Disaster Planning Drills and Readiness Assessment (continued)

Cindy DiBiasi: Gary, you emphasized that the Incident Command System is perhaps the most critical component of a disaster preparedness system. But you have also said it is the most difficult aspect of the drill to evaluate. In the drills that you did evaluate, how did you evaluate Incident Command functions? For example, what did you mean before when you mentioned cross evaluation?

Dr. Gary Green: I do think the Incident Command System is the most difficult part of a drill to evaluate. That is really hard. First there really isn't a clear, totally agreed upon standard yet that describes exactly what the Incident Command structure is or the best way to structure Incident Command Systems. We have talked some about the HEIC system. That is becoming more generally accepted, but it is still not uniformly accepted. So for example, if you ask ten different experts around the country who exactly should be stationed in the Incident Command Center during an event, you are likely to get ten different answers. So even if we could accurately measure and record Incident Command system operation during a drill, we still wouldn't really have a good, clear gold standard to compare it to. So that is something that needs further work.

The second problem that Incident Command is really all about communications, so in order to evaluate the effectiveness of the Incident Command System, you have to monitor not just the occurrence of communications, but you really have to get some sense of the content of that communication, which of course is practically impossible to listen in on and record the contents of all the communications going on simultaneously during a drill. But to get around the problem, we have used a variety of approaches. One way to do it is to assign an observer to shadow the incident commander and sub-commanders and track their activities as best you can. The incident commander is probably the most important to have somebody tracking or shadowing him or her.

We also have an observer record some general observations about the functioning of the Incident Command Center in general like who is present in the Command Center and what data is being recorded or tracked. Beyond that, another approach that we have taken that is somewhat different is an indirect approach, an approach that focuses on outcome rather than process. In other words, in trying to record every communication that occurs when it occurs, we go to a post-drill debriefing survey or structured interview which immediately after the drill you give to each participant in the Incident Command System and by using structured questionnaires you can have the function unit commanders in essence cross-evaluate each other with respect to Incident Command activities so that each reports the nature and content of their communications during the drill as well as assess the other members of the command structure who they have communicated with during the drill.

One limitation of that is that you have to deal with the inaccuracies of self-reporting, but I think this is probably the most practical approach to take.

Cindy DiBiasi: A question from John Stuckert. During preparedness planning, has consideration been given to provide for transitions from identification and treatment to the local, State and Federal law enforcement agencies that will need to address issues surrounding the origin and chronology of the events, collection, sampling, construction of evidence, interviews, victims, witnesses and suspects? Mary?

Mary Massey: Actually, a lot of the work that Howard and I have done with the Domestic Preparedness Program when it was led by the Department of Defense and their U.S. Army soldiers in biological chemical command addressed a lot of those issues in that they spent a lot of time focusing on the integration of law enforcement and helping the medical community understand the criminal investigation and helping the law enforcement understand the epidemiological investigation and bringing those two communities together so there is a number of publications out there that address those topics that are available to the public.

Cindy DiBiasi: A question from Lloyd Clark on physician education. With respect to this issue, in response to possible terrorist attacks, what area has been found to be the most overlooked in developing physician education programs?

Dr. Howard Levitan: That is a tough question. I am not sure really what has been overlooked. I think more interesting is we are not even sure to what degree even how much training needs to be provided. For example, is it better to train a physician to sit in a classroom for eight hours to learn about bioterrorist events or is it better to have them recognize four or five symptoms that they can learn in ten or fifteen minutes? So there are a lot of issues on content and length of training but beyond that I am not really sure.

Cindy DiBiasi: Gary?

Dr. Gary Green: I would say that I don't know if I can identify the thing that is most overlooked in terms of content of training, but I think the one thing that really needs a lot more work and is just very recently being focused on is simply knowing what does work. We see a wide variety of reports on different methods that people use for training. Everything from giving a simple lecture to handing physicians a copy of the disaster plan for a given institution to various kinds of drills and tabletop simulations and so on. We still really have only a very, very limited idea of which of those work and which are better than others. If you go back months or a year after a particular educational intervention is done, which one gives us the best knowledge and retainment?

Mary Massey: I think the CDC has also done an excellent job in providing information for us at all levels. Not only physician levels, but there is also the average citizen level and even a children's portion to the Web site that we are all using to have the same information.

Cindy DiBiasi: A question from Glynnis Lau. Please tell me where I can locate the HEICS forms online and a sample of the Universal Drill Critique Form?

Mary Massey: EMSA.ca.gov is the Web site where you will find all the HEICS or HIKES, I have to give it equal time, HEICS information.

Dr. Gary Green: Also the evaluation forms for the drills that have been developed and piloted in Guatemala, the methodology description will be published in May in the Annals of Emergency Medicine and the forms themselves will be on the Web site for Emergency International which is www.emgint.org.

Cindy DiBiasi: Howard, a question on motivation. I guess what motivates these hospitals to become prepared. Is the threat of bioterrorism enough? Is that enough of a motivator?

Dr. Howard Levitan: I think it is. In addition, the threat of any highly communicable disease outbreak is a sufficient motivator for healthcare response readiness on a wide-scale basis.

Bioterrorism preparedness really has dual applicability. It is the key countermeasure to the threat of bioterrorism, but is also the same response that would be required when the world is faced with the next influenza pandemic. But preparedness does not come cheaply and who is going to pay the bill is still in question.

Cindy DiBiasi: A question from Pamela Parra. Are there any emergency planning and bioterrorism preparedness resources specific to high-rise residents and office buildings? Do you specifically have that issue in California?

Mary Massey: We practiced our first high rise drill last August. The City of Glendale did their MMRS, one of the first high rises one I have participated in. We did a chemical attack. We had a lot of things we had to learn there. We haven't done a lot of that before. So you always want to try something a little different.

Cindy DiBiasi: What did you learn from that specific drill?

Mary Massey: We learned access is different. It was a lot of focus on mass decon. You have a lot of issues with contaminated people, moving them through high rises. You are contaminating a lot more square area.

Cindy DiBiasi: I am imagining as we go on it is just going to get more sophisticated and more detailed and more focused. That is really, how much does the previous drill help with the next drill? It seems like a lot of these things would be apples and oranges.

Mary Massey: If you just took what you learned at the last drill and realized you did something wrong and left it there, nothing. But you need to take what you learn that you did wrong, come up with a new way of doing it and then at the next time test it and see do your new methods work? Otherwise you have a book full of these really nice observations. So you need to take what you did wrong and do something about it and test it.

Cindy DiBiasi: OK. Go ahead, Gary.

Dr. Gary Green: I agree completely. I think the other thing to, the way to prepare for these various different scenarios, and of course there is almost an endless variety of scenarios that you can come up with, is to think of this in a modular format. So the basics are the same for most drills. Certainly there is a series of other modules or other concerns that have to be addressed in an organized way for bioterrorism. The same would be true for an incident in a high rise or an incident that is water-based rather than land-based or any other scenarios that you can come up with. So each group of people or each disaster planning organization really should be doing a risk assessment based on their own geography, their own socio-economic situation, their own population and the likely event that might occur in their own area. They should be focusing first on those events that are more likely to occur in their area.

Cindy DiBiasi: In fact, our next question is how do you deal specifically with issues of language, culture and special population issues in planning drills? You must have to face that, Mary, in California.

Mary Massey: To be honest it is an everyday occurrence because of our high tourist industry so it is not a big deal for us. We are used to dealing with interpreter lines. Many of our forms are done in three different languages depending on what the population break down is. But we have just about every language you can think of running through Anaheim.

Cindy DiBiasi: How does modeling help hospitals prepare for bioterrorism?

Sue Skidmore: Well, in our last project our modeling helped us visualize how our response might differ if certain variables or factors were changed. So for example, we would run the model based on a certain number of staff or types of staff and we could see the impact where in the facility that had the most impact. Another example is the assumption is that there is enough smallpox vaccination to protect all Americans, then modeling can evaluate the strength or weaknesses of the delivery approach.

Cindy DiBiasi: Gary, can you outline for us specifically how a group of hospital disaster planners might prepare to evaluate a disaster drill at their own institutions?

Dr. Gary Green: Sure. I first would like to again emphasize the fact that there is no standard or correct way to do this, but based on my experience I can tell you that what I think would be a reasonable approach and I can describe what I think the most important first step towards this is.

First you want to determine the extent of the drill activities and make some basic decisions about the drill and the evaluation of the drill. So the stakeholders, the drill planners, first need to know what the specific goals for their drill are. That can be quite variable. Are we looking to train and evaluate clinical response? Are we mostly focused on Incident Command Systems? Are you talking about a bioterrorism event or a radiation event or are we only talking about a conventional event?

You also have to decide pretty early on what the borders of your drill are meaning are you also going to evaluate the interface with outside organizations? Are you going to evaluate only the emergency department response or the entire hospital response? How much detail are you going to go into? You can really focus in on how the pharmacy responds, which is not an unimportant aspect for a bioterrorism incident. So you have to decide beforehand whether you are going to include that or not. Which component of the departmental unit that will participate, which ones are you actually going to evaluate, what resources do you have to evaluate?

The next step is really to select the evaluation methods and instruments for those specific needs from those that are available out there. Although right now there is really a very, very limited number of tools and instruments out there and methods to report out there, but there is a very rapidly growing toolbox of these instruments. Within a relatively short time there is going to be a number of different tools that can be pulled off the Web or come from other organizations. You will be able to pick the tool that you need and then you can decide what method and what tool you are going to use for each part of the drill you want to evaluate. So for instance, if you are going to evaluate clinical care, you have to make a decision on whether you are going to use trained observers or are you going to use smart patients that I talked about earlier. When you are talking about drill flow, do you really want to go to the extent and do you have the resources to be able to evaluate patient movement and supplies and entrance and exit observers? If so, then you would pull off those appropriate forms off of the Web site and so on. So that is really that first step.

Then of course you really have to sort of think through the flow of the drill. Another thing to really keep in mind that I found is a disaster drill sort of takes on a life of its own. It almost has its own personality once it gets rolling. You can't really make major changes or corrections once it goes, so you really have to think through step by step everything that is going to happen and try to anticipate every communication and every problem and position your evaluators in the right places at the right time to capture that information.

Cindy DiBiasi: You said there is no cookbook approach earlier. Having said that, Julie Jeffordson who is an RN from Siena Medical Center in Smithtown, New York wants to know if there are any pre-packaged drills available and if so where might you find them?

Dr. Gary Green: I don't know of anything like that that is available right now. I think that there are groups around that are working on such things and I think they will be available either in publication form or on the Web in the not-so-distant future. I don't know of any that you can pick up on right now.

Mary Massey: There are a couple of scenarios on the HEICS Web site. There is a lot more that goes into it. But it provides you with as much as it can. It gives you the lesson plans and a scenario to use.

Cindy DiBiasi: On the HEICS Web site. OK. On the phone we have Joan Morganthal from Connecticut. Hello Joan.

Joan Morganthal: Hello. I have two separate questions. One, could you repeat slower the URLs for AHRQ and HEICS and the second one is has there been any experience in evaluation of wrapping free-standing ambulatory centers such as community health centers and others into disaster drills?

Sue Skidmore: I can address the freestanding community centers. There was a concept of operations developed again to the Domestic Preparedness Program and through the U.S. Army Soldiers and Biological Chemicals Command and it was called the Neighborhood Emergency Health Center. After they developed the concept, they did do a throughput test of the NEHC or Neighborhood Emergency Health Center in order to identify whether the processes inside their concept worked and at what rate they could process patients. So that is one piece of work that I know of that is available in that area.

Joan Morganthal: What is that again?

Sue Skidmore: It is available through the U.S. Army Soldiers and Biological Chemical Command and it is called the Neighborhood Emergency Health Center or NEHC and you can certainly contact me after the proceedings and I can get you hooked up with more information on that.

Joan Morganthal: Great. Could you give us a little slower again the URLs for AHRQ and...

Cindy DiBiasi: Yes. If you are on your computer it is also...

Joan Morganthal: I'm not. I'm on the telephone.

Cindy DiBiasi: OK. That is fine. I will say it slowly. It is http://www.ahrq.gov/research/sep02/0902ra23.htm. Then the HEICS Web site, which is easier, is www.emsa.ca.gov.

Joan Morganthal: Thank you very much.

Cindy DiBiasi: Thank you for calling. A question. Are there specific peer-reviewed journals that focus on terrorism, emergency management and preparedness? This caller says, "I have seen articles in medicine and nursing journals, but relatively little in traditional public health or epidemiology journals."

Dr. Gary Green: There are emergency medicine journals who certainly publish a lot of this work. There is a journal called Annals of Emergency Medicine and another one, Academic Emergency Medicine. There is also Pre-hospital and Disaster Medicine, which is another publication that publishes some of it.

Sue Skidmore: Actually in May of, I might have the year wrong, in May of 2001, The American Journal of Public Health was entirely dedicated to the topic of bioterrorism. I am pretty sure I have that reference correct but if not it is easily found because it is the main journal for public health and it was an entire issue devoted to bioterrorism along that timeframe.

Cindy DiBiasi: OK. A question from Joseph Liveressa. What measures have been taken in your planning to keep the stress level down on hospital staff and how are you planning to keep staff safe and healthy in respect to working long hours and the immune system weakening making them at even greater risk of them becoming sick themselves?

Mary Massey: That is a very good question and we spend a lot of our planning towards making sure that our staff is taken care of. In the HEICS structure there are certain personnel that that is their job to watch them. We make sure that our staff, we have planning ahead of time for their families, what their dependents are. When we did our biological stockpiling, we have enough to take antibiotics to take care of our staff plus two members of their family for ten days. We try to take into account, staff won't come in if we aren't taking care of their families first so we look at dependent care. Whether it is for children, elderly or their pets.

Cindy DiBiasi: Interesting. OK. Follow up question. Bob Maiden from the Florida Bureau of EMS. Do you use any pre-hospital patient tracking systems?

Mary Massey: For disasters are we tracking the patients?

Cindy DiBiasi: I am assuming. It is a written question and that is all the information he gave us.

Mary Massey: We use forms once they arrive at the hospital. We keep track and we do patient tracking. I don't know...

Sue Skidmore: This is Sue Skidmore. One of the items I have seen was actually developed and is used by the Metropolitan Washington Council of Governments. It is Disaster Tag. It is formatted to fit with the smart assessment, rapid assessment triage system and you can write on it as well as peel it off and stick it on stuff that would tag the patient in the field and then portions of it could be applied to the patient's record once they hit the treatment facility. That is available publicly through the Metropolitan Washington Council of Governments.

Cindy DiBiasi: Gary?

Dr. Gary Green: There is a variety of different methods that have been used and that are out there for documenting triage levels and conditions in pre-hospital and for relaying that information between pre-hospital and hospital based. The tags that were just referred to is probably the most often used where you tear off pieces of the tags that mark their triage level. Some people have criticized that both because the tags can be easily lost and it is complicated.

One of the first rules of disaster training is that you try to make the activities during a disaster as similar as you can to the daily activities of regular care so people will be more familiar with them. Some people have advocated simpler systems even just using a simple colored wrist band to mark the triage color, the triage level or even colored tape to put on the patient that can be removed and a new color put on if a triage assessment changes. It is also something that is not yet a standards as to what is the best way to do this.

Cindy DiBiasi: Thank you so much. You have given us so much great information today. Before we end though, I would like to just go give you one more shot around the table for any last comments, final words. Sue, let's start with you.

Sue Skidmore: I would just like to emphasize that our questionnaire is closely aligned with HRSA and their priority areas and it will continue to be developed on an (unclear) process. The goal on measuring a facility's progress is not focused at all on ranking but more on moving facilities along that continuum and in the meantime identifying any best practices as we go through the process.

Cindy DiBiasi: Howard?

Dr. Howard Levitan: I think today a lot of the calls and questions have looked at many things besides bioterrorism. I think bioterrorism poses very unique challenges in planning because of the tremendous resource demands placed on the institution in general, on the entire institution. In our project, our goal is that guidance will soon be available to hospitals to start with a minimum level of preparedness where can they begin and move forward and that should be available soon.

Cindy DiBiasi: Great. Gary?

Dr. Gary Green: Throughout our conversations today I think we are hearing a fair amount of concern and anxiety from people and I think that is definitely true that we all have been experiencing that over the last couple of years and are sort of scrambling to try to get ready for these kinds of events.

Sort of one message that I would like to tell people is to first of all realize that by definition that a disaster is an event that overwhelms local capacity. You can never be totally prepared. That is not a reason for not working at it; that is a reason for working at it harder. But also people shouldn't try and reinvent the wheel. Every institution in the country does not need to develop their own evaluation methods and their own training techniques. Take advantage of the work that others have already done and are continuing to do in a variety of reports and techniques and evaluation methods and tools will be getting out there in the near future. Also whenever possible, work together in collaborative relationships with other institutions.

Cindy DiBiasi: Great. Mary?

Mary Massey: Two quick things I wanted to say was first of all, you may think that a disaster may never strike your area. Bioterrorism preparedness may seem very far-fetched whether you would have a terrorist event. But the more you prepare for a bioterrorism event, the more you are going to be prepared for that huge pile up on the interState next to you, the more you are going to be ready to have your community prepared for these events.

Finally, make it fun. Take lots of pictures. Laugh at yourself. Remember the goal is to find a way of taking care of you and your community. Not to make the prettiest, most perfect disaster drill that has ever happened.

Cindy DiBiasi: Thank you. Good advice and thank you all for joining us this afternoon. If you have any unanswered questions, please send an E-mail to info@ahrq.gov and depending on the number of questions, we will try to answer you directly. We also encourage you to send us any researchable questions that you are facing at the State or local level for AHRQ's consideration as the agency plans its future research priorities.

As we wind down, let me mention that a number of products from this audioconference will be available at a later date. An audio streamed archive of today's call, a written transcript and all of the presenter's slides, including those used in the question and answer session, will be posted to the ULP Web site.

An audiotape of this event will be available for purchase in several week's time and the cost for the tape of this audio conference will be $10. To order a copy call the AHRQ Publications Clearinghouse. The number is 1-800-358-9295. Ask for AHRQ03-8V06A. It is entitled Disaster Planning Drills and Readiness Assessment. Similar archive items are available for the first event in this series. It is entitled Addressing the Smallpox Threat: Strategies, Issues and Tools and was held on March 3, 2003. These products can be obtained through the same Web site.

Before we sign off today, please mark your calendars for the next events in our bioterrorism series. On Tuesday, June 17 from 2:00-3:30 in the afternoon Eastern Time, we will be addressing surge capacity assessment and regionalization issues. Then on Tuesday, October 21, we will examine the role of information and communication technologies as well as surveillance and monitoring systems across the healthcare spectrum. As they become available, more details on these and future audio conferences will be sent to everyone who registered for this series.

If you are listening in to today's event but have not yet registered for this series and would like to receive information about future calls, go to www.hsrnet.net/ahrq-ulp/bioterrorism to register. Information about this series is also posted on the AHRQ Web site at http://www.ahrq.gov/news/ulp/biotconf.htm. You may E-mail your comments to us at info@ahrq.gov.

Thank you and we look forward to you joining us on future calls in this series. Have a nice day.

Return to Audioconference

Current as of July 2003

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Internet Citation:

Addressing the Smallpox Threat: Issues, Strategies, and Tools. Transcript of Web-assisted Audioconference, broadcast April 15, 2003. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/ulp/disastertele/disastertrans.htm

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