TOP TEN COMPETENCIES FOR PROFESSIONAL1 EMERGENCY MANAGEMENT B. Wayne Blanchard October 7, 2005 The purpose of this document is to provide assistance to academicians who have the responsibility of designing or maintaining a collegiate emergency management program (such as a degree, certificate, or concentration). The design of individual college courses and an emergency management curriculum should be informed by an appreciation of the functions of emergency management and skill sets needed to perform those functions. A previous and different version of this document was developed in the Spring of 2003, in preparation for a presentation at the 28th Annual Workshop on Hazards Research and Applications in Boulder Colorado.2 Since that time there have been two FEMA Emergency Management Higher Education Project Conferences which included breakout sessions to discuss emergency management competencies and curriculum as well as a workshop in Denver Colorado in the Fall of 2004 on The Hazards Manager of the 21st Century.3 In addition, the recent failure of governments to quickly and adequately respond to Hurricane Katrina in the Gulf and subsequent levee breaks in New Orleans, has caused me to re-evaluate and re-write the earlier document. The format will first be a simple listing, to be followed by amplifying notes. 1. Comprehensive Emergency Management Framework or Philosophy 2. Leadership and Team-Building 3. Management 4. Networking and Coordination 5. Integrated Emergency Management 6. Emergency Management Functions 7. Political, Bureaucratic, Social Contexts 8. Technical Systems and Standards 9. Social Vulnerability Reduction Approach 10. Experience 1 One would think it apparent by now that emergency managers at all levels of government need to have emergency management competencies when obtaining their positions. It should no longer be accepted that anyone, at any level of government, be put into a lead emergency management position without having such competencies as those described herein. 2 Accessible at: http://training.fema.gov/emiweb/downloads/CoreCompetenciesEMHiEd.doc 3 Findings from these events are accessible at: http://training.fema.gov/emiweb/edu/EMCompetencies.asp 5/10/2019 2 1. Adopts “Comprehensive Emergency Management” framework or philosophy. Comprehensive emergency management can best be summarized as “all hazards, all phases,4 all actors.” This is in contrast with a homeland security (terrorism) response primary orientation. It should be obvious by now that an imbalanced focus on uniformed first responders and their response to a terrorism event has harmed the development and maintenance of broader capabilities for a broader audience and broader range of hazards. The best response capability in the world does little or northing to address future disaster losses. Only mitigation, reduction, prevention and readiness activities address the ever increasing vulnerability of the United States to disasters and ever increasing disaster losses.5 2. Leadership and Team-Building The necessity of good leadership is another obvious lesson to be tragically relearned yet once again in the wake of Hurricane Katrina. Especially, but not just, in the immediate pre-impact and early response phases, leadership is needed – not just an ability to provide a command presence, but the demonstration of vision, compassion, flexibility, imagination, resolve and courage.6 Without leadership, bureaucratic organizations and their personnel will tend to stay within more or less business as usual bureaucratic systems and methods of operation. It takes a leader to break down theses barriers to expeditiously move people and resources to where they are needed. Leadership is also needed in the hard-to-sell mitigation, reduction, prevention arena of emergency management – to seek to create an culture of disaster prevention and preparedness. Leadership means fighting for resources so that not only good risk assessments can be made, plans developed, people trained and systems exercised, but equipment, facilities, supplies can be procured which allow plans to be implemented. Without resources, even the best laid plans are but fairy dust. 3. Management Leaders need also to be able to manage, or have managers under them – people who have the ability to implement, to make happen. This was singularly lacking in pre-impact and initial Hurricane Katrina response wherein very detailed plans existed at local, state, federal levels and in the private sector, many hundreds of people had been trained and exercised against those plans, and yet the plans were not adequately implemented. This disconnect between Refers to all phases of the “disaster life cycle” – mitigation, preparedness, response, recovery. See the Emergency Management Higher Education slide presentation at: http://training.fema.gov/emiweb/downloads/highedbrief_course2.ppt#265,1,Slide 1 6 The Hurricane Katrina response at the federal level demonstrates how good systems can fail without good leadership, and how operations improve with good leadership. We reiterate here the 9/11 Commission Report on the importance of imagination and how things can go terribly wrong without it when working out of bureaucratic systems. As an example, picking, this time the local and state levels of government, local and state officials have said that hundreds of buses were not used to move citizens without transportation out of New Orleans prior to hurricane impact (as both local and state plans called for) due to lack of drivers. Yet gathering in such staging areas for evacuation as the Superdome, were thousands of people, many hundreds of whom could have been called upon to drive municipal and school buses filled with evacuees out of New Orleans along with those other citizens who had cars. 4 5 5/10/2019 3 good planning, training and exercising on the one hand and implementation on the other demonstrates, among other things, the criticality of managerial implementation abilities. 4. Networking and Coordination Emergency management offices are typically short staffed or no staff at all – just someone with the responsibility but insufficient resources. This situation requires that emergency managers network and coordinate with a broad range of other organizations -- up, down and laterally in government levels, private sector, voluntary associations and community based organizations. Particularly in large scale disasters, the failure of emergency management officials and their supervisors to adequately network beforehand with other levels of government, will prescribe a second governmental failure disaster. Within a jurisdiction or an organization, stakeholder organizations need to plan, train and exercise together. Indeed, one disaster researcher has suggested that successful and unsuccessful disaster response operations can be predicted beforehand based on knowledge of two variables alone – (1) the extent and variety of an emergency managers network (how many different stakeholders are communicated with and involved), and (2) the frequency of contact – once a year, twice, monthly, weekly, daily.7 5. Integrated Emergency Management Beyond the importance of networking and coordinating with a broad range of stakeholders, is the need to integrate hazard, disaster and emergency management concerns into broad range of organizational entities. In the local government context, for example, this means integrating emergency management planning into not just all the emergency services, but such other organizations as public works, public health, human services, transportation, planning, etc.). Emergency managers are seldom thought of until a threat looms, are too few, and typically have too little in the way of resources. This requires that emergency management organizations work to get other governmental organizations within their jurisdiction to “integrate” emergency management concerns (such as risk assessment, planning, training, exercise participation) into their thinking, systems and operations. The more heads the better. 6. Key Emergency Management Functions Emergency management functions are variously described and enumerated – as in lists of 10 or a dozen or 16, etc. These should be consulted. Herein will be stressed several key functions: ◼ Risk Assessment – what are the hazards facing ones jurisdiction/organization, their scope and probability, and the demographics, capabilities and resources of ones jurisdiction or organization ◼ Planning – emergency operations, mitigation, tie in to comprehensive plan ◼ Training 7 Drabek, Thomas E. 2003. Strategies for Coordinating Disaster Responses. Boulder, CO: Program on Environment and Behavior, Monograph 61, Institute of Behavioral Science, University of Colorado. 5/10/2019 ◼ ◼ ◼ ◼ 4 Exercising Emergency Operations Center Operations – setting up, equipping and managing Establishing interoperable communications within jurisdiction/organization Applying lessons learned and research findings to emergency management functions on an on-going basis 7. Political, Bureaucratic, and Social Contexts Emergency management is situated and must operate within various constraining and enabling circumstances. Key among them are the political, bureaucratic (or organizational), and social contexts of a jurisdiction/organization and those of lower and higher jurisdictions. Thus there is a great need to instruct on forms of government and bureaucratic politics, but also a need to understand the social dimensions of a jurisdiction/organizations and the social dimensions of disaster (how people and organizations react to disaster). 8. Technical Systems and Standards Students need to learn the tools of the trade, which today include such subjects as: ◼ National Incident Management System (NIMS) ◼ National Response Plan (NRP) ◼ NFPA 1600 (National Fire Protection Association “Standard for Disaster/Emergency Management and Business Continuity Programs” ◼ Certified Emergency Manager credential administered by the International Association of Emergency Managers ◼ Geospatial and geographical information systems (GPS and GIS) ◼ Communications systems ◼ Warning systems ◼ Computers and hazard and emergency management related software packages 9. Social Vulnerability Reduction Approach The Hurricane Katrina experience provides yet again the lesson that there are groupings of people in most, if not all jurisdictions, who are more vulnerable than others and are differentially impacted when a disaster crosses a community. The make-up of highly vulnerable groups varies across communities, so there is no simple listing of poverty, race or gender, for example, that allows one to simply “fill in the blanks.” The prevailing emergency management approach in the U.S. has been variously label, but a label that can be found in the academic community is “technocratic” – getting at reliance on traditional governmental managerial approaches, technology, and engineering to solve the problems of hazards. In looking at how many emergency management organizations spend their too-limited resources, there is frequently to be found a utilitarian, or biggest-bang-for-the-buck approach. This often translates into what can be done for the largest numbers of people in a community – for the most people. Frequently, though, “the most” does not translate into “the most vulnerable” and in need of assistance – “the most” often translates into white middle class. The social vulnerability perspective teaches practitioners to focus first and foremost on those most vulnerable to disasters in their communities, instead of the largest number of people, in recognition of the fact of life that most emergency management organizations have 5/10/2019 5 traditionally not had, and probably will not have in the future, the resources to do both things well – to do their job adequately. There is an upper division college course on the FEMA Emergency Management Higher Education website precisely on this topic – entitled “A Social Vulnerability Approach to Disaster” – and accessible at: http://training.fema.gov/emiweb/edu/completeCourses.asp In my opinion, no upper division or graduate degree program in emergency management should be viewed as complete without the inclusion of this or a similar course. 10. Experience It has been stated since the beginning of the FEMA Emergency Management Higher Education Project in late 1994, that the three keys to emergency management are education, training, and experience (preferably disaster experience). Successful disaster operations, for example, work best when standard bureaucratic methods of operating can be modified to act more expeditiously or outside of normal business as usual constraints. This is easier learned through experience than taught. There are many ways administrators of collegiate emergency management programs can assist their traditional (non-emergency management practitioner) students with the gaining of experience – such as through internships, service learning,8 exercise participation, CERT9 Team training and membership, and registration with disaster response organizations (such as the American Red Cross or as a FEMA’s disaster reservist. The gaining of even modest experience will be of assistance to traditional college students who will need to find jobs upon graduation – and will be competing against those without the educational foundation, but with experiential credentials. 8 See, for example the Emergency Management Service Learning section of the FEMA Emergency Management Higher Education Project website -- http://training.fema.gov/emiweb/edu/sl_em.asp 9 Community Emergency Response Teams – see: http://www.training.fema.gov/emiweb/CERT/ 5/10/2019 OUTLINES OF COMPETENCIES TO DEVELOP SUCCESSFUL 21st CENTURY HAZARD or DISASTER or EMERGENCY or HAZARD RISK MANAGERS By B. Wayne Blanchard, Ph.D., CEM Higher Education Project Manager Readiness Branch Emergency Management Institute National Emergency Training Center Federal Emergency Management Agency Department of Homeland Security 16825 S. Seton Avenue Emmitsburg, MD 21727 (301) 447-1262 wayne.blanchard@dhs.gov http://training.fema.gov/emiweb/edu 2003 Draft 6 5/10/2019 7 The development of the emergency management competences outlines below began with an invitation to participate on a panel on “Hazard Managers in the 21st Century: Needs in Higher Education,” July 15, 2003 at the 28th Annual Workshop on Hazards Research and Applications, in Boulder Colorado, sponsored by the Hazards Research and Applications Center at the University of Colorado at Boulder. The description of the panel in the Workshop Program document read: “To meet the challenges of disaster reduction in the 21st century, today’s hazard managers must possess some distinctly different characteristics from more traditional emergency managers. Hazard managers must develop a body of knowledge that goes beyond incident response to include expertise in social science and technology. Fostering interdisciplinary opportunities at colleges and universities is one way to build these capabilities. Unfortunately, there is no agreedupon framework that currently exists to guide these programs. This session addresses the fundamentals of an educational framework for refining a hazard management core curriculum.” In that I believe that a hazard or emergency management curriculum should be informed by the expected competencies of a hazard or emergency manager, my approach to preparing for the panel was to put on paper thoughts, in an outline format, on hazard/emergency management core competencies. This is a subject that I have some familiarity with, having collected several attempts to address occupational competencies from a range of perspectives – emergency management, public entity risk management, industrial safety management, and the training and education field – having participated in one of those exercises, and having observed and participated in discussions of this topic at every Emergency Management Higher Education Conference held at the Emergency Management Institute. My own exercise started with the requirement of the Hazards Center for every panelists to submit an abstract of their remarks in no more than one-page (outline acceptable) prior to the workshop – for insertion in participant packages. To accomplish this, I sought to put on the hat of an academic who had the task of developing a curriculum to support a degree in emergency management. Having developed the required one-page document I began to solicit comments from academics, practitioners and other interested parties. The responses, acknowledged at the end of this document, tended to fall into three categories: (1) A one-page treatment is just about right – neither too hot or too cold, as Papa Bear would say – and all that was needed was tinkering here and there, and a variety of recommendations were forthcoming on that score. (2) While essentially on-the-mark, the one-pager struck several reviewers as potentially off-putting to emergency management students or others interested in attempting to join the profession – could be viewed as too daunting, intimidating, or even impossible of accomplishment. Or, it was just too busy or too long. Thus, could I come up with a shorter, simpler treatment. This I did by changing hats from one of a hazard or emergency management academic to that of someone responsible for hiring a future emergency manager for a political jurisdiction, and drafting the second document of ten “things” I would look for in a candidate. (3) The third type of response was that there were many subjects on the one-pager that just cried out for expansion, description, explanation, detail. Thus, would it be possible to expand on the one-pager. In that I was in agreement with such commentaries, I sought to begin the process of expansion – though with absolutely no attempt to aim at comprehensiveness. As comments came across the desk and as additional thoughts came into my own head based on whatever I happened to be reading at the moment, I have attempted to expand – in an illustrative manner. The following is the on-going result. 5/10/2019 8 Document One: Outline of Core Competencies to Develop Successful 21st Century Hazard/Emergency Managers 1. Personal, Interpersonal and Political Skills, Traits and Values a. Listening, Communicating (oral and written – superior level) and Presentation Skills b. Networking, Facilitating, Partnering, Coalition-Building, Community Consultation c. Negotiating, Mediation, and Conflict Resolution Skills d. Representational, Marketing, Salesmanship Skills – Visible, Engaged, Effective e. Bureaucratic, Organizational, Public Policy and Political skills f. Committed, Dedicated, Enthusiastic, Reliable, Imaginative, Creative g. Diverse Social/Cultural/Class/Special Needs/Disadvantaged Sensitivity and Activity h. Leadership and Motivational Skills – walks the talk, compassionate, has integrity i. Proactive, Progressive, Open to Change and New Ideas, Life-Long Learner j. Problem Solving, Critical Thinking, Decision Making k. Flexibility, Adaptability and Improvisational Skills l. Strategic (long term) thinking and planning, visionary, ability to anticipate 2. Administrative, Management, Public Policy Knowledge, Skills and Principles a. Personnel Mgmt.--Recruiting, Retaining, Managing People (staff/volunteers), Teams b. Program Management -- Developing and Managing Programs c. Fiscal Management -- Acquiring and Managing Funding (Budgets) d. Resource Management – technical and physical e. Information Management – gather, analyze, interpret, sort, act upon f. Organizational Management (normal and crisis) g. Creating Public Value Skills – getting others to value and promote disaster reduction 3. Subject Matter Knowledge, Skills, and Abilities – i.e., Theory, Principles, Fundamentals of Hazards, Disasters, and U.S. Hazard, Disaster, Risk, Emergency Management a. What Are Hazards and Disasters, including Related Terms and Definitions b. Hazard Taxonomies or Categorization Schemes (natural, technological, intentional) c. Theories of Disaster (acts of God, acts of nature, social/nature intersection, societal) d. Hazards Foundation, and exposure, risk, vulnerability, risk communication treatment e. History and Theory of Emergency Management f. Hazard/Risk/Emergency/ Management Scope/Approaches, Public and Private Sectors, including Traditional Technocratic, Social Vulnerability, Risk-Based approaches. g. Emergency Management Models, e.g. CD, Emergency Services, Public Administration h. Emergency Management Fundamentals, e.g. CEM, IEM and intra-governmental context, 4-Phases, Intergovernmental (local, state, federal) context i. Emer. Mgmt. Functions/Practice/Operations, e.g. risk assessment, planning, public ed. j. Roles and Responsibilities of Key Players in Emergency Management k. Roles of Other Disciplines (e.g. engineering, geology, sociology, psychology, met.) l. Sustainable Development, Community Organization, and Urban and Regional Planning m. Legal, Ethical, Social, Economic, Ecological, Political Dimensions and Context n. Emergency Management Best Practices – Identification and Application 4. Technical Skills and Standards – i.e., Tools of the Trade a. Technological tools e.g. computers (software), GIS, mapping, modeling, simulations b. Scientific Method; Research, Analysis, Evaluation Tools and Methods c. Experience (practicum, internship, service learning, volunteerism, professional orgs.) d. Professional Standards, Procedures, Certifications, Organizations e. Emergency Management Systems -- EOC Operations, ICS, warning, communications 5/10/2019 Document Two: April, 2003 Top Ten Things BWB Would Look For in 21st Century Professional Emergency Manager 1. Philosophy: Disaster Reduction through Building Disaster Resilient Communities 2. A People-Person – Personable with people-oriented skills, traits, and values e.g. communicating, networking, representational, customer service oriented 3. Politically Savvy – Organizational, Community, EM “System” – knows importance of partnerships, networking, inclusiveness, and flexibility 4. A Leader -- who walks the talk and demonstrates integrity and compassion. 5. A Professional, with Executive-Level Administrative and Management Skills 6. A Visionary -- Strategic, Big-Picture Thinker, Strategic Planning Ability 7. Motivated and Energetic – Positive attitude hard worker – can motivate others 8. Hazards Foundation and Legal, Ethical, Social, Economic, Ecological, Political Contexts 9. Technical Skills and Standards, e.g., computers, GIS, research, analysis, evaluation 10. Has Experience – And Learned From It – Successful at Improvisaton 9 5/10/2019 10 Document Three: Expanded Outline of Competencies for Successful 21st Century Hazard/Emergency Managers 1. PERSONAL SKILLS, TRAITS, ABILITIES AND VALUES a. b. c. d. e. f. g. h. i. j. k. l. m. n. Committed, Dedicated, Reliable, Hark-Working Imaginative, Creative, flexible, can improvise Enthusiastic Proactive, Self-Starter, Displays Independent Initiative, Willing to Take Risks Progressive, Open to Change, New Ideas and Research Findings, Flexible, Adaptable Life-Long Learner Problem Solving – knowing the rational thinking processes that assist problem-solving Demonstrated Decision Making Skills, Decisive Ethical, Responsible, Tolerant, Demonstrates Integrity, Promotes Diversity, Inclusive Compassionate Can Apply Lessons Learned Ability to Respond Appropriately to Criticism, Advise, Guidance, Direction Can Function Under Stressful Conditions Intellectual Versatility – ability to recognize, explore and use a broad range of ideas and practices – thinking logically and creatively without undue influence from personal biases o. Demonstrates Sound Judgment and Discretion p. Can Obtain, Evaluate, Analyze, Synthesize, Organize Data and Information q. Customer Service Oriented 2. INTERPERSONAL SKILLS AND TRAITS a. Listening (sometimes referred to as “Active Listening”) and Observational Skills b. Communicating Skills (oral, written, via visual mediums – superior level) 1. Recognizes that communication is a two-way street 2. Open to participative communication c. Presentation Skills d. Networking, Coordinating, Facilitating, Partnering, Coalition-Building, Community Consultation, Outreach Skills and Abilities 1. Understands Obstacles to Successful Coordination, etc., e.g., independent or egotistical individual or organizational mindsets, competition for scarce resources, personal and organizational rivalries, lack of trust, no history of, lack of upper-level support, lack of common terminologies and understanding. 2. Knows how to address networking, coordination obstacles and challenges e. Tactful and Diplomatic Traits f. Negotiating, Mediation, and Conflict Resolution Skills g. Diverse Social/Cultural/Class/Special Needs/Disadvantaged Sensitivity and Activity 3. POLITICAL SKILLS AND TRAITS a. Bureaucratic, Organizational, Public Policy and Political Skills 1. Familiar with political and legal institutions and processes 2. Familiar with economic and social institutions and processes b. Representational, Marketing, Salesmanship Skills – Visible, Engaged, Effective 4. LEADERSHIP AND MOTIVATIONAL SKILLS AND TRAITS 5/10/2019 11 a. b. c. d. e. Visionary Strategic (long term) thinking and planning, ability to anticipate Walks the Talk, sets the example “Creating Public Value” Skills – getting others to value and promote disaster reduction Capacity to act as agent promoting needed change in organizations, communities, society 5. ADMINISTRATIVE, MANAGEMENT, PUBLIC POLICY THEORY, PRINCIPLES, SKILLS a. Understands Basic Management Theory, Principles and Tools b. Familiarity with Organizational Management, Theory, Concepts, Environment and Behavior (Normal and Crisis) c. Familiarity with Public Policy Environment 1. Understanding of policy formulation, implementation and evaluation processes d. Demonstrated knowledge of Administrative Roles of an Emergency Manager 1. Personnel (Human Resource) Management--Job Analysis and Design, Recruiting, Interviewing, Selecting, Placing, Training, Coaching, Retaining, Managing, Delegating, Appraising, Counseling, Rewarding People (staff/volunteers) 2. Team Building – knowing the factors that inhibit team effectiveness and what can be done to promote teamwork 3. Program Management -- Developing and Managing Programs 1. Proficiency in program formulation, implementation and evaluation 4. Fiscal Management -- Acquiring and Managing Funding (Budgets) 5. Resource Management – technical and physical 6. Information Management – gather, analyze, interpret, sort, act upon 7. Technical Writing Skills (e.g. grants writing) 8. Adult Learning Understanding – knowing how adults acquire and use knowledge, skills, and attitudes – understanding individual differences in learning 9. Time Management 10. Can identify, set, review and assess goals and objectives. 6. SUBJECT MATTER KNOWLEDGE, SKILLS AND ABILITIES--THEORY, PRINCIPLES, AND FUNDAMENTALS OF HAZARDS AND DISASTERS a. b. c. d. What Are Hazards and Disasters, including Related Terms and Definitions Hazard Taxonomies or Categorization Schemes (natural, technological, intentional) Theories of Disaster (acts of God, acts of nature, social/nature intersection, societal) Hazards Foundation – causes, characteristics, consequences, terminology, categorizations (meteorological, hydrological, geological, extra-terrestrial, etc.), countermeasures, trends, stakeholders 1. Can describe and discuss the trends in disaster losses in the US 2. Can describe and discuss major hazard specific stakeholders – Local, State, Regional, National 3. Familiarity with Hazards Terminology, e.g., 1. Fujita scale 2. Mercali scale 3. Richter scale 4. 100-year flood e. Understanding of Key Hazard-Related Concepts, e.g. Exposure, Risk, Vulnerability, Resiliency, Risk Communication f. Understanding of Societal Context of Hazards and Disasters 5/10/2019 12 1. Understanding of the societal variables that bear on hazards exposure, vulnerability, resiliency and risk, e.g., 1. Population growth/decline 2. Development, particularly inappropriate development (location, construction, materials) 3. Interdependencies, particularly technological and infrastructure 4. Countermeasures or lack thereof 5. Extent to which knowledge and lessons learned are or are not applied 7. SUBJECT MATTER KNOWLEDGE, SKILLS, AND ABILITIES–THEORY, PRINCIPLES, FUNDAMENTALS OF HAZARD/DISASTER/RISK/EMERGECNY MANAGENMENT a. Scope of Hazard/Disaster/Risk/Emergency Management (Public and Private Sectors) 1. Terminology and Definitions 1. Understanding major U.S. public sector terms and concepts, e.g. a. Emergency management or services b. Disaster management or services c. Hazards management d. Hazards risk management 2. Understanding of major U.S. private sector terms and concepts, e.g. a. Business contingency planning b. Business continuity planning c. Business crisis or consequence management d. Business disaster recovery planning e. Business impact analysis f. Business resumption planning g. Business risk management 3. Understanding of major International terms and concepts, e.g. a. Civil defense b. Civil emergency preparedness c. Civil protection 2. What Does the Field Cover? 3. History of Emergency Management b. Legal, Ethical, Social, Economic, Ecological, Political Dimensions and Context of EM 1. Social Dimensions and Context of Hazards and Emergency Management: 1. Develop a critical understanding of how society and social institutions operate 2. Acquire basic knowledge of social science research methods, advantages and limitations 3. Understand social science theory of the disaster behavior of organizations 4. Understand social science theory of the disaster behavior of individuals 5. Be able to adequate address “Disaster Mythology” 6. Be able to apply basic principles of sociology to the design of effective community warning systems 2. Knowledge of Economic Development Strategies and Community Impact c. Approaches to Hazard/Risk/Emergency Management (Public and Private Sectors) 1. Traditional Technocratic/Managerial Approach 2. Social Vulnerability Approach 3. Risk-Based Approaches 5/10/2019 13 4. Building Disaster Resistant and Resilient Communities Approach 5. Business Impact Analysis, Business Contingency Planning d. Emergency Management Models 1. Civil Defense Model 2. Emergency Services Model 3. Public Administration Model e. Emergency Management Fundamentals 1. Comprehensive Emergency Management (i.e. all hazards, actors, phases) 2. Integrated Emergency Management and intra-governmental context 1. Understands why it is necessary to integrate hazard/disaster/emergency management and community planning. 3. Four Phases of the Disaster Life Cycle Model 1. Mitigation a. Understand mitigation legal basis, history, philosophy, strategies, methods, programs, obstacles, issues, concerns, and consequences b. Can discuss structural and non-structural mitigation approaches c. Can discuss historical and current trends in mitigation practice d. Can discuss major Federal mitigation programs, including strengths and weaknesses, e.g., i. FEMA, National Flood Insurance Program, major elements 1. Can describe the Community Rating System ii. FEMA pre- and post-disaster mitigation programs iii. National Earthquake Hazard Reduction Program 1. Can summarize roles and responsibilities of the four primary NEHRP agencies/organizations e. Can discuss the Disaster Mitigation Act of 2000 f. Can discuss major mitigation stakeholders -- Local, State, Regional, National g. Can discuss major obstacles/challenges to implementing mitigation h. Can discuss the role of insurance in hazards mitigation i. Describe adverse selection 2. Preparedness 3. Response 4. Recovery 4. Functional Approach 5. Intergovernmental Context (i.e., local, state, federal) f. Knowledge of Key Players/Stakeholders in Emer. Mgmt.--Roles and Responsibilities 1. Public Sector 1. Local, State, Federal Legislators 2. Local, State, Federal Policy-Makers 3. Local, State, Regional, Federal, International Decision-Influencers, DecisionMakers, and Stakeholders e.g., a. Budget and Finance b. Building and Inspections Departments c. Communications Centers d. Community Affairs e. Community Right-To Know (Hazardous Materials) Committees f. Convention Center Administration g. Councils of Government 5/10/2019 14 4. 5. 6. 7. 8. 9. h. Economic Development i. Educational Services, such as school districts j. Emergency Services Personnel (Fire, Police, EMS/EMT, SAR, Public Health) k. Floodplain and Storm-Water Management l. Homeland Security m. Land Use, such as planning, zoning n. Law Enforcement o. Legal Affairs p. Military (Federal and State National Guard) q. Natural Resources, e.g., agricultural, timber, water, environmental, fish and wildlife r. Parks and Recreation, especially highly visible tourist attractions s. Planning t. Public Affairs u. Public Health v. Public Works w. Public Utilities x. Risk Management y. Seismic Safety Commissions z. Social and Human Services aa. Transportation bb. United Nations International Strategy for Disaster Reduction, etc.) Emergency Management Personnel Community and Faith-Based Organizations Associations, Professional and Voluntary Organizations (e.g., IAEM, State EM Associations, NEMA, NFPC, PERI, CUSEC, Western States Seismic Policy Council, Association of State Floodplain Managers, Project Impact Coordinators Association, ACP, DRI Inc., American Red Cross) Issue Organizations (e.g. Sierra Club) Business and Industry a. Architects and Engineers b. Better Business Bureaus c. Building Administrators d. Communications Sector e. Construction Industry f. Developers g. Energy and Fuel Sectors h. Health, Medical and Care-Giving i. Insurance Industry j. Safety, Preparedness, Recovery Specialists, e.g. business continuity planners (Association of Contingency Planners), recovery planners (Disaster Recovery International, Inc.), risk managers k. Shopping Mall Administrators l. Special Events Cite Administrators and Organizers, e.g. sports, concerts m. Transportation Sector n. Utilities Academia a. Recognizing, understanding, using contributions from such disciplines as: i. Atmospheric Sciences 5/10/2019 15 ii. iii. iv. v. vi. vii. Communications Studies Earth Sciences Economics Engineering Environmental Science Planning 1. Knowledge of land use planning & strategies 2. Familiarity with community comprehensive plans viii. Political Science ix. Public Administration 1. Knowledge of community organization 2. Knowledge of community development 3. Knowledge of community change processes 4. Understands formal community power structures 5. Understands informal community power structures 6. Understands community norms, values, culture x. Public Health and Medicine xi. Sociology b. Recognizing and using contributions from Disaster Research Orgs. e.g., i. Natural Hazards Center, University of Colorado at Boulder ii. Disaster Research Center, University of Delaware iii. Hazard Reduction and Recovery Center, Texas A&M 10. Media 11. Other Private Sector Entities a. Dam Administrators 12. General Public g. Emergency Management Functional Areas, e.g., 1. Communications 2. Continuity of Government 3. Direction and Control 4. Energy 5. Essential Public Services Maintenance 6. Health and Medical 7. Information and Planning 8. Public Safety Maintenance 9. Public Works and Engineering 10. Resource Support and Management 11. Transportation h. Emergency Management Practice, e.g. 1. Legal Basis (e.g. relevant laws, codes, ordinances, regulations, statutes, standards, governing authorities, standard operating procedures, guiding policies) and Liability Issues a. Be able to identify and discuss local, State and Federal legal provisions relevant to emergency management b. Be able to identify and discuss legal issues relevant to emergency management 2. Hazards Risk Assessment (hazard identification and analysis, community analysis/demographics/resources, risk assessment, vulnerability assessment) 1. Has an awareness of a variety of risk assessment methodologies 5/10/2019 16 2. Can apply at least one risk assessment methodology 3. Hazards Risk Management 1. Plans – e.g., emergency operations plans, mitigation, recovery plans a. Demonstrate knowledge of emergency operations planning 2. Procedures (e.g. standard operation procedures) 3. Policies (e.g. families of emergency services personnel in disaster) 4. Programs, e.g., public education, mitigation, preparedness, training, exercises a. Demonstrate knowledge of emergency management training programs 5. Measures, e.g., insurance, mutual aid agreements 6. Systems, e.g., warning, sheltering, communications, and Equipment 4. Hazards Risk Communication, e.g., 1. Familiarity with risk communication theory, e.g., a. Actively seek to engage publics b. Understand value systems and perceptions of various publics c. Be open, fair, inclusive, transparent, don’t keep secrets d. Treat audience as equals – respect the concerns of others, respect other points of views e. Seek to empower the audience f. Be truthful 2. Familiarity with risk communication models, such as Mileti’s eight steps to new behavior adoption process through risk communication: a. Hearing the warning b. Believing the warning c. Confirming that the threat exists d. Personalizing the warning, confirming that others are heeding it e. Determining whether protective action is needed f. Determining whether protective action is feasible g. Determining what protective action to take h. Taking the protective action 3. Understand how to tailor information characteristics based on specific communications goals, such as awareness or behavior change a. Can translate technical risk information, terminology and data into the non-technical language of each communication partner or audience 4. Working knowledge of message characteristics, e.g., amount of material, speed of presentation, number of arguments, repetition, style, clarity, ordering, forcefulness, specificity, consistency, accuracy, and extremity of position advocated 5. Working knowledge of the major obstacles to communicating hazards risk and changing behavior, such as competing demands for attention, complacency, denial, the “levee effect,” conflicts with existing beliefs, differing value systems, the “hazard adaptation phenomenon” 6. Conversant with risk averse, risk tolerant and risk seeking typologies i. Emergency Management Systems 1. Knowledgeable of the theory, purpose, design, management of or role in the range of emergency management systems, e.g., a. Emergency Operations Center Operations b. The Incident Command System c. Warning Systems 5/10/2019 17 i. Can distinguish between watches and warnings ii. Can discuss the major components of a wide range of specific hazard warning systems, e.g. hurricane iii. Can discuss the functions of warning systems, e.g., 1. Detection 2. Measurement 3. Collation 4. Interpretation 5. Decision to warn 6. Message content 7. Dissemination iv. Can apply basic principles of sociology to the design of effective community warning systems v. Can discuss the various warning system “players” and stakeholders d. Communications Systems j. Emergency Management Emergency Operations 1. Knowledgeable of Full Range of Emergency Operations Activities, such as: a. Warning b. Emergency Public Information c. Emergency Operations Center Management d. Evacuation e. Mass Care, e.g. sheltering, feeding and provision of emergency services f. Urban Search and Rescue g. Damage Assessment h. Debris Removal i. Donated Goods Management j. Volunteer Management k. Restoration of Essential Services l. Critical Incident Stress Debriefings – possess background and knowledge of the theoretical concepts and practice of critical incident stress management 2. Capable of Coordinating Jurisdictional Emergency Management Operations 3. Knows how to seek immediate and short-term disaster recovery assistance k. Sustainable Development, Community Organization, Urban and Regional Planning l. Emergency Management Best Practices – Identification and Application m. Emergency Management Theory 1. Can discuss the major variables put forth as determinants of successful emergency management 8. TECHNICAL SKILLS AND STANDARDS – i.e., TOOLS OF THE TRADE a. Technological tools e.g. computers (software), GIS, mapping, modeling, simulations 1. Can apply technological tools within an emergency management context 2. Proficiency in state-of-the-art information and communications technology 5/10/2019 18 3. Able to maintain currency in state-of-the-art information and communications technology b. Scientific Method, Research, Analysis, Integration, Evaluation Tools and Methods 1. Ability to understand, evaluate, and analyze scientific data and reports (e.g., earth science and engineering information related to seismic hazards, reports on risks associated with weapons of mass destruction), including the uncertainties associated with such data 2. Ability to clarify choices, tradeoffs, costs and benefits of alternative loss-reduction strategies, so as to improve decision-making by households, businesses, community officials, owners of critical infrastructure facilities, and other stakeholders 3. Ability to perform cost benefit analysis – assessing alternatives in terms of their financial, psychological, social, environmental and strategic advantages and disadvantages c. Experience (practicum, internship, service learning, volunteerism, professional orgs.) d. Professional Standards, Procedures, Certifications, Organizations e. Ability to write clearly for a variety of audiences, including other professionals, decisionmakers, and the general public Key Outcomes of and for Academic Programs: 1. Achieves a balance between academic (theoretical) and practical (applied) aspects of Hazard/Emergency Management 2. Enhanced emergency management professionalism, credentials, and recognition 3. Enhanced Community Outreach and Service mission of schools of higher education. 4. Contributes to multidisciplinary university initiatives. Key Outcomes of and for Students: 1. The knowledge, skills, abilities and traits to efficiently and effectively manage and lead the hazard/disaster/risk/emergency management function. 2. Personable 3. Knowledgeable – hazards, emergency management, research methods, analysis, evaluation 4. Leadership in building disaster resilient and resistant communities 5. Ability to articulate persuasive case for disaster prevention and reduction 6. Ability to find balance between technocratic and social vulnerability approaches to EM 7. Ability to integrate multi-disciplinary and multi-organizational perspectives Acknowledgements I wish to thank the following individuals who have reviewed, commented upon and/or contributed to this outline: Beth Armstrong, Richard Bissell, Jane Bullock, Arrietta Chakos, Louise Comfort, Henry Fischer, George Haddow, Walter Hays, Sam Isenberger, Lorna Jarrett, Ron Kuban, John Lunn, David McEntire, William McPeck, Jim Mullen, Laura Olson, John Peabody, Laurie Pearce, Robert Schneider, Guna Selvaduray, Greg Shaw, Gavin Smith, Stephen Stehr, Richard Sylves, Kathleen Tierney, Frances 5/10/2019 19 Winslow. I also wish to thank the participants of the six annual FEMA Emergency Management Higher Education Conferences who have discussed and shared their thoughts on this subject. 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page i HEALTH CARE EMERGENCY MANAGEMENT PRINCIPLES AND PRACTICE Editors Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor, Public Health Practice New York Medical College School of Health Science and Practice Valhalla, New York and David Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York 55133_FMxx_Reilly:Achorn Int'l World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com 5/21/10 1:36 AM Page ii Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Publisher: Michael Brown Editorial Assistant: Catie Heverling Editorial Assistant: Teresa Reilly Production Manager: Tracey Chapman Associate Production Editor: Kate Stein Senior Marketing Manager: Sophie Fleck Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Achorn International Art: diacriTech Associate Photo Researcher: Sarah Cebulski Cover Design: Kristin E. Parker Cover Image: Top left: Courtesy of Andrea Booher/FEMA; Top Right: Courtesy of Win Henderson/FEMA; Bottom left: Courtesy of Jocelyn Augustino/FEMA; Bottom right: Courtesy of Cynthia Hunter/FEMA Printing and Binding: Malloy, Inc. Cover Printing: John Pow Company Library of Congress Cataloging-in-Publication Data Health care emergency management : principles and practice / [edited by] Michael J. Reilly and David S. Markenson. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7637-5513-3 (pbk.) ISBN-10: 0-7637-5513-3 (pbk.) 1. Emergency medical services. 2. Emergency management—Planning. 3. Hospitals—Emergency services. I. Reilly, Michael J. II. Markenson, David S. [DNLM: 1. Disaster Planning—organization & administration. 2. Emergencies. 3. Emergency Service, Hospital—organization & administration. WX 185 H4336 2011] RA645.5.H38 2011 362.18068—dc22 2010001554 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page iii Dedication MICHAEL REILLY I dedicate this text to my family and friends who have supported me throughout this project. I especially thank my parents, who have provided their unwavering advice and support throughout my life and career. I also dedicate this text to my professional mentors Dr. Linda Degutis and Dr. Robyn Gershon, who continue to give me invaluable guidance throughout my professional development. Finally, I dedicate this book to my coauthor David, who has provided me with the opportunity to pursue academic emergency and disaster medicine professionally, and who continues to encourage and support my development as a scientist and scholar in this evolving area of medicine and public health. DAVID MARKENSON This text is dedicated to my parents, who have always guided, supported, and encouraged me, and who, as physicians, have shown me through their work that providing care to others in a compassionate and knowledgeable way can be a rewarding endeavor. This text is also dedicated to my brothers, sister, and sisters-in-law, who are a constant source of advice, support, and energy; without their help and involvement in my life none of my efforts could have been accomplished. Most importantly this text is dedicated to my wife Heidi and my wonderful children, Emily, Rachel, and George, who not only support me but who were willing to give of their time with me to allow me to write this text. iii 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page iv iv | Dedication MICHAEL REILLY AND DAVID MARKENSON Lastly, this text is dedicated to all healthcare providers, emergency managers, and those in their care. Healthcare providers and emergency managers work each day in an environment that is unpredictable, often dangerous, and constantly challenging. They have become champions in changing the system to become better prepared. They dedicate their lives to aid the sick and the injured and prepare for any disaster, terrorism event, or public health emergency, driven only by their care for others and their devotion to this profession we call healthcare emergency management. We salute all of you in your professionalism and dedication. Also, we dedicate this to our patients who, in allowing us the privilege to provide them care, teach us each day about humanity. 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page v Contents About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Chapter 1 Chapter 2 Principles of Emergency Management for Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction to Hospital and Healthcare Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Healthcare Incident Management Systems . . . . . . . . . . . . . 21 Arthur Cooper, MD, MS v 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page vi vi | Contents Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 II Chapter 8 Section Chapter Chapter 9 10 Section III Chapter 11 Chapter 12 Improving Trauma System Preparedness for Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . 47 Michael J. Reilly, DrPH, MPH, NREMT-P Legal Issues and Regulatory Compliance . . . . . . . . . . . . . 67 Doris R. Varlese, JD Developing the Hospital Emergency Management Plan . . . 89 Nicholas V. Cagliuso, Sr., MPH; Nicole E. Leahy, RN, MPH; and Marcelo Sandoval, MD Introduction to Exercise Design and Evaluation . . . . . . . . 111 Garrett T. Doering, MS, EMT-P, CEM, MEP Integration with Local and Community Resources . . . . . . 143 Isaac B. Weisfuse, MD, MPH Hospital Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . 161 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Sean M. Kelly, MA, CCEMT-P and Lindsey P. Anthony, MPA, CEM, CHEC-III Functional Roles of Hospital Workers in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . 187 Tony Garcia, RN, CCEMT-P Credentialing and Management of Volunteer Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Deborah Viola, PhD, MBA and Peter Arno, PhD Hospital Operations During Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 221 Quantitative Planning for Epidemic and Disaster Response: Logistics and Supply Chain Considerations . . . . . . . . . . . 223 Nathaniel Hupert, MD, MPH; John A. Muckstadt, PhD; and Wei Xiong, PhD, MS Risk Communication and Media Relations . . . . . . . . . . . . 233 Linda C. Degutis, DrPH, MSN and Lauren Babcock-Dunning, MPH 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page vii Contents | vii Chapter 13 Chapter 14 Chapter 15 Chapter 16 IV C h a p t e r 17 Section Chapter 18 V C h a p t e r 19 Section Chapter 20 Chapter 21 Chapter 22 Security and Physical Infrastructure Protections. . . . . . . . . 271 Robert Michael Schuler, BGS, NREMT-P and Veronica Senchak Snyder, MHS, MBA Hospital Decontamination and Worker Safety . . . . . . . . . . 299 Michael J. Reilly, DrPH, MPH, NREMT-P Pharmaceutical Systems Management in Disasters. . . . . . 317 David S. Markenson, MD, FAAP, FACEP, EMT-P Laboratory Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 331 Ramon Rosal, PhD Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Principles of Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . 341 E. Brooke Lerner, PhD and Richard B. Schwartz, MD Managing an Infectious Disease Disaster: A Guide for Hospital Administrators . . . . . . . . . . . . . . . . . 353 Ariadne Avellino, MD, MPH Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 Vulnerable Populations and Public Health Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Elizabeth A. Davis, JD, EdM; Rebecca Hansen, MSW; and Jennifer Mincin, PhD (ABD) Altered Standards of Care in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 401 John Rinard, BBA, MSCPI Mass Fatality Management . . . . . . . . . . . . . . . . . . . . . . . 423 Barbara A. Butcher, MPH and Frank DePaolo, RPA-C Research in Emergency and Disaster Medicine . . . . . . . . 447 Kobi Peleg, PhD, MPH and Michael Rozenfeld, MA Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page viii 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page ix About the Authors MICHAEL J. REILLY, DRPH, MPH, NREMT-P Dr. Michael Reilly is currently the Assistant Director of the Center for Disaster Medicine at New York Medical College in Valhalla, New York. Additionally, he is an Assistant Professor of Public Health Practice and the Director of the Graduate Program in Emergency Preparedness at the School of Health Science and Practice. Dr. Reilly has over a decade of multidisciplinary experience in emergency preparedness, public safety, intergovernmental relations, public health, and emergency management. He has been published in the world’s leading disaster medicine and public health preparedness journals, and received international awards and recognition for his work on trauma systems and health systems in the context of disaster and public health preparedness. Dr. Reilly is an internationally recognized expert in the areas of emergency medical services, and health system preparedness and response, with direct experience in responding ix 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page x x | About the Authors to mass casualty events and public health emergencies. Dr. Reilly is frequently called upon to provide expert consultation, subject matter expertise, and to evaluate healthcare systems preparedness, emergency planning, and drills and exercises. Dr. Reilly has designed numerous educational curricula and training programs for a variety of preparedness functional roles for public health, emergency management, and public safety audiences at the professional and graduate levels. He is a senior lecturer for multiple federal agencies including the Department of Justice, Department of Homeland Security, and the Occupational Safety and Health Administration. Additionally, he is an active member of several state and national committees on homeland security and emergency management programs. He received his undergraduate education at Northeastern University in paramedic technology and health science. He earned his Masters of Public Health from Yale University, and a doctorate in public health from New York Medical College. Dr. Reilly remains active as a paramedic in the Metro New York City region and maintains numerous specialty and technical certifications and instructor credentials in the areas of emergency medical services, worker safety, environmental health, hazardous materials emergency response, emergency management, counterterrorism, and weapons of mass destruction preparedness and response. DAVID SAMUEL MARKENSON, MD, FAAP, FACEP, EMT-P Dr. David Markenson is a board-certified pediatrician with Fellowship training in both pediatric emergency medicine and pediatric critical care. He is the Vice President and Medical Director of Disaster Medicine and Regional Emergency Services at the Westchester Medical Center and Maria Fareri Children’s Hospital. In addition, he is the Director of the Center for Disaster Medicine and the Interim Chair of Epidemiology and Community Health at the School of Health Sciences and Practice at New York Medical College. Dr. Markenson is also a Professor of Pediatrics and an Associate Professor of Public Health at the School of Health Sciences and Practice at New York Medical College in Valhalla, New York. He is an active member of, and has served in leadership positions within, multiple professional societies, including the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, the Society of Critical Care Medicine, the American College of Physician Executives, and the National Association of EMS Physicians. Dr. Markenson has been actively involved with the American Red Cross for over 20 years and currently serves as the National Chair of the Advisory Council which oversees disaster health, preparedness, and health and safety. In this role he directs the scientific and technical as- 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xi About the Authors | xi pects of all programs and products in these areas including their development, implementation, and research. Prior to coming to Westchester Medical Center and New York Medical College he was the Deputy Director of the National Center for Disaster Preparedness at the Mailman School of Public Health, Columbia University, and was also the Director of the Program for Pediatric Preparedness of the National Center, a program dedicated to improving the care children receive in times of disasters or acts of terrorism. His career has been dedicated to improving the approach to pediatric care, disaster medicine, EMS, and emergency medicine. He is the principal investigator on several federal grants related to pediatric disaster medicine, including Model Pediatric Component for State Disaster Plans and National Consensus Conference on the Needs of Children in Disasters. He has also addressed the needs of other special and vulnerable populations and directed a federal grant to develop the first and only national guidelines for emergency preparedness for persons with disabilities. In addition to this, he has conducted research on healthcare preparedness and healthcare provider and student education. In this area he was the principal investigator for a federal grant which developed the first competencies for all healthcare students in emergency preparedness and then piloted this set of competencies in a medical, dental, public health, and nursing school. Dr. Markenson has been recently appointed to the FEMA National Advisory Council as the In-Patient Medical Provider representative. The FEMA NAC is comprised of emergency management and law enforcement leaders from state, local, and tribal government and the private sector to advise the FEMA Administrator on all aspects of disaster preparedness and management to ensure close coordination with all partners across the country. He is a frequent presenter and lecturer at medical conferences across the country, serves in editorial roles for multiple professional scientific journals, and has authored numerous articles and books on pediatric care, disaster medicine, and prehospital medicine. His work in disaster medicine started during his college career when he worked in disaster services in upstate New York providing direct services and education to other disaster services workers on behalf of the local Red Cross and county office of emergency management. Dr. Markenson is a graduate of Albert Einstein College of Medicine in the Bronx, New York. 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xii 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xiii Contributors Lindsey P. Anthony, MPA, CEM, CHEC-III Operational Medicine Education Coordinator Center for Operational Medicine Medical College of Georgia Augusta, Georgia Peter Arno, PhD Professor Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York xiii 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xiv xiv | Contributors Ariadne Avellino, MD, MPH Research Associate Center for Disaster Medicine New York Medical College Valhalla, New York Lauren Babcock-Dunning, MPH Research Associate Center for Transportation Safety, Security and Risk Rutgers, The State University of New Jersey New Brunswick, New Jersey Barbara A. Butcher, MPH Chief of Staff Office of the Chief Medical Examiner City of New York New York, New York Nicholas V. Cagliuso, Sr., MPH Corporate Director Emergency Management Continuum Health Partners, Inc. New York, New York Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma and Pediatric Surgical Services Harlem Hospital New York, New York Elizabeth A. Davis, JD, EdM Principal EAD & Associates, LLC Brooklyn, New York Linda C. Degutis, DrPH, MSN Associate Professor of Surgery (Emergency Medicine) and Public Health Director, Center for Public Health Preparedness Yale University School of Medicine New Haven, Connecticut 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xv Contributors | xv Frank DePaolo, RPA-C Director Special Operations Division Office of the Chief Medical Examiner City of New York New York, New York Garrett T. Doering, MS, EMT-P, CEM, MEP Director of Emergency Management Westchester Medical Center Valhalla, New York Tony Garcia, RN, CCEMT-P Training Specialist Texas Engineering Extension Service Texas A&M University System College Station, Texas Rebecca Hansen, MSW Senior Project Manager EAD & Associates, LLC Brooklyn, New York Nathaniel Hupert, MD, MPH Associate Professor of Public Health and Medicine Weill Cornell Medical College New York, New York Sean M. Kelly, MA, CCEMT-P Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York Nicole E. Leahy, RN, MPH Manager Burn Outreach and Professional Education New York-Presbyterian Hospital / Weill Cornell Medical Center New York, New York 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xvi xvi | Contributors E. Brooke Learner, PhD Associate Professor Department of Emergency Medicine Department of Population Health Medical College of Wisconsin Milwaukee, Wisconsin David S. Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York Jennifer Mincin, PhD (ABD) Senior Project Manager/Director EAD & Associates, LLC Brooklyn, New York John A. Muckstadt, PhD Acheson/Laibe Professor Business Management and Leadership Studies School of Operations Research and Industrial Engineering Cornell University Ithaca, New York Kobi Peleg, PhD, MPH Director, Israel National Center for Trauma and Emergency Medicine Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Co-chair, The Multi-disciplinary Program for Emergency and Disaster Management School of Public Health Tel-Aviv University Tel-Aviv, Israel Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor of Public Health Practice New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xvii Contributors | xvii John Rinard, BBA, MSCPI Milano, Texas Ramon Rosal, PhD Chemical Response Director Public Health Laboratory New York City Department of Health and Mental Hygiene New York, New York Michael Rozenfeld, MA Researcher National Center for Trauma & Emergency Medicine Research Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Tel Hashomer, Israel Marcelo Sandoval, MD Faculty, Department of Emergency Medicine Co-Chair, Emergency Management Committee Beth Israel Medical Center / Petrie Division New York, New York Robert Michael Schuler, BGS, NREMT-P Training Coordinator Texas Engineering Extension Service The Texas A&M University System College Station, Texas Richard B. Schwartz, MD Chair and Professor Department of Emergency Medicine Medical College of Georgia Augusta, Georgia Veronica Senchak Snyder, MHS, MBA Emergency Management Coordinator Emergency Management Services Geisinger Health System Geisinger Medical Center Danville, Pennsylvania Doris R. Varlese, JD Visiting Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xviii xviii | Contributors Deborah Viola, PhD, MBA Associate Professor of Public Health Practice Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York Isaac B. Weisfuse, MD, MPH Deputy Commissioner Division of Disease Control New York City Department of Health and Mental Hygiene New York, New York Wei Xiong, PhD, MS Instructor in Public Health Weill Cornell Medical College New York, New York 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xix Acknowledgments he material contained in this text reflects the contributions of many authors, editors, emergency managers, healthcare providers, reviewers, and others who provided assistance and valuable suggestions. While here we acknowledge them, our sincere appreciation for all of their efforts is truly hard to express in this limited space. In addition, we could not possibly acknowledge all those who participated in this important endeavor, and so we would like to also extend our sincere appreciation to every person who helped with this project, whether listed by name or not. Many talented people at Jones & Bartlett Learning have been involved in developing and producing this new text. As authors and editors, we turned our manuscript to the exceptional editorial staff and publishers at Jones & Bartlett Learning to create this finished product. We are fortunate to have been able to work with this team of people, who have contributed so much and had such a tremendous impact on T xix 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xx xx | Acknowledgments the quality of the textbook you now have in your hands. Specifically Michael Brown, Publisher, assisted by Catie Heverling and Kate Stein, has been our support at Jones & Bartlett Learning. As Publisher, Mike is committed to publishing quality books; his energy, intelligence, patience, and helpful efforts have enabled us to create an exceptional product. With the additional day-to-day support and guidance of both Catie Heverling and Kate Stein we were able to keep our project on track and ultimately produce this important text. A significant amount of coordinating and operational support in moving this project forward would not have been possible without the tireless work of our administrative assistant Patience Ameyaw. We thank her for her hard work and support of this project along with Geordana Roa, Nina Luppino, and our numerous disaster medicine interns over the past several years. Components of this text have been based on the exceptional work of the Center for Disaster Medicine at the New York Medical College, School of Health Sciences and Practice for which we serve as the Director and Assistant Director. Without the support of our Center, the prior research and models developed, and the strong and supportive academic environment of New York Medical College, this work would not have been possible. We would like to specifically thank Dean Robert Amler of the New York Medical College, School of Health Sciences and Practice, who in his own right is an internationally recognized expert in public health and healthcare preparedness, for providing his personal expertise and his leadership in creating an academic environment where work such as this text is not only encouraged but supported, and for his continued dedication to providing education to improve emergency preparedness. We would like to also acknowledge the Westchester Medical Center and its Maria Fareri Children’s Hospital, which serves as the regional center for healthcare emergency preparedness. The source and realworld testing of many of the theories and models in this text come from the preparedness efforts of this institution, which is recognized as not only a regional but as a national leader in emergency preparedness. We would like to thank the leadership of this institution for allowing us to use the wonderful preparedness work they have done as models for others to follow. While not being able to list all, we would like to acknowledge the members of the senior leadership who day in and day out support the preparedness activities: Mr. Michael Israel, Mr. Gary Brudnicki, Dr. Renee Garrick, Dr. Michael Gewitz, Ms. Marsha Casey, and Mr. Anthony Costello. Lastly, we would especially like to thank the institution’s Director of Emergency Management and chapter contributor Mr. Garrett Doering for sharing his professional insight and experience with us as we completed this project. 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xxi Acknowledgments | xxi Finally, we are extremely grateful to the numerous healthcare providers, emergency managers, educational consultants, and members of the preparedness academic community who carefully critiqued the manuscript to ensure that the information in this text would be both relevant and appropriate. Many more dedicated professionals than we could name here gave unstintingly of their own time and expertise. Their enthusiastic participation has been a motivating force behind this project, and they received no compensation beyond the knowledge that they were helping to create a greatly needed resource. We hope the final product lives up to their efforts, hopes, and expectations. Our warmest and kindest regards, Michael and David 55133_FMxx_Reilly:Achorn Int'l 5/21/10 1:36 AM Page xxii 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 1 Section I Principles of Emergency Management for Healthcare Facilities 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 2 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 3 Chapter 1 Introduction to Hospital and Healthcare Emergency Management Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Describe the need for and responsibilities of healthcare emergency management. ■ Describe the role of the hospital emergency manager. ■ Identify the activities performed by healthcare emergency management. Emergence and Growth of Healthcare Emergency Management The concept of healthcare emergency management is not entirely new, but may seem strange and foreign to those who have worked in healthcare or emergency management and, until recently, have not known anyone working in this profession. If one looks back more than 30 years, it would be almost impossible to find a hospital role called hospital 3 55133_CH01_Reilly:Achorn Int'l 4 | Chapter 1 5/13/10 12:08 PM Page 4 Introduction to Hospital and Healthcare Emergency Management emergency management or even a position for a healthcare emergency manager in a hospital or medical center.Yet healthcare emergency management responsibilities have always been addressed by hospitals, such as fire safety, backup power, and the ability to handle victims from a mass casualty event. A fundamental tenet of emergency management is that institutions must prepare for events that may rarely occur while taking protective actions to mitigate any likelihood that they will occur at all. Due to the low frequency of events testing the health system’s ability to respond to a disaster, an act of terrorism, or a public health emergency, the ability to evaluate the strengths and weaknesses of hospital emergency preparedness is limited. In addition, the public has strong expectations of the roles hospitals should play during times of disaster. Healthcare institutions are expected to provide both emergency care and continuance of the day-to-day healthcare responsibilities regardless of the volume and demand. Recently, they have also become sites of community refuge, bastions of safety in a threatening and dangerous environment. The public believes that hospitals will have light, heat, air conditioning, water, food, and communications capabilities, regardless of the fact that the institution may itself be affected by the calamity. During the terrorist attacks in the fall of 2001 and the Northeast Blackout of 2003, the public flocked to hospitals, even when they did not require medical care. Furthermore, with increased intelligence of the vulnerabilities of the healthcare infrastructure and the desire of terrorists to exploit this, institutions have been forced to focus limited resources on safety and security rather than on comprehensive emergency management efforts. A major change in the way hospitals plan for hazards and vulnerabilities includes less planning for specific single issues or threats but rather the adoption of an all–hazards comprehensive emergency management planning process. Additionally, hospitals need to look beyond their emergency department doors and engage community stakeholders to assist in this process, reaching out to local and regional emergency planners to assist in larger communitywide emergency preparedness planning. The interest of nonhospital entities in health system emergency preparedness can be seen through several examples, including emergency management and public health initiatives on mass vaccination, pandemic planning, increasing hospitals’ ability to perform decontamination of casualties contaminated with hazardous materials, etc. Recent reflection of the role of the hospital in emergency management and population health can been seen in revised laws, regulations, and even accreditation standards. An example of this is The Joint Commission on the Accreditation of Healthcare Organizations’ (JCAHO) change from placing emergency preparedness standards in the Environment 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 5 Emergence and Growth of Healthcare Emergency Management | 5 of Care section to placing the standards in a separate and distinct section with specific goals and requirements, as well as the release of the Occupational Safety and Health Administration (OSHA) document Best Practices for Hospital-Based First Receivers.1–3 Over the past eight years we have embarked on an interesting marriage of these two separate disciplines—health care and emergency management—whose common ground has historically been brought together in the street or on the disaster scene by emergency medical services workers, or sometimes brought into the emergency departments of hospitals and trauma centers across the country. Both disciplines have separate roles and responsibilities, but where the seemingly disparate goals of these fields come together is the reduction of morbidity and mortality following disasters, acts of terrorism, and public health emergencies. Emergency management agencies have traditionally been responsible for bringing first responders, government agencies, and community stakeholders together to assist with comprehensive emergency planning or disaster response and recovery. A common cornerstone of emergency management has been to protect life, then property, then the environment. As a result, when conducting emergency planning activities, the health and medical needs of the population are among the most significant and are considered with basic public health and human needs including sheltering, mass care, sanitation, environment health, food and water, and other essential services. In addition, as public health professionals, we also believe that population health activities include the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency. In healthcare delivery, we attempt to meet the health and medical needs of the community by providing a place for individuals to seek preventative medicine, care for chronic medical conditions, emergency medical treatment, and rehabilitation from injury or illness. While a healthcare institution serves the community, this responsibility occurs at the level of the individual. Each individual expects a thorough assessment and treatment if needed, regardless of the needs of others. This approach is different than that practiced by emergency managers, whose goal is to assist the largest number of people with the limited resources that are available. As such, emergency management principles are focused on the needs of the population rather than the individual. When either planning for a disaster or operating in a disaster response mode, the hospital should be prepared at some point to change its focus from the individual to the community it serves and to begin weighing the needs of any individual patient versus the most good for the most patients with scarce resources. Moving from the notion of doing the most for each individual to doing the best for the many is a critical shift in thinking 55133_CH01_Reilly:Achorn Int'l 6 | Chapter 1 5/13/10 12:08 PM Page 6 Introduction to Hospital and Healthcare Emergency Management for healthcare institutions considering a program of comprehensive emergency management. While the initial planning for emergencies by hospitals is focused on maintaining operations and handling the care needs of actual or potential increased numbers of patients and/or different presentations of illness or injury than is traditionally seen, there is also the need to recognize that at some point during a disaster, act of terrorism, or public health emergency there may be an imbalance of need versus available resources. At this point the approach to delivering healthcare will need to switch from a focus on the individual to a focus on the population. This paradigm shift is one of the core unique aspects of hospital emergency management that allows the hospital to prepare to maximize resources in disasters and then to know when to switch to a pure disaster mode of utilizing its limited and often scant resources to help the most people with the greatest chance of survival. The healthcare delivery system is vast and comprised of multiple entry points at primary care providers, clinics, urgent care centers, hospitals, rehabilitation facilities, and long-term care facilities. The point of entry for many individuals into the acute healthcare system is through the emergency department (ED). Since the late 1970s, the emergency medical services (EMS) system has allowed victims of acute illness and injury to receive initial stabilization of life-threatening medical conditions on the way to the emergency department. Among the many strengths of the ED is the ability to integrate two major components of the healthcare system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in this process by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate life-saving medical care until specialty resources become available.4–11 In this context, the healthcare system is an emergency response entity. Healthcare Emergency Management Activities Hospital emergency management activities vary and can be categorized in many ways, however some common areas of focus within healthcare emergency management include the following areas: ■ ■ ■ ■ ■ ■ ■ communication surge capacity volunteer management security issues hazmat/CBRNE preparedness collaboration and integration with public health education and training 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 7 Healthcare Emergency Management Activities | 7 ■ ■ ■ ■ ■ equipment and supplies worker safety drills and exercises emergency department disaster operations trauma centers COMMUNICATION Communication issues in disaster preparedness and response are cited throughout the literature as a major source of frustration and inadequacy for coordinating and executing disaster operation plans.4–5,8,11–16 By identifying the vulnerabilities in the existing system of healthcare communication systems, we can take steps to address these issues and further increase our health system preparedness. Addressing the vulnerabilities in communication systems and planning how to overcome them is an essential responsibility of a hospital emergency manager. Many of the criticisms of the current state of health systems’ communication systems center around the inability to communicate easily with external agencies and share critical information. Disaster after-action reports and exercise improvement plans almost universally cite poor communication as one of the problems associated with incident management and the event being reviewed. Infrastructure support is an important consideration when examining whether adequate safeguards are in place to support the systems we will rely upon during a disaster. On September 11, 2001, while one New York City hospital was preparing to treat a large number of (anticipated) casualties from the disaster, they experienced a loss of their computer and information systems.17 This unplanned event arose because the communication system line that supported their system’s infrastructure ran beneath the World Trade Center.17 Additionally, other reports have cited problems with battery failure and the lack of a prolonged power supply as limiting communication systems’ abilities during an event.14 This example illustrates a major point in emergency communication systems: hospitals need the ability to connect all significant parties during a disaster or other emergency and the system should be based on a redundant infrastructure.5 Clearly, from a planning perspective, this would be a desirable option. However, the reality remains that investing in communication systems is a significant financial burden on already underfunded hospitals and healthcare systems. Risk communication is often overlooked during the planning phase of an event, and this can lead to frustration and confusion during disaster operations. Risk communication is sometimes the only way for the public to gain an understanding of the scope and severity of an incident. Additionally, risk communication information provided by hospitals may be used to help families of disaster victims find information about 55133_CH01_Reilly:Achorn Int'l 8 | Chapter 1 5/13/10 12:08 PM Page 8 Introduction to Hospital and Healthcare Emergency Management their loved ones’ condition. Reviews of risk communication have shown that a predesignated public information officer (PIO), who will liaise with the media and the public and who has specific training and experience in giving briefings and fielding questions, should perform all risk communication tasks during disaster operations.13 Specific elements of risk communication that may be conveyed to the public may include information on evacuations, scope and breadth of the event, where and how to obtain assistance if needed, whom to call for specific information, location of postexposure prophylaxis or vaccination clinics, and what to expect over the next several hours and/or days of the event. This is discussed in more detail in Chapter 12. SURGE CAPACITY The General Accounting Office (GAO), which changed its name to the Government Accountability Office (GAO) in 2004, finalized reports during 2003 on the public health and hospital preparedness for bioterrorism and emerging infectious diseases.9,16 These reports found that most hospitals in the United States do not have the means to care for a surge of patients during a public health emergency.9,16 They stated that, based on the national emergency department diversion rates in urban and suburban areas, shortages in the healthcare workforce, and the general lack of available supplemental medical equipment and supplies in hospitals, the medical community is not prepared to handle a patient surge caused by an infectious disease outbreak or bioterrorism related event.9,16 Emergency departments are being utilized more often as urgent care centers because the growing population utilizes the ED as their point of primary care. This increasing phenomenon is contributing to ED overcrowding and diversionary status (hospital EDs asking that ambulances refrain from bringing patients to their facility for a period of time) in virtually every healthcare and trauma system in the country. The current state of affairs in the nation’s EDs makes it very difficult to prepare for surge capacity when many hospitals cannot effectively handle their daily patient volume.18 Referral patterns of patients presented to medical facilities will vary in terms of how they arrive at the facility (EMS or self-transport) as well as which facilities they access (hospital ED or physician’s office), depending on the type of disaster or public health emergency. In cases of natural disasters, explosions, and acute catastrophic events where there is a clear and defined “scene,” many patients will be triaged, treated, and perhaps transported to hospitals or trauma centers by EMS personnel. In cases of bioterrorism or infectious disease outbreaks, patients would normally exhibit minor signs and/or symptoms of an illness (e.g., fever, rash, flu-like symptoms, etc.). These patients may be 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 9 Healthcare Emergency Management Activities | 9 presented to their primary care physician or an urgent care center to receive initial diagnosis and treatment. The patients that can be expected to arrive at the ED in these cases would be those who could not access a private physician, those too acutely ill to seek care in an office setting, those referred to the ED by their physicians, and those patients who called EMS for assistance. This latter group would yield the least number of ED arrivals.19–20 Incidents of chemical and biological terrorism as well as pandemic or epidemic incidents of infectious diseases may arguably produce the most significant burden on the healthcare system.9,13,16,18,21 A main reason for this is the unpredictable referral patterns of patients who fall victim to a chemical or biological hazard. Although some disaster after-action reports do suggest that even victims of conventional disasters will self-refer to medical facilities, the issues of delayed onset of symptoms, cross-contamination, and person-to-person disease transmission that are associated with a chemical, biologic, or radiologic incident call for more detailed contingency plans. An example of hospital referral patterns after a chemical agent event can be seen in the post-event summary of the sarin attack in the Tokyo subways in March of 1995.22 In this incident 12 people were killed, but more than 5000 people sought medical attention, and only 688 of them were medically transported to area hospitals.22 At some point during the evolution of a disaster or other public health emergency, patients will converge on acute care hospitals. Studies have consistently shown that despite rigorous planning initiatives, hospitals and emergency departments are not prepared to handle the mass influx of patients that a bioterrorism event or infectious disease outbreak would produce.9,16,19–20 During the sarin attack on the Tokyo subway in 1995, the nearest hospital had 500 patients in the first hour after the incident and more than 20% of its staff was secondarily contaminated.22 It is important that planners additionally recognize that in certain catastrophic disasters involving bombings, building collapse, etc., mass injuries and a patient surge may not occur as anticipated because of the high rate of mortality.17,23 The hospital emergency manager and all those involved in hospital emergency management must ensure that their hospital has adequate plans for the surge of patients that will arrive during a disaster, terrorism event, or public health emergency. VOLUNTEER MANAGEMENT The use of volunteers in disasters and public health emergencies presents a unique set of considerations for the hospital emergency manager. Volunteers can be utilized in several ways to assist in disaster relief services. However, the problems of volunteer management, credentialing, 55133_CH01_Reilly:Achorn Int'l 10 | Chapter 1 5/13/10 12:08 PM Page 10 Introduction to Hospital and Healthcare Emergency Management safety, and security often preclude their utility in the acute disaster environment unless significant pre-planning for their use has occurred and their arrival is through a pre-defined system. Cone et al. describe “convergent volunteerism” (the influx of citizens and/or health providers to a major incident) as a “critical problem” in disaster management.24 Intuitively, you may think that the outpouring of community support to assist in rendering aid during a disaster or other public health emergency is a welcome show of support for disaster victims. However, the reality is that convergent volunteerism brings with it security, resource, and worker safety problems that require personnel and critical resources to manage. In their discussion of convergent volunteerism in the September 11 terrorist attacks in NYC, Cone and colleagues discuss the myriad of additional challenges and problems that the unsolicited and often intrusive behavior of “Good Samaritans” imposed on the NYC responders. Issues included the unsupervised practice of medicine and paramedicine; credential verification of certified and/or licensed personnel; the performance of search and rescue operations by lay responders; the need to feed, shelter, and provide sanitary facilities for volunteers; potential injury and illness to volunteers who were unsupervised and lacked proper personal protective equipment; and personal vehicle congestion on scene access and egress.24 Many of these concerns may seem trivial to some who view a community response to a disaster as being the quintessential demonstration of altruism and support for fellow citizens. However, as mentioned by Cone and colleagues, untrained and unauthorized volunteers can ultimately put themselves and others in danger, and deplete emergency response resources by attempting to provide assistance at disaster scenes. This was most poignantly illustrated during the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, when an untrained and unprotected volunteer nurse was crushed by falling debris while trying to assist with urban search and rescue operations.24 SECURITY ISSUES Hospitals frequently overlook the need to maintain adequate security of the healthcare facility and overall medical operations as part of both daily operations and emergency planning. The concept of “locking down” or restricting access to a healthcare facility is often contradictory to the typical hospital design and approach of open access to both patients and their families and other visitors. But during a disaster this type of control is essential for many reasons, which include but are not limited to: control of the flow of patients to the areas where care will be provided; access to the facility only by authorized staff; accounting for staff and patients 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 11 Healthcare Emergency Management Activities | 11 in time of evacuation; prevention of potentially contaminated patients entering the hospital from contaminating staff, other patients, and facilities; and prevention of acts of terrorism. Security resources generally vary among hospitals. Some hospitals and trauma centers have sworn police officers present in their facilities 24 hours a day, and others may hire a private security firm to maintain safety or simply serve a concierge or customer service role. Security concerns during disasters and public health emergencies can become significant when considering the potential vulnerabilities associated with the chaotic response environment.15,17,24–25 Specifically cited issues with security during the response to a disaster or public health emergency include access control to medical facilities; credentialing of employees, responders, and volunteers; crime scene and evidence preservation; infrastructure and resource protection; and crowd control.15,17,24–25 HAZMAT/CBRNE PREPAREDNESS There is no question that in the current state of health system and public health preparedness the medical community is ill-prepared to deal with an incident that involves the management and treatment of multiple potentially contaminated victims, including those from chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Multiple recent reports of hospital preparedness cite decontamination capabilities as a serious weakness of disaster readiness plans.4–5,8–9,11,15–16,26–27 One study cites as few as 6% of Level I trauma centers as having the necessary equipment on hand to safely decontaminate a single patient.26 Planning for these events has traditionally centered around the fallacy that patients will be decontaminated at the scene by first responders and then be triaged, treated, and transported to the ED. The decontamination process serves a dual purpose. First, it removes the potential agent that is causing harm to the patient, and second, it prevents the spread of secondary contamination to other patients and hospital staff. We have come to realize from recent incidents involving victim contamination that many ambulatory victims will leave the scene and bypass EMS decontamination and triage, seeking medical care on their own.11,15,19–20 The reality of dealing with an intentional release of chemical, biological, or radiological agent is that by the time acute care facilities can be made aware that an event has taken place, they may have already been contaminated themselves.22 The specifics of hospital decontamination and worker safety are discussed in Chapter 14. Throughout the nation, trauma systems, acute care hospitals, and first responders are unprepared for handling an event involving the release of a nuclear, biological, or chemical (NBC) agent.8,15,26 Largely, this is due to ineffective planning and relying on resources that may not be available 55133_CH01_Reilly:Achorn Int'l 12 | Chapter 1 5/13/10 12:08 PM Page 12 Introduction to Hospital and Healthcare Emergency Management during a disaster or public health emergency.15 The most often cited weaknesses are an overall lack of training, lack of personal protective equipment (PPE), lack of resources and equipment to rapidly and reliably perform preliminary agent detection, and lack of appropriate medical facilities, equipment and supplies to effectively isolate infectious patients and manage them through the course of their illnesses.8,15,21–22,26 COLLABORATION AND INTEGRATION WITH PUBLIC HEALTH In order for disaster preparedness and response to be successful, it must involve interagency resources and consider the 3C’s of emergency response planning: Collaboration, Cooperation, and Coordination. Response plans cannot be designed and implemented in a vacuum. Disaster response and recovery operations will certainly consist of a multiagency response at the local, state, and federal levels. In order to ensure that the response plan is valid, and will operationally integrate with other key responding agencies, the planner must collaborate with fellow agencies and develop plans that involve aspects of interagency response. Interagency planning groups, such as the Local Emergency Planning Committee (LEPC), operate under the assumption that if a hazardous event occurs, all key public safety and health agencies will respond in a unified approach with common goals to protect the welfare and safety of the community. These principles of collaboration, cooperation, and coordination among the agencies that will likely respond to a disaster or other public health emergency will minimize unnecessary redundancy in response plans and create partnerships with agencies that can provide expertise and resources during the public health emergency response. In a large-scale disaster or act of terrorism, such as the World Trade Center attacks in 1993 and 2001, the Oklahoma City bombing in 1995, and the 1994 and 1995 sarin attacks in Tokyo, continuous medical monitoring and follow-up of the survivors, responders, and participants in these events is needed to detect the associated long-term health effects. With the exception of large academic medical institutions that may perform epidemiologic analysis on specific cohorts of individuals, the public health community must recruit and maintain a database of affected individuals so they can study the long-term impact of these events on the health of the population. It is important to note that although the imminent threat of danger may no longer be present, the need for medical care, disease surveillance, and follow-up studies is essential to the completion of the public health role in a disaster or other public health emergency. Additionally, public health agencies at the federal, state, and local levels have the responsibility under the National Response Framework (NRF) to coordinate and serve as the lead agency for disasters involv- 55133_CH01_Reilly:Achorn Int'l 5/13/10 12:08 PM Page 13 Healthcare Emergency Management Activities | 13 ing mass care. This may include assisting both hospitals and communities to establish alternate care sites (ACS) where patients can be directed to receive medical treatment during a public health emergency, which will allow a hospital to use its resources to treat higher acuity patients and remain open to handle routine emergencies during a pandemic or other public health emergency. EDUCATION AND TRAINING Reports have suggested that healthcare workers lack the knowledge to detect and mana...
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