as the first talk, and I will also give you the disclosure that I am not an expert in mass casualty incident preparation, but what I do like to do is ruffle some administrative feathers every now and then, and I'll at the end of the presentation, I'll show you kind of how we did that a couple of years ago and what came out of that. So nothing to disclose as it pertains to this presentation. Objectives in this one are going to be more of what I would call logistics and setup for your institution and some of the boxes you have to check in order to be accredited. So you need to understand the six critical assessment areas for incident preparation and assessment of performance, understand your components of what the CMS Emergency Preparedness Rule says for you, and then to learn some potential benefits and resources of a healthcare coalition in managing these mass casualty incidents. The reality is it's not a matter of if, it's a matter of when, and we all know it. And when we do, you can't just act within the walls of your medical center. It's going to be a regional exercise, and you better play well with others and everybody else in your community, even if your competitor hospital sits two to three miles away, because both of you are going to be in the mix at that time. So disasters can come in the form of being man-made, as we saw with 9-11, chemical, biologic fires, transportation accidents, you name it, it can happen. Or what we've seen more recently as well are natural disasters, Hurricane Katrina right here in New Orleans, tornadoes, floods. So you have different kinds of disasters, and you're going to have to be prepared for everyone because the fact is, when we get up and go to work every morning, you don't know what's coming and if today's going to be the day. So that day, when it starts hitting your door, is not the time to prepare. And Dr. Fragberg, in 2010, said, because all disasters are sudden, unexpected, unpredictable, and random events, they cannot be managed without established plans in place that are regularly rehearsed. And the key is to rehearse these. You know, it's like my little girl in a dance competition, why do they have dress rehearsal? Because you don't want to find all the little flaws whenever you're out there in the big performance for the year. In 2004, a questionnaire of 243 EAST members went out, and 73% said they thought they were equipped to manage a blast injury, but then when you got into biologic exposures, less than 50%, and then exposure to nerve agents, less than 30%. Well, we're not always going to get blast injuries, and you never know when one of these others is going to pop up. So when you look at your trauma center saying less than 50% thought they were ready to handle this, and this is supposed to be the place that is the most prepared, we've got real problems. Madsen and colleagues, in 2010, found that 4.9% of ED directors said they were confident that they had appropriate preparation to handle a disaster. So fast forward to the things that we've tried to do in the last several years and some of the stipulations that have been placed on our trauma centers. So disaster preparedness, the fact is, this is a recurring cycle. You've got to get your preparation for your equipment, procedures, it gets down to you plan, organize, train, equip, exercise, evaluate, fix, and then what do you do? You start it all again. Because things change, and as much as we would love to think that our institutional memory is that good, and that a year from now we're going to remember all the things that we learned then, or two years from now, or three years from now, that's not the case. You have to keep testing the system, and what you find is that things change and evolve as time goes on. And then types of exercises, discussion-based. You've got seminars, workshops, tabletops, and games, if you will. And I'll tell you, hospital administration loves tabletop exercises. Why? They don't cost money. And that was what we found at our institution. You can sit down and we can play war games on a tabletop and see how we think it's all going to look, but that's not the case. What you need are operations-based exercises. You've got drills, functional exercises, and even to the point as I'll show you at the bottom, a full-scale regional exercise. If I am one hospital and I'm doing my exercise, everything looks great, I check all the boxes, that's wonderful. But the fact is, like we've seen in Las Vegas, people are going to get dispersed to several different hospitals. They're going to come by EMS. They're going to come by local bystanders. It's going to be very unpredictable. And all of a sudden, just because you've got one hospital that functions well, if we're truly looking at disaster preparedness, what happens if those other 14 hospitals in your region fall down or aren't prepared? And I would argue as level one trauma centers or whoever your flagship is in your region, it's your responsibility to work with the community to make sure everybody's up to par and prepared. So JCO, as far as accreditation, what boxes do we have to check? So they say that you've got to have emergency operations plan testing twice per year. If you offer emergency services or are a community-designated disaster receiving station, you have to conduct at least one exercise a year that includes an influx of actual or simulated patients. At least one exercise a year has to be escalated to look at how effectively the organization performs when it cannot be supported by the local community. You have to look and say, what can you do within your walls if you don't have any help coming from the outside? And then the organizations that have a defined role in the community-wide management have to participate in at least one community-wide exercise a year. This gets into the oversight, that if you're going to be a flagship and you're going to be the regional leader, then one, you have to act like it, and two, you have to do it. So when JCO looks, there are six critical assessment areas, communications, and they want to see internal and external communication, because you've got to be able to communicate within your walls where the patients are going, make sure your systems work, but at the same time, with all your community care partners, and then what's going to happen as soon as all this goes down? You're going to have the state and federal government, everybody getting involved, where you have to have communications plans and strategies and things to work with them as well. Supplies. You've got to know that you have enough supplies and that it's appropriate to what your vulnerabilities are, which this is tough, right? Because what are our vulnerabilities in the community? We don't really know. It could be anything, anytime, anyplace, and that's the hard part of what we have to prepare for in today's environment. Security. You've got to be able to continue normal hospital operations as much as you can, but then you've got to protect your staff and your property, because then, and what we've seen with some of the other recent incidents, is you get secondary threats, that there are people out there that will call in bomb threats to the hospital knowing that they have a surge of patients coming in to try and derail your whole process. And then staff. What are your roles and responsibilities? And then the standard hospital incident command structure and what happens there, and I'll show you some interesting findings from an exercise we conducted. And then utilities. The goal is to try and be completely self-sufficient for 96 hours, as long as you possibly can, but in a regional disaster, power goes out, whatever, to try and ensure that your facility can keep going for four days without external help if necessary. So when you put all this together, what they look at are these four major areas. Risk assessment and planning, your policies and procedures, your communications plan, and then training and testing. Are you checking all these boxes? So risk assessment and planning, you've got to have your plan based on what your expected vulnerabilities would be. You use an all hazards approach. You want to focus on capacities and capabilities. What can I do? How many can I hold? What's going to redirect? And then what can this center do in and of itself? And then include your emergency operations plan and what you deem as pertinent hazards. And as I've already said three times by now, we'd love to say we can all predict what's coming, but we can't. So it's you can say what I think would be most likely, but as soon as you do that and you prepare only for that, then you're going to get a curveball. And you've got to update your plan annually. You know, institutional memory is there. You go and say, oh, yeah, we did all this, but you have to look at this every year and change it up for given situations. Or maybe the next event has happened somewhere else that put something new on our radar that we weren't prepared for in our own center. And then you think, well, all right, it's time to adjust. You've got to implement your policies and procedures based on your plan and your risk assessment. So you have to do both. You've got to do a real risk assessment, what's it going to look like this year, and then change your policies accordingly. Now this is what you have to include, subsistence needs, food, water, medical, pharmaceutical supplies. How much do I think I'm going to need? How much are we going to have? And then this one is extremely tough, tracking of patients and staff during your emergency. You have to have a system in place to know where your staff is, where the patients are both during and after. Because that's the hard part, is as we're bringing people in and we triage and we're moving them around, you need to know where they went. You're going to have families showing up, loved ones showing up. And granted, this, in the heat of the moment, is not what we're focused on, right? It's saving lives, taking care of the patient, but at some point, you're going to have to address that and know where all these patients are. And so you need to have a tracking system in place. Evacuation plans, transportation, communication, and even alternate care sites. Once you've overrun your capacities, what's plan B? Where are you going? Do you have a mobile hospital? Do you have other hospitals in your region? What can you do once you've exceeded what your facility is capable of? And then procedures for sheltering, what a lot of us don't think of is, what do you do with the patients that are there in the bed? Can they be diverted, moved? But then what about staff and volunteers? Because you get into a situation where you may have staff there for several days that aren't leaving. You know, where are you going to put them? What facilities do you have for your staff and your volunteers that have showed up to help during this situation? Because you can get into a situation where you don't want your patients and staff leaving. It may not be safe. Who knows, you know, who's outside the hospital? Does the hospital itself become a target in some of these situations? Communications plan. you have to comply with both federal and state laws, including your HIPAA rules, but at the same time, communication is number one. You better have the system in place and make sure it works and everybody's talking to everybody and understands where everybody is, what the responsibilities are, because if this falls down, everything else is gone. Yes, we want to be HIPAA compliant. We want to comply with the, you know, all the federal and state laws. Bottom line is, we have to communicate to make sure our patients are taken care of. And then coordinate patient care within the facility and then with your health department's emergency systems all across, so it has to be communication at every level. And once again, this is another one you have to review and update annually. Well then, the final part of it, training and testing. Maintain training and testing programs with your policies and procedures, and what do most of us get as far as training for policies and procedures? We go and I know for us, every single year by September 30th, I have to sit down in front of a computer and answer questions and fill out, you know, things on the site, right? Is this really adequate when we are truly training for a major event like this? No, but that is initial training in what you do. And then demonstrate knowledge and procedures and continue to conduct drills and exercises to test your emergency plan. Bottom line is, we can all sit around a table. We can talk about how great our plan is, but until we actually test it and put it into motion and see where we fall down, we aren't going to know our own deficiencies. So the key is, as Dr. Vail mentioned, these exercises should stress our limits. They should make us uncomfortable. They should make administration uncomfortable, because the goal is to push yourself to the breaking point to see where we're going to fall down, because I look at it two ways. One, if I get to that point, I know where my deficiencies are and when I've exceeded my capabilities. But on the other end, I know where we're good and what I can do up to that point. And then communicate the strengths and weaknesses. You have to have a true after-action review. You know, you've got to go and not only do the event and everybody's there, feels like it did this. No, you've got to bring everybody back together and from all representations, from EMS, from your physicians, administration, nursing, all the way down to look at the logistics and see how it really went. And you know, I'll stand here and argue and tell you there's absolutely no substitute for a full-scale regional exercise. The downside of this is it costs money. It costs a lot of money and we know it and people don't want to pay for it, because what's the return on investment? Well, the only return on investment is, well, you save lives if you have a true event. But it's all theoretical planning. So we actually did this a couple of years ago, got a grant back around 2010, conducted a full-scale regional exercise in the Charlotte area, multi-agency, multi-jurisdictional, multi-organizational. We had 16 area hospitals. Our level one trauma center brought in 281 moulage victims. So we did a train derailment and just to really throw a curveball into it, we did a chemical spill because then, you know, everybody can get the blunt trauma coming in with a train derailment, but now there's a chemical spill. What are we going to do with that? Which that's where it got really interesting. We hired third-party contracted evaluators to come in, because we all know that within our systems, we will bias ourselves, our administration will get biased, and we will all pat ourselves on the shoulders about what a great job we did. So we brought in a third party and said, take the bias out of it. We want to see what it looks like to evaluators on the outside. And then looked at operational and logistical deficiencies in five areas, communications, the decontamination process, command structure, patient tracking, and then staffing during the event. So we had 15 out of 16 hospitals participated. One hospital got shut down after 50 minutes due to a chiller outage, was deemed 100 percent deficient. So every patient that would have gone to that hospital would have had to been rerouted immediately. If you actually looked at our mean hospital compliance on a scale of zero to five in those categories, our average compliance was two. We weren't even at 50 percent across the board. No hospital was 100 percent functionally compliant, and the most common problems were communications with the Viper and Smart, the radio systems that we went to, and then deficient decontamination. So here's the big problem. If communications goes down, and most people were noncompliant with communications, what does that do to your system? You just destroyed it up front. So when we look, here's our list of the 15 hospitals that participated and the deficiencies listed by each hospital. You look at hospital C, as I said, chiller, it was gone right from the get-go. And you look, look at the number of hospitals that have four deficiencies. We've got four, so 25 percent, and then all the way down to three. I mean, if you were a good performer, when we looked at it, you had two. So these are some of the comments we got back when we looked, communications, no training on the Viper radio system. Well, how do you expect to even run a mass casualty incident if people are telling you they haven't even had training on the radio system that you're going to activate as soon as this goes into effect? Plan structure. Somebody said there's no procedure for who, how, and when the facility, or for facilities to follow. It took considerable time to fill positions and plan meeting. Security plan policy didn't exist at one of the hospitals. Three-minute triage system is not the system used elsewhere in the healthcare system. And then the command center did not start any type of planning. Well, the problem was with the command center, it's, they didn't receive the smart message, they had poor radio reception in the building, they weren't even able to call back. They were having internal paging issues. And then as far as running the command center itself, what do you think happened? All the administrators knew there was going to be a full-scale regional exercise coming, right? Everybody wants to be involved because we're going to do this, it's going to look great. We had too many administrators all in the incident command area and nobody that was actually leading it and deferring the people that should have been. So that was, that was something that really came out of it. Staffing, triage doctor overwhelmed, well, we're all going to be overwhelmed at the time and you need more resources. Patients had to wait a long period of time before being triaged, as we know, you've got a matter of minutes as each one's coming in and you've, you know, you've basically got to label them and keep moving. Decontamination, and I got to witness this one firsthand. Our decon drainage leaked into our room one triage as we were running patients through because this was a full-scale exercise. We set up all the decon tents, every decon room. This wasn't a, oh, we bring them in, spray them down and bring them through. No, we went through the full decon procedure. As we are in there assessing trauma patients, we start getting a flow of water coming underneath the wall in our trauma triage room. That was our level one trauma center and all of a sudden we estimated we would have had to divert 70 patients just because we contaminated rooms one and two. Once again, if you don't fully test the system, you're not going to know what your weaknesses are. I can tell you now, it doesn't leak anymore. They fixed that pretty quick. They were unable to get the water flowing in one of the decon areas, unable to effectively set up the equipment. As I said, we threw a curve ball in just to see what would happen. People here, mass casualty, you don't think chemical spill, we're going to have to decon people. Well, guess what? Now everybody knows how to set up all the tents and everything we have left. Runoff was directed at the storm drain for the outside as they were coming through. Once again, you think if we had an internal reviewer looking at this, that this would have popped up? No. Directing drains to the storm drain. So there you go. We have a chemical spill. Now we're putting it in the storm drain. It's going to the water treatment plant, and we're spreading it all over the region. Good job. Command structure, and this was it. Far too many people at the command post. Too many cooks in the kitchen. So this was, you know, potential consequences. The cross-contamination from the leakage in trauma room one, 70 patients would be diverted. Poor communication, multiple hospitals didn't know how many patients were coming, and incident command had blinded direction of patients and where they were sending them. So that led us to, from now on, whenever we're doing this, we have to have a physician in the incident command center to help as well. It doesn't need to be one of me, because I need as many of us on the ground as we can, but I have to have somebody that understands triage, and if it's an emergency physician, whoever's most skilled that we have to put out there. And then understaffing led to slow decontamination and poor and inaccurate triage. What this ultimately led to for us is the Metrolina Healthcare Preparedness Coalition looked at it and said, you can't have all this within one center and expect them to take it and lead it and do it, you know, I don't want to say honestly, but do it with the rigor that you have to have for the entire region. And what it is is basically a coalition between all the hospitals, EMS, public health, emergency management, and licensed continuing care for our entire region. And you can see all the partners there, and a brief history, this used to be housed under MTAC, and in 2012, following a lot of these findings, we managed to get ASPR funding, moved out of MTAC and became the coalition. We formalized a new name, logo, et cetera, and then a new leadership and department home in 2016. And what we've done in North Carolina now, you can see is divided up, and these correspond to our regional advisory committees, and then who the lead is, and a lot of these have gone away from necessarily just the trauma center as the lead, but more of a coalition for everybody there, because you've got to involve all the hospitals. And at ours, this is, if you've ever seen it, are the Med 1 units that we have that we can deploy either to other states or, if we need it locally, to be able to pull this up, and this is basically a mobile unit where, with the tents, we can get up to 150 beds, we've got two ORs, four ICUs, even a dental chair, and basically we can get in and have the ORs and the 14 beds up and running within an hour to an hour and a half on site, and everything can be fully operational within about 12 to 18 hours for the tents and the rest of it. And so even, and then, outside of the tents comes with more beds that we can bring in if we have local safe shelters to do it. And then if you look at this, this is another area with deployment. What's another key you have to think about is security. So if you notice, when these go up, you see the fencing around that you've actually got to control patient influx, outflux, and security for the people that are working there in these situations. All right. Thank you very much.

mass casualty incident preparation

collaboration

rehearsals

communications

deficiencies

healthcare coalition