Disaster Planning Drills and Readiness Assessment Gary B. Green, MD, MPH, FACEP Associate Professor of Emergency Medicine & Pathology Johns Hopkins University School of Medicine and Johns Hopkins University Evidence-Based Practice Center President, Emergency International, Inc.

“Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness” (AHRQ Evidence Report/Technology Assessment #51) First evidence based report on this topic First evidence based report on this topic Work sponsored by AHRQ, done by JHU EPC Work sponsored by AHRQ, done by JHU EPC Structured review & evaluation of literature Structured review & evaluation of literature Released January 2002 Released January 2002 Available on Web at: Available on Web at:

Current Evidence About Hospital Disaster Preparedness Training Very few high quality/scientifically based publications Basic “building blocks” of response system established Variety of training, assessment techniques reported Drills shown to be effective training tools Drills are dual purpose, also provide opportunity for system evaluation Terminology not yet standardized “Best” practices not yet defined Rapid development and dissemination of training and evaluation techniques (growing “toolbox”)

Basic Steps Toward Hospital Disaster Preparedness Assemble key stakeholders into interdisciplinary team Assemble key stakeholders into interdisciplinary team Review current resources, strengths, weaknesses Review current resources, strengths, weaknesses Develop detailed, written response plan Develop detailed, written response plan Disseminate and practice plan Disseminate and practice plan Evaluate adequacy of knowledge, skills and resources Evaluate adequacy of knowledge, skills and resources Review and re-engineer plan based on data Review and re-engineer plan based on data Modify training as needed to target weaknesses Modify training as needed to target weaknesses Continuously repeat cycle Continuously repeat cycle

Continuous Quality Improvement (CQI) Process Applied to Disaster Preparedness Capacity Building Review/modify disaster plan Didactic education training (modular courses) Skills/practical training (drills) Report & analysis of strengths & weaknesses Modification & re-engineering of training interventions Pre-course Knowledge exam Post-course Knowledge exam Drill evaluation: (Institutional & Individual skills assessment) (Re) Define stakeholders & goals

Preparation for Conventional vs. Bioterrorism Event Preparedness for biologic, chemical or radiation events is built on conventional preparedness Preparedness for biologic, chemical or radiation events is built on conventional preparedness Additional needed preparations include: Additional needed preparations include: –Decontamination of victims –Protection of health care workers –Containment of infectious agents –Agent/vector specific treatments –Preparedness for “chronic” disaster

Disaster Response PREHOSPITAL SCENE RESPONSE HOSPITAL DRILL RESPONSE IN-HOSPITAL EVENT RAD & CHEM BIO EMS & PUBLIC SAFETY RAD & CHEM BIO INCIDENT COMMAND SYSTEM (ICS) SYSTEM INTEGRATION

Basic Components of Disaster Response System Incident Command System Incident Command System System integration (communications) System integration (communications) Logistics (materials, facilities, transportation) Logistics (materials, facilities, transportation) Clinical operations Clinical operations Human resources Human resources Security Security Public relations Public relations Others as defined by local plan Others as defined by local plan

Training Techniques Results of AHRQ-sponsored EPC report “Traditional” educational techniques “Traditional” educational techniques –Lectures, discussions, AV aids, written material Standardized (smart) patients Standardized (smart) patients –Accepted by physicians –Effective for one-on-one training –Usefulness for training of large numbers? –Cost prohibitive? Teleconferencing or satellite broadcasting Teleconferencing or satellite broadcasting –Simultaneously reaches large numbers –Seems as effective as traditional techniques

Training Techniques “Tabletop” exercises “Tabletop” exercises –“Theoretical” drill with limited/no physical operations –Usually focuses on ICS, system integration –Successfully applied to physician training for bioterrorism preparedness –Best as part of comprehensive training plan? Computer simulations Computer simulations –May replace expensive drills, allow identification of weaknesses in disaster plan and implementation –Very limited data available

Training Techniques Disaster Drills Disaster Drills –“Cornerstone” of disaster preparedness efforts –Significant collective experience –High variability in methods used –Limited data concerning objective evaluation –Shown to improve knowledge of disaster plan –Successful in identifying problems in plan execution

Drill Evaluation: Define Goals & Boundaries Define specific goals for the drill Define specific goals for the drill –Don’t be ambitious beyond resources!!  Clinical response training?  ICS effectiveness evaluation?  Chem, Bio, Rads included? Define borders of drill activities Define borders of drill activities –Interface with outside agencies? –ED only, entire hospital, selected departments? –Moulaged patients, “smart” victims, no victims? –Security, pharmacy, radiology also involved? Resources available Resources available –Adequate time before drill? –Buy-in by key stakeholders? –Separate evaluation team?

Drill Evaluation: Methods and Instruments from Available “Tool Box” Clinical care evaluation Clinical care evaluation –Trained observers –Providers recording events (triage tags, etc.) –“Smart” patients ICS, system integration ICS, system integration –Direct observation difficult –Self-assessment & “cross-evaluation” Drill flow Drill flow –Movement of patients, staff, supplies, etc. –Entrance/exit observers Qualitative evaluation Qualitative evaluation –Evaluators narrative comments –Videotape review –Debriefing comments –Surveys, structured interviews of drill participants

Evaluation of ICS Lack of “gold standard” Lack of “gold standard” Limitations of direct observation: Limitations of direct observation: –Difficult to capture communications among many key personnel –Nearly impossible to monitor content of communications –Evaluation may disrupt flow of events Focus on result vs. occurrence of communication Focus on result vs. occurrence of communication –Post-drill survey or interview of key personnel  Clear understanding of roles?  Knowledge of command structure?  Communication frequency and adequacy?  Narrative comments, critique