Hospital Readiness Assessment

1 st National Health Emergency Preparedness Conference “Preparing Your Hospital for Disaster” H. Roslyn Devlin May 29, 2006

Ready: A Definition

• Prepared mentally or physically for some experience or action • Prepared for immediate use • Willingly disposed • Likely to do something indicated • Immediately available

Readiness Assessment Tools

• OSHA Best Practice for Hospital-Based First Receivers of Victims • Centers for Disease Control and Prevention. Local Public Health Preparedness and Response Capacity Inventory. December 2002; Version 1.1

• Bioterrorism and Other Public Health Emergencies – Tools and Models for Planning and Preparedness Evaluation of Hospital Disaster Drills: A Module-Based Approach • Bioterrorism Emergency Planning and Preparedness Questionnaire for Healthcare Facilities. Booz-Allen and Hamilton • Mass Casualty Disaster Plan Checklist: a Template for Healthcare Facilities. American Practitioners in Infection Control. http://www.apic.org/bioterror/checklist.doc

CEEP Readiness Assessment Tools

• General readiness checklist: A template for healthcare facilities – 24 Sections • CBRNE plan checklist: A template for healthcare facilities – 8 Sections • Reviewed by individuals with expertise in Emergency Medicine, Emergency Management and Public Health

Assumptions

• Disasters/emergencies may occur inside or outside the organization • Healthcare facilities will be expected to respond to these emergencies in a coherent fashion • Checklists provide a Gap Analysis • Primary target are traditional (“short stay”) hospitals • Yes mean Yes • No can have many meanings

Process

• Identification of the need 2003 • Literature review. 2004 • First draft 2004 • Second literature review 2005 • Panel review and edit of .

initial tool 2006 • Trial of tool at test sites • Incorporation of feedback • Release of final document

General Readiness Checklist I

• Definitions • General Facility Information – Where do patients go and who cares for them • Foundational Considerations – Does a disaster plan exist – How is it managed – Is it integrated with other disaster plans • Identification of Authorized Personnel – Who is in charge – Who does what

General Readiness Checklist II

• Plan Activation and Response – Human resources – Supplies – Inter-facility/agency agreements – Departmental plans – Chain of custody – Morgue facilities – Back-up plans

General Readiness Checklist III

• Incident Command System • Security and Access – External traffic control • Internal Traffic and Control – Tracking of patients, staff, volunteers, media • Communications – Organized runner system – Contact directory

General Readiness Checklist IV

• Visitor Management – Release of patient information – Identification of visitors – Designated spokesperson • Media – Location – Spokesperson – Release of information policy – Integrated community response

General Readiness Checklist V

• Reception of Casualties – Temporary patient tracking – Tracking of patient belongings • Field Communications – Notification to stand down – Regular updates – TV, radio and other sources of information • Redirection of Hospital Operations • IT Concerns – Ability to process patients in non-standard locations • Inter Agency Agreements

Evacuation Procedures

• Relocation of Patients and Staff – Satellite locations – Evacuation routes – Transportation requirements – Bad weather plans • Inter Agency Agreements • Discharge Routine – Patient tracking – Medical records

Stand Alone Procedures

• Auxiliary Power • Food and Water • Waste and Garbage Disposal • Rest and Rotation of Staff • Medication and Supplies

General Readiness Checklist VI

• Diagnostic Capabilities • Information Technology • Critical Incident Stress Management • Post Disaster Recovery – How much did it cost?

• Education and Training

CBRNE Checklist Assumptions

• Victims will arrive with little or no warning • Information about the hazardous agent will not be immediately available • A large number of victims will be self-referred • Victims will not necessarily have been decontaminated prior to arriving at the facility • Many people arriving at the facility will have had little or no actual exposure • Most victims will go to the healthcare facility closest to the site where the emergency occurred • Victims will attempt to use other entrances in addition to the Emergency Department

CBRNE Checklist

• Foundational Considerations – Is there a plan/planner/planning committee – Inter-Agency collaboration – Internal and external disasters – External and internal facility Requirements • Training and Awareness – Signs and symptoms of a CBRNE event – Roles and responsibilities – Chain of custody – Where’s the equipment?

– Role of ER team and content specialists

CBRNE Procedures I

• Communication – With and without PPE • Baseline Syndromic Surveillance Numbers • Decontamination Equipment – Heating – Containment of water run-off • Triage and Segregation of Patients • Ventilation Controls • Security Arrangements

CBRNE Procedures II

• Standard Orders • Antidotes and Therapy – Dosage requirements – Drug administration equipment • Who Accepts Deliveries from the National Pharmaceutical Stockpile • Regulatory Requirements for PPE

Biological Incident Module I

• Category A Agents – Anthrax – Plague – Smallpox – Botulism – Viral Hemorrhagic Fevers – Tularemia • Characteristics – Easily disseminated – High mortality rates – Cause public panic – Require special action for preparedness

Biological Incident Module II

• Clinical Presentation • Laboratory Diagnosis • Infection Control Procedures • Treatment – Stockpiles: Local, Municipal, Provincial, National • Prophylaxis • Vaccination • Public Health Requirements

Biological Incident Module III

• Internal/External Surveillance • When Does the ER call Infection Control?

• Can Your Facility Test for Biologic Agents 24/7 • Processing/referral of Class A Agents • Chain of Custody Issues • Pharmacy – Surveillance of drug use – 24/7 coverage

Chemical Incident Module I

• Nerve Gases – Sarin, Tabun, Soman VX • Pesticides • Blood Agents – Cyanides • Vesicants – Sulfur Mustard, Lewisite, Phosgene • Pulmonary Agents – Chlorine, Phosgene, Diphosgene, Ammonia • Riot Control Agents – Tear gas, Vomiting gas, Pepper Spray

Chemical Incident Module II

• Atropine • Pralidoxime • Diazepam • Tropicamide • Pyridostigmine • Cyanide antidote kit – Amyl nitrite, Sodium nitrite, and Sodium thiosulfate • Dimercaprol • Acetylcysteine aerosol

Chemical Incident Module III

• Safe Storage of Inventories • Rapid stockpile Access • Tracking Antidote Inventories – Expiry dates • Maintaining Antidote Inventories • Plan for Both External and Internal Event – Internal response team – Role of Hazmat

Chemical Incident Module IV

• Decontamination Protocol • Containment and Remediation • Monitoring of Chemical Contamination • Decontamination of Pregnant Patients • Chemically Resistant/Vapour Tight Plastic Bags/Containers for Waste • Air Exclusion Policy • Handling of Deceased People

Chemical PPE

• Appropriate PPE • Respiratory Protection Program • Fit Testing • Tracking of PPE • Appropriate Size Distribution Regularly Checked • Staff Training/Certification – Frequency of staff training/certification

Radiological/Nuclear Incident Module

• Radiation Safety Officer • Contact List for Radiation Experts – Radiation Safety Officer – Nuclear Medicine Specialist/Radiologists – Radiation Oncology Staff – External Experts • Internal and External Events – Exclusion of Pregnant HCW’s • Irradiated Victims vs. those Contaminated with a Radioactive Material • Decontamination Facilities

Radiation Detection

• Appropriate Instrumentation – Use of instrumentation and interpretation of data – Documentation of the radiation monitoring results • Dosimeters for Staff – Program to monitor dosimeters • Appropriate PPE • Mitigation of a Procedure Breach

Treatment of Victims

• Anti-emetics • Anti-diarrheal agents • Potassium iodide • Fluid and Electrolyte Balance • 24 hour Urine Collections • Measurement of Faecal Radioactivity • Safe Transportation of Specimens • Specimen Analysis

Contaminated Personal Property and Waste

• Lead Lined/Concrete Room for Storage • Plastic Bags and Containers for Waste

Health Care Workers Ability and Willingness to Report to Duty

• 47 Health Care Facilities in NYC – 31 hospitals, 11 LTCF’s, 3 CHC’s • 6 Scenarios – Weather emergency – Bioterrorism – Chemical terrorism – Mass casualty incident – Environmental disaster – Radiation terrorism – Untreatable infectious diseases outbreak • 2 Categories Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Employee Demographics

• 88% fulltime • 69.4% female • 42.7% > 45 years • 26.2% nurses • 24.8% support staff • 19.3% administrators • 10% physicians • 11% others Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Personal Safety Concerns

Level of Concern Biological Event Chemical Event High/moderate

3,298 (54.7%) 3,168 (52.5%)

Slight/Low

2,736 (45.3%) 2,870 (47.5%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

40% 30% 20% 10% 0% 100% 90% 80% 70% 60% 50%

Ability to Respond to an Emergency

Snow Smallpox Chemical MCI Not Able Not Sure Able Environmental Radiation SARS Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Willingness to Respond to an Emergency

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Not Willing Not Sure Willing Snow Smallpox Chemical MCI Environmental Radiation SARS Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Barriers to Ability to Respond to an Emergency

• Transportation (33.4%) • Childcare (29.1%) • Personal Health Concerns (14.9%) • Eldercare Responsibilities (10.7%) • Pet Care (7.8%) • Second Job (2.5%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Barriers to Willingness to Respond to an Emergency

• Fear and Concern for Family (47.1) • Fear and Concern for Self (31.1%) • Personal Health Problems (13.5%) • Child/Eldercare Issues (1.4%) Quereshi K, et al. Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 82 #3 378-388. 2005

Response to Barriers

• Car Pools • Use of EMS/Police to Transport Staff • Emergency Childcare/eldercare pools • Medication on site for some staff • Pet Care Arrangements • Appropriate PPE • Appropriate Education

Process

Failure Mode & Effect Analysis (FMEA) • FMEA: Determine the probability of the

potential

cause or risk Design a system to absorb errors - Simulation of application and removal of the Personal Protective Equipment, Code Blue Special and Operating Rooms scenarios • Standardize procedures – Reduce variation, eliminate the exposure risk to unknown contaminants • Training & re-training – Competency assessments of the education program • Create a safe caring environment where staff and patients both feel protected – Survey of staff satisfaction and confidence when providing care

Precautions for High risk Procedures

Process Hospital-Wide Module

• Train the trainer model • 2-4 trainers were designated for each area • Trainers work with Infection Control Practitioner in scheduled sessions • Group 1 -6 hours • Group 2 -4 hours • Group 3 -3 hours • Return demonstrations appropriate to designated area

Competency Checklist Application and Removal of N95 Respirator

NAME: _____________________________ REVIEWED BY:______________________ UNIT: _____________________ DATE: _____________________ In order to be approved for this advanced clinical competency you must demonstrate the knowledge, skill and judgement in the following: KNOWLEDGE: •Outline proper technique for the application and removal of N95 respirator •State importance of fit testing •Describe proper method for completing seal check •State indications for changing respirator •State rationale for not touching mask with hands once applied •State indications for use of surgical/N95 masks for different isolation types SKILL: •Wash hands or use waterless hand rinse •Cup the respirator in hand with nose piece at fingertips •Position respirator under chin with nose piece up •Pull top strap over head resting strap at crown of head •Pull bottom strap to position that ensures proper fit •Pinch nose piece using two fingers from each hand •Perform seal check and adjust straps accordingly •Cup hands over respirator and exhale •Adjust nose piece and straps to ensure complete seal •Proper removal of mask: •Grasp lower strap and then upper strap at sides •Carefully pull straps back and over head ensuring respirator remains positioned on face •Using straps carefully allow respirator to move very slowly away from face •Discard respirator into biohazard waste •COMMENTS

Group

Educational Module by Hospital Area

BSP Review Environmental Cleaning Central Processing Department Protocol Patient Transport Policy Revised Oxygen Therapy Guidelines Code Blue Special RCP* RCPE * T4 Stryker* 1

Critical Care Areas Diagnostic Imaging Emergency Department Peri-operative services Respiratory Therapy Special Procedure Units Ward areas with negative pressure rooms

√ √ 2

Central Housekeeping Clinical support staff and labs Community practice clinics Morgue attendants Security Out-patient clinics

3

Ward areas without negative pressure rooms All administrative staff

√ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √

Physician’s Specific Module

• Self learning educational packages with a CD containing video demonstration of appropriate use of PPE.

• A return demonstration, one hour workshop for certification purposes.

• A questionnaire to review at the workshop.

• This module was applied to all staff and in house physicians in addition to midwifes, family physicians and fellows.

Survey of staff

• As of Aug 31/2005, a number of 4364 staff has been certified • 400 Physicians, Fellows and Midwifes • Ongoing sessions still scheduled once a month for each level of certification • A survey of staff demonstrated the following results

Evaluations

• • • • • 151 responses were received.

4 did not indicate any type of education, therefore were removed of the study.

Questions were related to their level of confidence in their Infection Control related Practices, their level of knowledge about the guidelines and their comfort level in educating family members on infection control issues.

The strength of the association was measured by using the RxC statistical analysis table.

Very confident Somewhat confident

A statistical significance was noticed between the two study groups with a p value of (p<0.001)

Received Competency based certification Did not receive Competency based certification 48 (72.7%) 29 (35.8%) 16 (24.2%) 43 (53.1%) Not Confident 2 (3.0%) 9 (11.1%) Total 66 81

Conclusions

• Readiness is a Multi-dimensional Challenge • No Organization is Ever “Fully Ready” • Flexibility is Key • Education is Essential • Our Staff are our Most Important Asset