This exercise program was developed and made available by the Missouri Hospital Association through funds from the ASPR Hospital Preparedness Program CFDA 93.889, through a subcontract from the Missouri Department of Health and Senior Services for the purposes of individual hospital preparedness and exercise. Sources used in the development of these materials are noted in the Notes Section except where general knowledge.

96 Hour Hospital Sustainability

Can We Make It?

Presenters

[Complete with presenter’s information]

Objectives

Overview of TJC 96 hour rule Strategies to “go the distance” Potential for Ice-Storms and other Severe

Winter Weather in [your area] Strengths and weaknesses related to

extended period without external resources

Strategies and next steps to “mitigate” this type of event

“96 Hour Rule” EM.02.01.01, EP3 Not a rule but a principle It takes into account that the federal

response inlarge scale disaster will be 72 hours +++

Does not mandate building of additional storagecapacity or maintaining additional supplies

It is an attempt to have organizations do realisticplanning and develop a means to make realisticdecisions in advance of an event

6 Critical Components

1. Communications EM.02.02.012. Resources EM.02.02.033. Safety and Security EM.02.02.054. Staff Responsibilities EM.02.02.075. Utilities EM.02.02.096. Clinical Activities EM.02.02.11

Disaster Traditional Impacts on Hospitals

Increased admissions Decreased discharges Traditional out patient services sought at

the hospital Chronically ill patients seeking support and

medications Citizens seeking non-healthcare services

and shelter Ever-increasing pressure put on limited

resources The question of “shelter in place” or

“evacuation”

Common Characteristics ofSignificant Disasters

Sustained (lasts multiple days) Affects multiple communities Impacted or debilitated public services Overwhelmed federal response Threatened healthcare infrastructure

Impact on Health Care

Home Care closed Long Term Care closed Physician Offices closed Outpatient Pharmacies closed Dialysis Centers closed Outpatient Cancer Centers closed Special medical needs patients can not be

supported at home Discharged patients won’t/can’t leave the

hospital

Strategies to Consider

Resource conservation Curtailment of services Obtaining additional resources from the

community Obtaining additional resources from

outside the community Closing the hospital to new patients Staged or total evacuation

Conservation of Resources

Know your current capabilities Plan for interruption of supplies and services Identify patients that can be discharged Limit use of resources that cannot be

replenished (fuel, water, supplies) Plan for alternative methods to meet common

needs (gas generators, waste management) Identify what utilities can be rationed and how

(power, air conditioning, waste water, linens)

Curtailment of Services

Cancel elective surgeries Shut down all non-essential services Close selected clinics Limit selected diagnostic testing as agreed

to bymedical staff leadership (in advance of an eventwhere possible)

Consolidation of Resources

Know your inventory and usage rate Construct estimates of usage rates during

emergencies Ensure your critical equipment is

compatiblewith your planning partners

Know the realistic response of your vendors

Ensure that supplies and medications areavailable from distant and disparate sources

Consider self-reliance strategies

Staged or Limited Evacuation

Identify criteria by which decisions will be made(less than 12 hours of fuel, 70% of resourcesconsumed, etc.)

Determine these through exercises Designate staff to accompany patients and

protect medical information Identify transportation requirements to

acceptingorganization

Communicate decisions to staff and family

Full Evacuation

Cannot be done on the fly or out of desperation

Must have pre-determined criteria to activatethis plan that all staff are aware of

If evacuation is necessitated by an abrupt event,have principles in place to guide staff

Must not lose track of patients or staff Be prepared for the fallout that such an

eventwill generate (media, liability, insurancecoverage, loss of revenue, impact on staff)

Evacuation Considerations

Background

All of Missouri experiences freezing temperatures every year. In winter there is an average of about 110 days with temperature below 32°

Freezing Rain is super-cooled on its descent and freezes after contact with freezing or below temp. objects on the ground.

As it is a liquid; it conforms to those objects before freezing and creates “glaze.”

Missouri Winter History (pre-2000) 1905-February 13, Warsaw records -40 1911-November 11, 50 temperature fall over 3 hour period; 65-70over

18-24 hours 1924-Ice Storm-wintry mix fell from 16th-19th. Three-fourths of the state

covered by a sheet of ice the last half of the month. 1940-January. Coldest month for the state with an average temp: 15.3 1951-Christmas Eve. Ice storms cripple the entire state transportation

system. 1960-March. Coldest March for the state and several monthly snowfall

records established (some as much as 3 feet on the ground at one time). 1970’s-Three consecutive frigid winters (beginning with ‘76-77) had some

climatologists describing it as a “mini” ice age. 1978-79-Coldest winter on record with average temp: 24.1 1983-December. Coldest Dec. for the state. 1995-January. Winter Storm that dumped almost 15” in a 24hr period over

portions of the state.

Missouri Declared Disasters for Winter Weather (2000-Present)

2002-Feb:Ice Storm 2006-Dec:Severe Winter Storms 2007-Jan:Severe Winter Storms and

Flooding 2007-Dec:Severe Winter Storms 2008-Mar:Severe Winter Storms and

Flooding 2009-Feb:Severe Winter Storm 2011-Mar:Severe Winter Storm and Snow

Storm

Ice Storm Effects

Unlike snow, ice layers (glaze) provide no traction and make driving dangerous if not impossible.

Ice can add hundreds of pounds to power lines causing many thousands to lose power for long periods of time.

Entire metropolitan areas can be shut down. Hospitals generally see a surge of patients at

the start of an ice storm as motorists attempt to navigate the slippery roads.

Most devastating ice storms contain totals of over one inch.

These storms can cause severe tree and power line damage.

Outages can last for days.

Severe Winter Storms Response Plan

[Where is your plan located?] Other response plans to consider during an ice

storm Structural Damage Response Communications Loss Response Electrical Power Failure Response Others?

Provide a short review of your winter response plan

Key elements: Storm monitoring Communication to staff Proactive measures - supplies, utilities,

staff Shelter in place plans Staff supplemental transportation plans

96 Hour Sustainability

Provide a brief summary of your facilities Emergency Management Assets and Resources Inventory Summary

Exercise Objectives

Test the ability of the hospital to maintain operations when the hospital can not be supported by the local community in the following areas: Communications Resources and assets Security and safety Staff Responsibilities Utilities Clinical activities IT

Exercise Participants [List your exercise participants]

Exercise Format

Four segments of scenario that will progress across 4 days

[Choose your format – large group open discussion or break out groups]

Groups will be asked to discuss what their response would be to the given scenario in the form of questions

Assign a recorder and someone to report back to the group [if in small groups].

DAY 1 Advance Warning 0800

A major ice storm is expected to hit Missouri tomorrow; with expectations of 1-2” of accumulation.

The Department of Transportation expects many road closures. Major travel arteries will receive priority for ice/snow removal.

Missouri Highway Patrol is advising that they will have limited patrol ability and will only respond to “priority” dispatches. They are encouraging people to stay home and off of the roadways.

Schools are already cancelling sessions in advance of this storm.

Day 1Freezing Rain 2300

Freezing rain begins to fall in the [your] area.

Night-shift staff are concerned with their ability to leave as well as the ability of replacement staff to arrive in the morning.

At this time, no power losses have been reported and no roads have been closed.

Patient Census

[complete with likely census]

End of Day 1Situation Report

[your organization or facility] facilities have power.

No roads have been closed. Travel is becoming difficult. Only the front line of this storm has hit.

Freezing rain continues to fall at a steady rate.

Day 1 Questions

How does the current situation effect the six critical areas? Communications Resources Safety and Security Staff Utilities Clinical Activities (Patient Care)

Day 1 Questions

How will the hospital coordinate it’s activities?

What are the hospital incident objectives at this time?

What strategies should be implemented to continue operations?

Day 2

Day 2 Accumulation totals average 1.5” Skies are overcast but no further precipitation is

falling. Temperatures are very cold; averaging 20, the

wind is blowing at 10-15 miles per hour Highways [insert major roads] are closed due to

accidents Most other roads are open, but travel is

dangerous, slow, and unreliable. Wrecked cars litter most roads.

The Highway Patrol and local law enforcement have asked people to stay off the roads unless travel is absolutely necessary.

The City/County activated its EOC during the night.

Day 2

Trash service is suspended. Delivery of medical gases is suspended. Staff members are unable to travel to

work. Supplies, linens, and pharmaceuticals will

not be delivered for at least 3 more days, depending on the road conditions.

Widespread power outages are starting to be seen across [your area of] Missouri.

Day 2 Situation Report

A surge of patients is being seen from the multitude of accidents from the slick roads.

[list your organization or some of your facilities] are without power, as are many of the homes and businesses in the southern portions of [your town].

[one of your facilities] still has power. There have been 35 people seeking shelter inside

the hospital but not requiring any other service. Many of the staff members that were on duty have

stayed, and the staff that have been able to relieve them expect to stay for the duration.

[list facilities] lose power at 23:00. The generators kick on, causing many of the electronic and computer systems to go temporarily off line.

Day 2 Questions

How does the current situation effect the six critical areas? Communications Resources Safety and Security Staff Utilities Clinical Activities (Patient Care)

Day 2 Questions

How will the hospital coordinate it’s activities?

What are the hospital incident objectives at this time?

What strategies should be implemented to continue operations?

Day 3

Temperatures for today are forecasted for high of 20 and low of 5 with winds at 15-20 mph.

Temperatures are low and wind-chill levels are dangerous.

Power is out to the entire [your part of] Missouri area. Fuel cannot be resupplied for another 3 days.

The EOC is reporting that some shelters in the community do not have emergency power, alternatives are being sought. They would like to know if they can send people to shelter at the hospital.

Day 3

More community members are arriving seeking shelter, some of them with special medical needs such as oxygen and lack of medications.

Dialysis patients are arriving as the community center is closed.

Many patients with flu-like symptoms are flooding the emergency room. Many are very sick who should have come for care 2 days earlier.

Patients are arriving with injuries from falling on the ice.

Day 3

[Other facility] lost power at about 02:45. Their generators are running.

An outage of the IT network has occurred causing VoIP phones to be inoperable.

Power is out to the city wastewater treatment plant.

Day 3

The phones are out intermittently and radio reception has been very staticky and hard to hear.

Cell phones are inoperable as the cell towers are running on generators and can’t get fuel resupply trucks to the towers.

2 nursing homes with 120 total residents have called to say they need to evacuate their residents and would like to bring them to [your hospital].

Day 3 Questions

How does the current situation effect the six critical areas? Communications Resources Safety and Security Staff Utilities Clinical Activities (Patient Care)

Day 3 Questions

How will the hospital coordinate it’s activities?

What are the hospital incident objectives at this time?

What strategies should be implemented to continue operations?

Day 4

Staff are starting to show signs of stress at the long hours, limited resources, lack of utilities, and overcrowded condition of the hospital.

Additional patients are arriving with carbon monoxide poisoning and hypothermia symptoms.

Power, linens, and supply deliveries have still not been restored.

They hope to have most utilities up and running tomorrow.

Most roads and bridges in [your and adjacent area] Missouri should be opening by tomorrow.

City/County EOC

The City/County EOC informs you that reimbursement for disaster expenses may be possible, IF the expenses were tracked from the beginning of the disaster

What have we learned?

What went well?

What did not go well?

What do we need to do to ensure we are ready should this happen in real life?

Questions?

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