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EFFECTIVE EMERGENCY MANAGEMENT DRILLS AND EXERCISES

Greater New York Hospital Association

EFFECTIVE EMERGENCY MANAGEMENT DRILLS AND EXERCISES


FOREWORD
This booklet has been prepared as part of GNYHAs continuing efforts to help its members undertake effective and efficient drills and exercises, specifically for emergency preparedness and response. It also explains the rationale for conducting emergency management drills and exercises. The booklet is intended for health care professionals involved with emergency management and response activities at all levels. GNYHA is committed to ensuring that its members are prepared to respond to the wide range of emergencies, disasters, and events that might take place in the areas where they are located. As part of that commitment, GNYHA has undertaken a variety of initiatives to assist its members in implementing effective emergency management drills and exercises. In the aftermath of September 11, 2001, GNYHA created its Emergency Preparedness Coordinating Council (EPCC). The EPCC brings together representatives of GNYHA members and other provider groups as well as local, state, and Federal public health officials and emergency management agencies to encourage collaboration and communication across the region and, ultimately, to ensure a more integrated response to any future attacks or events. GNYHA has also created a Workgroup on Emergency Management Drills, which consists of members of the EPCC (both GNYHA member and governmental representatives), as well as additional GNYHA members with specific expertise in undertaking emergency management drills for their institutions. Through this workgroup, GNYHA has designed a number of workshops consisting of didactic sessions and small group sessions with a curriculum tailored specifically to health care facilities to assist them in undertaking effective exercises. The materials from the workshops are
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available online in the Drills and Exercises section of the Emergency Preparedness Resource Center on GNYHAs Web site, www.gnyha.org/ eprc/general/drills_exercises. Following actual emergency events (for instance, the regional power outage of August 2003), GNYHA has held debriefing sessions with members and governmental agencies to discuss lessons learned from those events. GNYHA staff has also coordinated the hospital component for numerous exercises organized by the New York State Department of Health, the New York City Department of Health and Mental Hygiene, the New York City Office of Emergency Management (OEM), the Westchester County Department of Emergency Services, and other governmental agencies that have held regional emergency management exercises. Finally, GNYHA has organized two tabletop exercisesone in June 2003 designed by the Naval War College, and the other designed by GNYHAs Workgroup on Emergency Management Drills in June 2004as well as four drills of the New York State Health Emergency Response Data System, known as HERDS, and drills of OEMs 800 MHz radio system.

ACKNOWLEDGMENTS
GNYHA would like to thank its Workgroup on Emergency Management Drills, and specifically Karen Biancolillo, R.N.; Kevin Brown, M.D.; Kevin Chason, D.O.; Andrew Chen; Jack Delaney; Dario Gonzalez, M.D.; Mark Marino; Frank Mineo; Brian ONeill; Steven H. Silber, D.O.; and Joseph Stevens. This brochure was produced by GNYHA and funded by a generous grant from the Federal Health Resources and Services Administration to the New York State Department of Health and Health Research, Inc., under grant/contract number 6U3RMC000260203.

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THE FOUR PHASES OF EMERGENCY MANAGEMENT


Effective emergency management takes into account an all-hazards approach that includes the following four phases: mitigation, preparedness, response, and recovery. Mitigation activities, according to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), are those that a hospital undertakes in attempting to lessen the severity and impact of a potential emergency.1 Preparedness activities are those that a hospital undertakes to build capacity and identify resources that may be used if an emergency occurs.2 Response involves activating the plan (including the incident command system, or ICS) and dealing with the actual event as it unfolds. In health care facilities, it usually involves treating victims of the emergency. Recovery involves activities designed to help facilities resume operations after an emergency.

Drills and exercises should ideally test as many of the four phases of emergency management as possible, although they may not necessarily test them all at the same time.

PRELIMINARIES: THE HAZARD VULNERABILITY ANALYSIS


Before designing and undertaking drills and exercises, staff members who are responsible for coordinating their facilitys emergency management activities (usually the emergency management committee) must develop an emergency management plan. The staff designs the plans based on the facilitys hazard vulnerability analysis (HVA). The purpose of the HVA is to
1. Joint Commission on Accreditation of Health Care Organizations, 2004 Comprehensive Accreditation Manual for Hospitals, Environment of Care Standard 4.10 (Oakbrook Terrace, Ill., 2004). 2. Ibid. 1

identify potential emergencies that could affect the need for its [the health care facilitys] services or its ability to provide those services.3 Facilities that are accredited by the JCAHO are required to conduct an HVA.4 Facilities that are not JCAHO-accredited should also conduct one. The purpose of the HVA is to enable a health care facility to identify, within its emergency management plan, the possible emergencies that it may need to address and their probable impact if they were to occur. When conducting an HVA, the facility staff should start by listing the emergencies that might affect the facility, including various factors in the surrounding area. For example, is the area prone to floods? Is a chemical plant located nearby? The HVA should include internal events (such as fires) as well as external events (such as power outages). The HVA should focus on the naturally occurring and man-made hazards that are most likely to have an impact on the facility and the surrounding community (such as floods, HAZMAT incidents, terrorist attacks). The probability that those events will occur should then be considered. The analysis is based upon history as well as events that might not have actually occurred but might be expected to occur. Next, the staff should consider how each event will affect the facility (sometimes called the severity of an event). For example, will lives be lost if the event occurs? Will the facility be damaged? Finally, staff should review the extent to which the facility and the community are prepared for each type of event. If an organization is not well prepared for a certain type of incident, it might want to devote more resources to preparing for that type of incident. Similarly, if community resources would not be available to assist in addressing the incident, then the facility would probably want to devote more resources to addressing it.

An organization may undertake the HVA in a variety of ways. The emergency management plan should reference the HVA in order to document that it was undertaken. Several tools have been designed so that health care organizations may undertake effective HVAs. Examples of these tools appear in Appendix 1 and on GNYHAs Web site, www.gnyha.org, in its Emergency Preparedness Resource Center.
3. Ibid. 4. Ibid. 2

DRILLS AND EXERCISES


Once an HVA has been completed, work can begin on making sure that the emergency management plan includes specific approaches to preparing for and responding to the emergencies that a health care organization is likely to face. The plan should include the mitigation, preparedness, response, and recovery activities that will need to be undertaken in order to address the priorities identified in the HVA. The approaches can be rehearsed through various types of drills and exercises. Based on the outcome of those drills and exercises, the emergency management plan might be modified and improved.

TYPES OF DRILLS AND EXERCISES


Drills and exercises simulate or are based on possible real-life scenarios in order to improve emergency management, and should be based on the vulnerabilities identified in each health care organizations HVA. There are several different types of drills and exercises. Drill: A drill is a supervised activity with a limited focus to test a procedure that is a component of the organizations overall emergency management plan. That is, drills usually highlight and closely examine a limited portion of the overall emergency management plan. For example, an organization might conduct a drill for the use of a radio system with those responsible for communicating on it. Tabletop Exercise: A tabletop exercise uses written and verbal scenarios to evaluate the effectiveness of an organizations emergency management plan and procedures and to highlight issues of coordination and assignment of responsibilities. Tabletop exercises do not physically simulate specific events, do not utilize equipment, and do not deploy resources. In a tabletop exercise, a facilitator usually coordinates discussion. Functional Exercise: A functional exercise simulates a disaster in the most realistic manner possible without moving real people or equipment to a real site. A functional exercise utilizes a carefully designed and scripted scenario, with timed messages and communications between players and simulators. The emergency operations center (EOC)the facility or area from which disaster response is coordinatedis usually activated during a functional exercise and actual communications equipment may be used.

Full-Scale Exercise, or Field Exercise: A full-scale exercise is often the culmination of previous drills and exercises. It tests the mobilization of all or as many as possible of the response components, takes place in real time, employs real equipment, and tests several emergency functions. In the hospital context, a full-scale exercise often involves pre-hospital as well as hospital response, and usually involves actors simulating patients and the activation of the EOC. It may also include other health care facilities in order to test mutual aid agreements. Controllers, who maintain order and ensure that the exercise proceeds according to plan, are also usually used. Full-scale exercises are generally intended to evaluate the operations capability of emergency management systems in a community and to evaluate interagency coordination.

RATIONALE FOR CONDUCTING DRILLS AND EXERCISES: ACCREDITATION AND REGULATORY STANDARDS
Hospitals that are accredited by JCAHO are required by JCAHO Environment of Care (E.C.) standard 4.20 to conduct drills regularly to test emergency management. Further, the elements of performance for E.C. 4.20 include the following:5 Hospitals must test the response phase of their emergency management plans twice a year, either in response to an actual emergency or in planned drills. Drills that involve packages of information that simulate patients, their families, and the public are acceptable. Hospitals must conduct drills at least four months apart and no more than eight months apart. Hospitals must conduct at least one drill a year that includes an influx of volunteers or simulated patients if the hospitals offer emergency services or are community-designated disaster receiving stations. For purposes of the influx of simulated patients requirement, tabletop exercises are not acceptable. Hospitals must participate in at least one communitywide practice drill a year (where applicable) relevant to the priority emergencies identified in their HVAs. The drill must assess the communication, coordination, and effectiveness of the hospitals and communitys command structures and may be conducted by means of a tabletop

5. Joint Commission on Accreditation of Health Care Organizations, 2004 Comprehensive Accreditation Manual for Hospitals, Environment of Care Standard 4.20 (Oakbrook Terrace, Ill., 2004). 4

exercise.Communitywide may range from a contiguous geographic area served by the same health care providers to a large borough, town, city, or region. The drill involving the influx of volunteers may be separate, simultaneous, or combined with the communitywide practice drill. Drills must be critiqued to identify deficiencies and opportunities for improvement.

In addition, many state regulations require hospitals to conduct drills. For example, New York State regulations that apply to hospitals require each hospital to have a written emergency and disaster preparedness plan that must be rehearsed and updated at least twice a year, with procedures to be followed for the proper care of patients and personnel, including but not limited to the reception and treatment of mass casualty victims in the event of an internal or external emergency or disaster arising from certain events.6 The New Jersey Administrative Code requires each hospital to conduct 1) at least one evacuation drill each year, either simulated or using selected patients, and 2) at least one drill a year in which a large influx of emergency patients is simulated.7 Under the New Jersey code, actual emergencies of each type are considered drills, if they are documented. Even if they were not required, drills are a good way to test an emergency management plan.

GOALS AND OBJECTIVES OF DRILLS AND EXERCISES


Drills and exercises are an excellent means of determining whether a health care organization functions as anticipated in a disaster and, if not, as a way to identify opportunities for improvement. They also provide an opportunity for staff to practice their skills and to identify future areas for training. When designing drills, the following objectives should be kept in mind: Drills and exercises should be designed to clarify the roles and responsibilities of those who are expected to respond to a disaster and to improve coordination among those responding. The objectives of drills and exercises should state who should do what, under what circumstances, and according to what standard. When designing drills and exercises, it is important to test the equipment that the staff will use during an actual emergency to ensure that it functions correctly and that staff knows how to use it.

6. 10 New York Code, Rules and Regulations Section 405.24(g). 7. New Jersey Administrative Code Section 8:43G-5.16(h),(i). 5

EVALUATING DRILLS AND EXERCISES


Following an exercise, the evaluator (either someone from the health care organization who is assigned that role, or an outside individual) should prepare a critique, also known as an after-action report. If other organizations (for example, Emergency Medical Services) have participated, comments from those agencies should be requested as well. The use of external evaluatorsthat is, personnel who dont work for the institutionshould be considered, since they enhance objectivity and help keep staff out of difficult situations (such as evaluating supervisors). Outside evaluators may be from another hospital, an agency in the community, or a party hired to help undertake the exercise. An effective evaluation takes into account the observations of evaluators, players, controllers, and actors. Evaluation forms are usually used to record the observations. The person (or people) evaluating drills and exercises should observe the action, report on what goes well and what doesnt, note how participants perform, and determine whether the goals and objectives of the exercise are met. In addition, the following approaches should be applied when evaluating drills and exercises: An organizations emergency management committee, which is charged with designing and reviewing the emergency management plan, should also be charged with designing drills and exercises. For an exercise to be effective, the players should be thoroughly evaluated using measurable standards, such as the length of time it takes them to decontaminate patients who have been exposed to a toxic chemical. Those standards should be specified in the exercise objectives. An evaluation should also focus on the exercise itself. Was it well designed? Did it test what it was designed to test? A discussion (debriefing) with actors and staff should also take place after the exercise, so they may share their experiences. The discussion should encourage critical thinking and honest evaluation and should focus on the following questions: What went right? What needs to be improved? How will improvements be made? An effective evaluation should include suggestions for revising the emergency management plan, if necessary, and retraining after the exercise is completed in order to address specific problems that might have been identified.
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An example of an evaluation form appears in Appendix 2 and may be found at www.gnyha.org/eprc/general/presentations/ Disaster_Eval_Tool.pdf. Additional evaluation tools developed by the Johns Hopkins Evidence-Based Practice Center for the Agency for Healthcare Research and Quality as well as by the U.S. Department of Homeland Security can be found at www.ahrq.gov/research/hospdrills/ index.html. Federally Funded Drills and Exercises. Beginning in 2005, for drills and exercises that are undertaken using Federal funding (including hospital drills and exercises undertaken with Federal funding from the Health Resources and Services Administration), the Homeland Security Exercise and Evaluation Program (HSEEP) will be the framework within which those drills and exercises will be initiated, implemented, and evaluated. The purpose of the program is twofold: 1) to evaluate performance on critical tasks, and 2) to validate strengths and identify improvement opportunities, all with the goal of improved preparedness. Performance during drills and exercises will be analyzed at different levels, including task level, agency/ discipline/function level, and mission level (within and across communities), and will be required to utilize both Homeland Security Exercise Evaluation Guides and HSEEPs After-Action Report template. A link to HSEEP can be found at www.gnyha.org/eprc/general/ drills_exercises/ under Design and Evaluation Tools.

DESIGNING A FUNCTIONAL EXERCISE: AN EXAMPLE


This example illustrates an approach to designing a functional exercise for a hospital. Please note that each hospital designing a similar exercise would indicate specific symptoms for possible incoming patients. Background. Hospital A is located near a subway station in New York City. In its HVA, Hospital A has identified the possibility of receiving patients who have been contaminated as a result of a chemical terrorism event. Goals. The goals of the exercise are to test the hospitals emergency management plan for mitigating the consequences of an event identified in its HVA (a chemical event, in this case), including decontamination, and to test the hospitals response, including the activation of the hospitals incident command system. Objectives. The exercise is intended to test the hospitals ability: to successfully prepare, within a specific period of time, for decontaminating patients;
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to prepare staff on the decontamination team to be outfitted in personal protective equipment (PPE) within a specific period of time; to prevent contaminated patients from entering the emergency department without being decontaminated; and to successfully decontaminate ambulatory and non-ambulatory patients within a certain period of time after their arrival at the emergency department.

Measures. The exercise can be evaluated using the following measures: How long did it take the hospital to get its decontamination equipment ready? How long did it take staff to be outfitted in PPE? Were patients stopped before entering the emergency department? How long did it take to decontaminate patients?

TIPS FOR DESIGNING EFFECTIVE DRILLS AND EXERCISES


If you want to test your staffs ability to recall the emergency management plan and respond accordingly, an unannounced exercise should be conducted. If you want to motivate staff to review the emergency management plan (when they wouldnt have otherwise) and test their ability to get equipment ready, an announced exercise is helpful. Drills and exercises should be conducted to test or practice only what staff have been taught. Asking staff to undergo a drill or exercise before they have been trained is like asking students to take a final exam before attending the course. Allow several months to design the drill or exercise. Drills and exercises should be based on the real hazards that a health care facility facesthat is, threats identified in its HVA and addressed in its emergency management plan. Maintain a limited focus. Dont try to test too many things at once. When undertaking a full-scale exercise, make sure that real patients continue to receive care. For example, if the exercise is taking place in the emergency department, make sure that staff continue to treat patients. Have a mechanism in place for terminating the exercise if necessaryfor example, if the exercise is causing harm to volunteers. Consider conducting an exercise that addresses multiple facets of an emergency at one time (for example, preparing for a large influx of patients while experiencing a power loss). When paper patients (sheets of paper or index cards with symptoms and other information written on them) are used, they should be triaged, put on stretchers or in wheelchairs, and transported through the hospital as if they were real patients. Remember to conduct drills and exercises during all shiftsday, evening, night, and weekendto test responses with various staffing levels. Use realistic staffing patterns in exercises. Remember to revise your emergency management plan based on what you learn from the drill or exercise.
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SUMMARY AND CONCLUSION


One of the keys to successful emergency preparedness and response is an effective emergency management planand in order to have an effective plan, it is critical to conduct well-designed drills and exercises before the plan is actually needed. This booklet provides you with some guidelines for designing and conducting drills and exercises. The steps a health care facility must take to prepare for potential emergencies and disasters that are specific to its geographic region are: 1. Conduct a hazard vulnerability analysis (HVA) to identify facility-specific threats. 2. Prepare an emergency management plan based on the hazards and threats identified in the HVA. 3. Design and conduct appropriate drills and exercises, taking into account the hazards identified in the HVA and addressed in the emergency management plan. 4. Evaluate the outcome of the drills and exercises. 5. Modify the emergency management plan as needed based on the evaluation of the drills and exercises. 6. Train staff in the modifications that have been made to the plan.

For additional information on drills and exercises, visit the Drills and Exercises section of the Emergency Preparedness Resource Center on GNYHAs Web site at www.gnyha.org/eprc/general/ drills_exercises.

APPENDIX 1

SAMPLE HAZARD AND VULNERABLILTY ANALYSIS

2001 Kaiser Foundation Health Plan, Inc.

Reprinted with permission.

Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc.

Reprinted with permission.

Hazard Assessment KP.xls

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This document is a sample Hazard Vulnerability Analysis tool. It is not a

INSTRUCTIONS:

2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Natural Hazards: Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Technological Hazards - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Human Hazards - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc. Reprinted with permission. Hazardous Materials - Hazard Assessment KP.xls

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2001 Kaiser Foundation Health Plan, Inc.

Reprinted with permission.

Hazard Assessment KP.xls Summary

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APPENDIX 2

SAMPLE EVALUATION FORM FOR EMERGENCY MANAGEMENT DRILLS AND EXERCISES

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Greater New York Hospital Association 555 West 57th Street, 15th Floor New York, New York 10019 212.246.7100 / FAX 212.262.6350 www.gnyha.org

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