this one thing:

the very definition of "emergency" is that it is

unexpected, therefore it is not going to happen

the way you are planning.”

Dwight D. Eisenhower. From a speech to the National Defense Executive Reserve Conference in Washington, D.C. (November 14, 1957)

“The Plan”

Well established processes for:

• Recognizing an “incident”

• Activation & notification

• Effective mobilization

• Rapidly achieving and maintaining situational awareness

• Timely and informed decision-making

• Effective implementation of decisions…

• Demobilization & return-to-readiness

MaHIMS Management Process

MANAGEMENT BY REACTION(Reactive)

Response Phase

Notification

MANAGEMENT BY OBJECTIVE(Proactive)

Response Phase

IncidentRecognized

First Response& initial

assessment

TacticalManagement

addressesimmediate needs

TransitionalMANAGEMENT

MEETING

establishesIncident Manager (IM)

& possiblyUnified Management (UM)

IM/UM sets overall

incident objectives& priorities

MANAGEMENT

MEETING

evaluates & revisesincident objectives

Assess progressutilizing measures

of effectivenessExecute AP &

initiate planningfor the next

Operational Period

Information processing²

& Supportive Plans³ development

OPERATIONS

BRIEFING

briefs theoperational

leaders on theAP

PLANNING

MEETING

develops incident strategy & tactics to

accomplish the incident objectives

The Planning

Cycle

Beginningof Operational

Period

Action Plan

(AP)¹

preparation

& approval

Figure adapted from: Planning Cycle, U.S. Coast Guard Incident Management Handbook,U.S. Coast Guard COMDTPUB P3120.17 April 2001

¹ ACTION PLAN (AP): A written description of the incident

objectives, strategies, tactics, and supporting plans for a

specific operational period.

² INFORMATION PROCESSING:

• Community health surveillance

• Patient tracking

• Resource status

• Boundary functions information

• Expert information

• Functional area reports

³ SUPPORTIVE PLANS:

• Health & Safety Plan

• Event Epidemiological Projection

• Alternative Strategies

• Contingency & Long-Range Planning

• Demobilization Planning

HCF A HCF CHCF B Healthcare Asset Management(EMP+EOP using incident management)

1st Tier

Medical Surge Capacity & Capability:

An Integrated Management System

2nd TierHealthcare “Coalition”(Mutual Aid & Support/Info Sharing/Coordination)

Jurisdiction I

(PH/EM/Public Safety)

Non-HCF

Providers

Medical

Support

3rd TierJurisdiction Incident Management(Medical IMS & Emergency Support-EOC)

4th Tier

Jurisdiction II

(PH/EM/Public Safety)

State Response & Coordination of Intrastate Jurisdictions

(Management coordination & support)

5th Tier

Federal Response(Support to State & locals) 6th Tier

Interstate Regional Coordination(Management coordination & Mutual

support)State A State B

Federal Response

(Regional & National)

Healthcare Coordinating Coalitions

@MGHDisasterMed 25

Specialty Responses

• Specialty annexes to the Emergency Operations Plan (EOP) must be developed to respond to unique situations that require special pre-planning and capabilities:– Mass casualty incidents (MCIs)

– Novel infectious disease outbreaks

– Hospital evacuation

– Active shooter/security threats

– Information systems downtime events

– Utility failures

– Chemical/hazmat events

– Nuclear/radiological events

– Inpatient and/or outpatient “surge”

– Fire

– Others

Anticipatable Challenges with

MCI Response

• The hospital’s notification interval will be very short, if it

exists at all

• Incident information will be inaccurate, incomplete, or

both

• The closest hospital is likely to be overwhelmed

• Patient distribution to other facilities may be uneven

• Patients will arrive by mechanisms other than EMS

• The ED and hospital will likely be full

• Triage must be brief, but must also be repeated

• Morbidity and mortality are likely to rise when the system

gets saturated

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Hospital Actions Required

Within 5-10 Minutes

• Assess available information about the incident

• Notify hospital and departmental leadership

• Establish a command structure

• Secure the facility

• Communicate with on-site staff about the event

• Move existing patients out of the ED

– ED staff

– Admitting office

– Nursing supervisors

– Hospitalists/internists

– Patient transporters

• Prepare for MCI triage and patient tracking

28@MGHDisasterMed

Hospital Actions Required

Within 5-10 Minutes

• Mobilize maximal number of bedside staff to conduct multiple simultaneous resuscitations– Emergency medicine

– Trauma surgery

– Surgical subspecialists

– Anesthesia

– Others

• Mobilize sufficient supporting personnel, materials and resources – Imaging (X-ray, CT, others)

– Respiratory care

– Blood product support

– Lab evaluation

– Physical carts of resuscitation supplies

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Essential Elements of a

Hospital MCI Protocol

1. Facility security

2. Triage

3. Patient registration

4. Patient tracking

5. Creation of immediate

ED capacity

6. Creation of

resuscitation teams

7. Creation of OR

capacity

8. Creation of support

capacity

• Blood bank

• Labs

• Imaging

• Morgue

9. Creation of inpatient

capacity

30@MGHDisasterMed

Training and Exercising

• Historically, the major focus of preparing clinical responders

for disasters has been via didactic education

• However, few clinicians remember much, if any, of this

training after 6-12 months

• Few also know specifically what their roles and responsibilities

in such events would be

• Robust disaster exercise programs are needed to find flaws

in plans and to train staff before the disaster occurs

• Performance in a disaster is highly correlated with having been

involved in a previous disaster

Special Tools to Support

Communication and Coordination

• Electronic notification systems– Private systems

– HHAN

• Web-based secure portals– WebEOC

• Alternative communications technologies– Radios

– Satellite phones

– HAMs

– Others…..

Persistent Challenges

• Access to disaster planning expertise

• Adequately supporting training and readiness

• Creating surge capacity

– Staff

– Stuff

– Space

• Funding

THANK YOU