1. Presented by: Scott Aronson, MS Principal Russell Phillips & Associates, LLC saronson@phillipsllc.com www.phillipsllc.com saronson@phillipsllc.com www.phillipsllc.com Offices in CA / CT / NY / OH / RI 2011: Impact on Northeast from Irene and the “Halloween Storm”

2. Recent Disaster Incidents (*2011 RPA On-site Assessments) Northeast Blizzards – January 2011 ( weekday ) Northeast Blizzards – January 2011 ( weekday ) MA Tornadoes - Springfield, MA area ( 6/1 – weekday ) MA Tornadoes - Springfield, MA area ( 6/1 – weekday ) Earthquake on the East Coast ( weekday ) Earthquake on the East Coast ( weekday ) Hurricane/Tropic Storm Irene (8/28) & Lee Flooding ( weekend ) Hurricane/Tropic Storm Irene (8/28) & Lee Flooding ( weekend ) 7,000 patients/residents evacuated in NY alone 7,000 patients/residents evacuated in NY alone CT hospital evacuation – generator fire CT hospital evacuation – generator fire Snowstorm/Power Failure – October 29 ( weekend ) Snowstorm/Power Failure – October 29 ( weekend ) Storm Alfred – “Halloween Storm” Storm Alfred – “Halloween Storm”

3. The Joplin Experience May 22, 2011 - 5:41 PM (Evacuation / Surge)

4. Tornado vs. Earthquake Drop, Cover & Hold Drop, Cover & Hold Move Patients into central corridors away from windows / doors to exterior Move Patients into central corridors away from windows / doors to exterior  If unable to do so (e.g. higher acuity): Move away from windows and cover with blankets / overbed tables  If unable to do so: Cover patients with blankets By all means, don’t stand in a door frame that has a door on it!

5. Window Impact - February 1998 - Dept. of Army Waterways Experiment - Equivalent to 1000lbs TNT at 275 feet distance

6. Hospital Impact St. John’s Hospital Evacuation St. John’s Hospital Evacuation  Fires and exposed electrical throughout  Evacuation of all patients in 90 minutes (~187)  Generator failure – destroyed (roof lands on the power plant)  Vertical evacuation completed in dark stairwells (NFPA 99 potential issue on lighting)

7. LTC - Immediately Post Strike Moved patients away from flowing water (sprinklers) Moved patients away from flowing water (sprinklers)  What is your shut-off valve strategy on Sunday evening? Gas odor strong on exterior of building Gas odor strong on exterior of building  Concerned about evacuating outside  What is your procedure for HVAC shutdown / containment? Coordination of staff by Nursing Super and Charge Nurses – no leadership for 1+ hour Coordination of staff by Nursing Super and Charge Nurses – no leadership for 1+ hour  What was the Incident Command System used? Staff Calm  Patients Calm Staff Calm  Patients Calm

8. Immediately Post Strike, cont’d Nursing Homes: Large influx / surge from community Nursing Homes: Large influx / surge from community  Says “healthcare” so they must be able to treat Established external treat and triage area Established external treat and triage area  Recommendation: No additional supplies needed  Addressed lacerations, missing limbs, etc.  Moved to hospital as quickly as possible

9. Key Components to a Full Building Evacuation (FBE) Plan Activation of Plan and Labor/Personnel Pool Activation of Plan and Labor/Personnel Pool Establishment of Internal Holding Areas Establishment of Internal Holding Areas Patient Preparation on Units Patient Preparation on Units Marking of Patient Rooms (evacuated) Marking of Patient Rooms (evacuated) Coordination of Transportation Coordination of Transportation Determination of Receiving Sites Determination of Receiving Sites Patient Tracking (internal and external) Patient Tracking (internal and external)

10. Joplin Evacuation Reality Emergent Situation Emergent Situation Patient Preparation on Units Patient Preparation on Units Meds & Personal Belongings in bags / Charts on laps Meds & Personal Belongings in bags / Charts on laps Marker with last name on arm Marker with last name on arm Marking of Patient Rooms Marking of Patient Rooms Checked over and over again (Door Tags Recommended) Checked over and over again (Door Tags Recommended) Immediate Threat Immediate Threat Patient moved vertically – all means employed Patient moved vertically – all means employed Marking of Patient Rooms Marking of Patient Rooms Checked over and over again Checked over and over again

11. Joplin Evacuation Reality Emergent Situation Emergent Situation Determination of Receiving Sites Determination of Receiving Sites No coordinated support No coordinated support Coordination of Transportation (patients) Coordination of Transportation (patients) Pick-up trucks and 4 door sedans Pick-up trucks and 4 door sedans All POVs destroyed at facility All POVs destroyed at facility EMS on-scene 2 hours post event EMS on-scene 2 hours post event 1 st ambulance transport at midnight due to disaster 1 st ambulance transport at midnight due to disaster Immediate Threat Immediate Threat Determination of Receiving Sites Determination of Receiving Sites No coordinated support No coordinated support Coordination of Transportation (patients) Coordination of Transportation (patients) Pick-up trucks, 4 door sedans and carried Pick-up trucks, 4 door sedans and carried All POVs destroyed at facility All POVs destroyed at facility Minimal EMS Capabilities in early phase due to community/infrastructure impact Minimal EMS Capabilities in early phase due to community/infrastructure impact

12. Joplin Evacuation Reality, cont’d Emergent Situation Emergent Situation Coordination of Transport. (equip) Coordination of Transport. (equip) Pick-up trucks Pick-up trucks Mattresses, wheelchairs, meds (beds - next day) Mattresses, wheelchairs, meds (beds - next day) 30 minute cycle 30 minute cycle Patient Tracking Patient Tracking Census Log - both ends Census Log - both ends No Patient Evacuation Tracking Forms used No Patient Evacuation Tracking Forms used Immediate Threat Immediate Threat Coordination of Transport. (equip) Coordination of Transport. (equip) Pick-up trucks / Box Trucks Pick-up trucks / Box Trucks Salvage Operation Salvage Operation Patient Tracking Patient Tracking None in initial window None in initial window

13. 126 Bed LTC - Surge Process Standard Process (24 hour period) Standard Process (24 hour period) Discharges  Additional Beds  Surge to 110% or 139 Residents ( rare event to go higher than 110%) Discharges  Additional Beds  Surge to 110% or 139 Residents ( rare event to go higher than 110%)

14. Catastrophic Surge (Joplin) Catastrophic Surge Process Catastrophic Surge Process Census Reduction (no time)  Surge  Equipment & staff may or may not come Census Reduction (no time)  Surge  Equipment & staff may or may not come

15. 389 Bed Hospital (licensed) - Surge Process Standard Process (24 hour period) Standard Process (24 hour period) Discharges  Additional Beds  Surge to 520 Patients Discharges  Additional Beds  Surge to 520 Patients

16. Catastrophic Surge (Joplin) Catastrophic Surge Process Catastrophic Surge Process Census Reduction (no time)  Surge  Equipment, Staff and Resources may or may not come Census Reduction (no time)  Surge  Equipment, Staff and Resources may or may not come

17. The New England Storms of 2011

18. June Tornadoes

19. Tropical Storm Irene

23. Earthquake Warning: None Immediate Actions Tornado Warning: Limited Immediate Actions Hurricane Warning: Extended Extended / Decompress Snowstorm Warning: Extended Minimal: Watch & See

24. Hospital & LTC Mutual Aid Plans Place and support continuity of care of evacuated patients Place and support continuity of care of evacuated patients Provide supplies/equipment/ pharmaceuticals as necessary Provide supplies/equipment/ pharmaceuticals as necessary Assist with transportation of supplies/ staff/equipment/evacuated patients/families Assist with transportation of supplies/ staff/equipment/evacuated patients/families Provide staffing support (whether a facility is evacuating or staying) Provide staffing support (whether a facility is evacuating or staying)

25. Regional Medical Coordinating Center/ Long Term Care Coordinating Center Operating in MA and CT

26. Function of Coordinating Centers Assist and coordinate patient placement Assist and coordinate patient placement Support patient tracking - “Close the loop” Support patient tracking - “Close the loop” Assist with obtaining staff, supplies and equipment Assist with obtaining staff, supplies and equipment Assist with transportation of staff, supplies and equipment Assist with transportation of staff, supplies and equipment Interaction with local, regional and state agencies Interaction with local, regional and state agencies ENSURE EVERYONE IS ACCOUNTED FOR

27. Prioritization / Coordination Facilities Grouped for Tracking Facilities Grouped for Tracking  Group 1: Reported No Issues (no actions taken / not called)  Group 2: Reported Issues (communicated with between 1-2 times daily for situation updates and resource needs)  Group 3: Did Not Report – Considered “at risk” until communicated with  Drains resources when the facility is “OK” and did not report

28. Actions in Irene and Halloween Storm Reporting: Online Emergency Reporting completed Reporting: Online Emergency Reporting completed Situation Report: Provided 1-2 Times Daily to DPH and Regional Partners (submitted to CMS/HHS) Situation Report: Provided 1-2 Times Daily to DPH and Regional Partners (submitted to CMS/HHS) “At Risk”: Members Communicated with “At Risk”: Members Communicated with  CT: 21 out of 91 (Irene) / 62 (Alfred) / 118 bed vent hospital  MA: 47 out of 447 (Irene) / 54 (Alfred) Activation: Full stand up on multiple occasions for potential or actual Evacuating Facility Activation: Full stand up on multiple occasions for potential or actual Evacuating Facility  IRENE NOTE: In CT - 4 of 91 had generator failures at one time or another (4.4%)

29. One Hospital’s Irene Experience Preparation: Preparation: Command Center activated – multiple operational period positions assigned Command Center activated – multiple operational period positions assigned Tree clearing completed – vulnerable areas Tree clearing completed – vulnerable areas Additional clinical, ancillary & support staff on duty Additional clinical, ancillary & support staff on duty Resources & Assets enhanced Resources & Assets enhanced Top off fuel tanks Top off fuel tanks Advance supply order received Advance supply order received Hospital Size: 98 beds / LTC facility on campus Hospital Size: 98 beds / LTC facility on campus Irene: *43 inpatients and 5 ED patients Irene: *43 inpatients and 5 ED patients * due to decompression ahead of storm * due to decompression ahead of storm August 28 – Irene Strikes: August 28 – Irene Strikes: 0820 Power Fails / Emergency Generator working 0820 Power Fails / Emergency Generator working 1527 Generator shorts and fails 1527 Generator shorts and fails

30. CT Hospital Evacuation Generator Fire: 750kw ( suppressed with extinguisher ) Generator Fire: 750kw ( suppressed with extinguisher ) Commercial Power Down / No Elevators Commercial Power Down / No Elevators 1532 Unified Command established with Fire Dept. 1532 Unified Command established with Fire Dept. 1547 Primary phone system fails 1547 Primary phone system fails 1600 Decision to Evacuate 1600 Decision to Evacuate Evacuation commenced for ED patients (not admitted) Evacuation commenced for ED patients (not admitted) 1615 Electronic patient tracking system in place 1615 Electronic patient tracking system in place 1643 EMS Strike Teams activated and Dept. of Public Health Licensure staff onsite 1643 EMS Strike Teams activated and Dept. of Public Health Licensure staff onsite 1905 Commercial power restored 1905 Commercial power restored Evacuation Continues (CEO decision – on hill/wind gusts) Evacuation Continues (CEO decision – on hill/wind gusts) 2200 Last patient evacuated 2200 Last patient evacuated

31. CT Hospital Evacuation (cont’d) Vertical Evacuation (EMS/Fire equipment): Vertical Evacuation (EMS/Fire equipment): No elevators / 3 flights of stairs No elevators / 3 flights of stairs Stairchairs Stairchairs Backboards Backboards Scoop Stretchers Scoop Stretchers Lighting Issues: Lighting Issues: Poor illumination from emergency lighting Poor illumination from emergency lighting Could not see >30’ into facility Could not see >30’ into facility Fire Dept. supplemented stairwell lighting Fire Dept. supplemented stairwell lighting Pyxis Issues: Access issues Pyxis Issues: Access issues

32. CT Hospital Evacuation (cont’d) Medical Records: Medical Records: Medical Records went with patient and a nurse sent to each receiving hospital Medical Records went with patient and a nurse sent to each receiving hospital Nurse copied medical records at Patient Accepting Facility Nurse copied medical records at Patient Accepting Facility 4 hours for first 33 patients and 2 hours for final 10 4 hours for first 33 patients and 2 hours for final 10 Issue: Had commercial power / Records copied on-site Issue: Had commercial power / Records copied on-site Holding Area: Holding Area: One point of discharge One point of discharge EMS had equivalent of Medical Services Officer EMS had equivalent of Medical Services Officer Hospital clinical handoff for Critical Care patients Hospital clinical handoff for Critical Care patients No clinical handoff or communications for Med/Surg No clinical handoff or communications for Med/Surg Patient Families: All communicated to Patient Families: All communicated to

33. CT Hospital Evacuation (cont’d) Distribution: 7 hospitals and 3 LTC ( not their own ) Distribution: 7 hospitals and 3 LTC ( not their own ) Patient Tracking: EM Tracker / EMS Log at exit Patient Tracking: EM Tracker / EMS Log at exit Activation: Major Communications Issue Activation: Major Communications Issue Disaster Struck Facility: Full Activation Disaster Struck Facility: Full Activation Patient Accepting Facilities: Limited to No Activations Patient Accepting Facilities: Limited to No Activations EMTALA: EMTALA: Stacked up patients at 1 ED - Real concern? Stacked up patients at 1 ED - Real concern? Close the Loop: Hospital called everyone for status Close the Loop: Hospital called everyone for status Mutual Aid Plan: Mutual Aid Plan: Design commenced in December 2011 Design commenced in December 2011 Go live date of May 17, 2012 to tabletop and FSE in Fall 2012 Go live date of May 17, 2012 to tabletop and FSE in Fall 2012 Major Success ( hospital, EMS, RESF8, Fire ): Major Success ( hospital, EMS, RESF8, Fire ): 3 C’s – Communication, Coordination, Cooperation 3 C’s – Communication, Coordination, Cooperation

34. Emergency Generators (failure) How deep have you gone? How deep have you gone?  Service Patient Care Towers  Service areas with High Acuity Patients  Do they parallel each other for redundancy  Do you have a quick connection pre-wired with transfer switch?  Voltage / Kw / Service Amperage  Cable Run (in feet to the electrical service)  Fuel Source  Exact Location on Campus (back-up)

36. Hospital Surge – Halloween Storm 520 Bed Hospital: 520 Bed Hospital: 80 – 120 additional patients 80 – 120 additional patients Excluding ED Boarders Excluding ED Boarders Conversions (sample): Conversions (sample): Closed Unit – 25 bed patient care area Closed Unit – 25 bed patient care area Rehab “Storage” Unit – 14 beds for “shelter boarders” Rehab “Storage” Unit – 14 beds for “shelter boarders” Swing Unit – 22 beds housing discharged patients Swing Unit – 22 beds housing discharged patients Could not go home Could not go home Day Care Activated 24/7: All staff Day Care Activated 24/7: All staff Showers / Sleeping: Any staff who required it Showers / Sleeping: Any staff who required it Electives: Cancelled in many areas Electives: Cancelled in many areas

37. Hospital Decompression Frail Elderly / Medical Equipment / Clinical Needs Frail Elderly / Medical Equipment / Clinical Needs 1.Standard Discharges - ??? 2.Medicare Eligible – 3 day length of stay requirement (major hindrance) 3.Medicaid Eligible – PASRR and Ascend Issue: Communication issue b/w hospital and LTC believing all of this was waived Issue: Communication issue b/w hospital and LTC believing all of this was waived Solution: DPH Blast Fax and E-mail Notification Solution: DPH Blast Fax and E-mail Notification Payment under Respite Care provision Payment under Respite Care provision 4.Private Insurance - 3-5 days / until can return home 5.Private Pay – 3-5 days / until can return home Hospital / LTC rate discussions Hospital / LTC rate discussions

39. Emergency Reporting System Information Key contact during event Key contact during event Beds Status and Type Beds Status and Type Operational Issues and Specifics Operational Issues and Specifics Transportation Vehicles, Capacity & Deployment Time Transportation Vehicles, Capacity & Deployment Time Staff, Numbers / Type and Deployment Time Staff, Numbers / Type and Deployment Time Resources & Assets you can provide Resources & Assets you can provide Resources & Assets you may need Resources & Assets you may need

44. Successes 100% accountability for all regional facilities 100% accountability for all regional facilities Effectively activated to support evacuation or imminent vendor / equipment needs Effectively activated to support evacuation or imminent vendor / equipment needs Prepared to support out of region facilities Prepared to support out of region facilities Communication Process with DPH, Coordinating Centers and ESF 8 Communication Process with DPH, Coordinating Centers and ESF 8 Communication Process with Members Communication Process with Members Surge Plan with DPH and Bed Reporting Updates Surge Plan with DPH and Bed Reporting Updates

45. Challenges Regional Shelters vs. Regional Medical Shelters Regional Shelters vs. Regional Medical Shelters Should the hospitals fully operate or locals? Age old question Should the hospitals fully operate or locals? Age old question WebEOC / ESAR-VHP (credentialing) WebEOC / ESAR-VHP (credentialing) Decompression of hospitals Decompression of hospitals 1135 Waiver would have minimized obstructions to decompress hospitals 1135 Waiver would have minimized obstructions to decompress hospitals Communications between hospitals and LTC Communications between hospitals and LTC Hospital Evacuation: What is an emergency to one may be a normal day to another Hospital Evacuation: What is an emergency to one may be a normal day to another

46. National Issue: Consistency in Handling Disaster Events Single Facility Event / Isolated Incident Single Facility Event / Isolated Incident Extremely challenging to preplan payer process Extremely challenging to preplan payer process Fire or other immediate threat emergency forcing evacuation Fire or other immediate threat emergency forcing evacuation Single Facility Event / Regional Impact Single Facility Event / Regional Impact State typically has exhausted all resources prior to waiver request State typically has exhausted all resources prior to waiver request Multiple Facility Event / Regional Impact Multiple Facility Event / Regional Impact Easiest to secure 1135 Waiver Easiest to secure 1135 Waiver

47. Scott Aronson, MS Principal Russell Phillips & Associates, LLC saronson@phillipsllc.com www.phillipsllc.com Offices in: California / Connecticut / New York / Ohio / Rhode Island