Evaluation of Hospital Disaster Drills: Pre-Drill Module

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Evaluation of Hospital Disaster Drills: A Module-Based Approach

Pre-Drill Module

These evaluation forms are designed to help hospitals compile responses from the modules and compare data.

Pre-Drill Module / Main Module / Biological Incident Addendum / Radiological Incident Addendum

Section	#	Question
I. Background Information	PD1	Name of person completing module
		Title
		Hospital
		Room number
		Street address
		City and State
		Office phone
		Cell phone
		E-mail
		FAX
		Pager
		Best method to contact during drill	Cell phone
			E-mail
			FAX
			Office phone
			Pager
	PD2	Name of additional contact person
		Title
		Hospital
		Room number
		Street address
		City and State
		Office phone
		Cell phone
		E-mail
		FAX
		Pager
		Best method to contact during drill	Cell phone
			E-mail
			FAX
			Office phone
			Pager
	PD3	Type of disaster scenario	Biological
			Chemical
			Fire
			Incendiary device/explosive
			Natural disaster
			Radiation
			Structural collapse
			Transportation accident
			Internal hospital system failure (specify)
			Other (specify)
	PD4	Proposed date of drill?
	PD5	Estimated start time of drill?
	PD6	Expected length of drill?
	PD7	Will disaster drill be announced to staff prior to beginning of drill?	Yes
			No
			Unclear
II. Level and Scope of Hospital Drill Activity	PD8	Format of drill	Operationalized Drill
			Tabletop Exercise
			Computer Simulation
			Other (specify)
	PD9	Main overall goal
	PD10	Specific objectives	a.
			b.
			c.
			d.
	PD11	Number of mock victims	Paper
	PD11	Number of mock victims	Actual
	PD12	Mock victim physical identification	Bar coding
			Clothing
			Victim tracking cards
			Wrist bands
			NA
			Other (specify)
	PD13	Mock victims include people with medical training?	Yes, #
			No
			Unclear
			NA
	PD14	Number of "smart" casualties?	#
	PD15	Triage levels for mock victims identified	Color codes
			Number codes
			Other (specify)
			Other (specify)
	PD16	Mock victim meeting and preparation area	Room & building (specify)
III. Drill Activity	PD17	Location of initiating event	In hospital
			Where
			Out of hospital
			<1 mile
			1-5 miles
			6-10 miles
			>10 miles
	PD18	Method to notify initiation of drill	By another hospital
			By first victim arrival
			By health department
			By government agency
			Other (specify)
	PD19	Hospital staff groups that will actively participate in drill activities	Administration
			Central supply
			Emergency department medical staff
			Emergency medical transport service
			Engineering and physical plant
			Infection control
			Intensive care unit
			Laboratory
			Medicine
			Nursing
			Oncology
			Pediatrics
			Pharmacy
			Psychiatry
			Public affairs
			Radiology
			Security/safety
			Social work
			Surgery
			Hospital-wide
			Other (specify)
			Other (specify)
	PD20	Approximate number of hospital personnel (not including victims or observers) participating	<10
			10-15
			16-50
			51-100
			101-250
			>250
	PD21	Levels of activity included in drill	Materials and supplies received
			Simulated clinical procedures performed
			Triage of victims
			Victim decon simulated
			Victim transport in emergency department only
			Victim transport throughout hospital
			Other (specify)
	PD22	Activities in active patient care areas?	Yes
			No
			Unclear
	PD23	Organizations/agencies involved in drill	Ambulance system
			Community
			Fire
			Media
			Police
			Hospital/health system(s) (specify)
			State agency(ies) (specify)
			Federal agency (specify)
			Military (specify)
			Other (specify)
	PD24	Existing memorandum of understanding (MOU)?	Yes
	PD24	Existing memorandum of understanding (MOU)?	No
	PD25	MOU to be activated during drill	Ambulance system
			Community
Fire
Media
Police
Hospital/health system(s) (specify)
State agency(ies) (specify)
Federal agency (specify)
Military (specify)
Other (specify)
None
IV. Incident Command	PD26	Format of disaster plan available to hospital staff	Complete manual
			Flow diagram
			Job action sheets
			No disaster plan
			Other (specify)
	PD27	Incident command center activated?	Yes, Location
	PD27	Incident command center activated?	No
	PD28	If no Incident Command Center (ICC) how will drill be managed?
	PD29	Will incident commander and functional leaders be identified?	Yes
			No
			Unclear
	PD30	Method to identify leaders	Arm bands
			Hats
			Tee shirts
			Vests
			NA
			Other (specify)
V. Communications	PD31	Methods to communicate during drill	2-way radio(s)
			AM/FM radio(s)
			E-mail and Internet access
			Direct line(s)
			FAX machine(s)
			Intercom
			Landline phone(s)
			Megaphone(s)
			Numeric paging
			Overhead paging
			Runner(s)
			Television(s)
			Text paging
			Wireless/cell phone(s)
			Other (specify)
VI. Decontamination	PD32	Location of decon	Ambulance ramp
			Inside the hospital
			Parking lot
			Street/road
			NA
			Other (specify)
	PD33	Decon equipment to be used	Fire department owned
			Hospital owned
			Owned by another hospital
			NA
			Other (specify)
	PD34	Method to decon victims	Emergency Medical Service (EMS) or fire department vehicles with hoses
			Permanent overhead showers/sprinklers
			Temporary decon tent(s)
			NA
			Other (specify)
VII. Evaluation	PD35	Zones to evaluate	Decon
			Incident Command
			Treatment
			Triage
			Other (specify)
	PD36	Specific areas most important to evaluate	Biological illness exposure
			Communications
			Equipment and supplies
			Information flow
			Patient documentation and tracking
			Patient flow
			Personnel
			Personal protective equipment (PPE) and safety
			Radiation exposure
			Rotation of staff
			Security
			Time points
			Zone disruption
			Zone location and boundaries
			Zone operations
	PD37	Type of observers	Administration staff
			Designated hospital clinical staff
			External clinical staff
			Other designated hospital staff
			Other external experts identified
			Other external experts requested
			Other (specify)
	PD38	Approximate number of observers planned to use?	#
	PD39	Expect to recruit observers from own hospital?	Yes
			No
			Unclear
	PD40	Name of lead observer
	PD41	Person to conduct debriefing session
		Title
		Hospital
		Room number
		Street address
		City and State
		Office phone
		Cell phone
		E-mail
		FAX
		Pager
		Best method to contact during drill	Cell phone
			E-mail
			FAX
			Office phone
			Pager
VIII. Additional Comments	PD42	Comments:

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