- Look at two of my classmate's posts. I need you to respond to each one separately. Don't write about how good their posts or how bad. All you need to do is to choose one point of the post and explore it a little bit with one source support for each response. In the attachment, you will find all the classmates posts. - APA Style. - Reading: Reilly, M., &Markenson, D. S. (2010). Health Care Emergency Management: Principles and Practice • • Chapter 6: Introduction to Exercise Design and Evaluation Chapter 8: Education and Training Emergency management principles and practices for healthcare systems (2006). Kaji, A, Langford, V, Lewis,R (2008) Assessing Hospital Disaster Preparedness: A Comparison of an On-Site Survey, Directly Observed Drill Performance, and Video Analysis of Teamwork, Annals of Emergency Medicine V52, No3, 195-201 • Assessing Hospital Disaster Preparedness.pdf - Discussion Board Question? * What are some of the biggest challenges in developing and implementing a preparedness exercise in a hospital setting? * What differences/similarities exist between hospital and municipal preparedness exercises? Student 1 post: Challenges Facing the Healthcare System During Emergencies The healthcare system plays an important role in times of disasters. Through proper planning, training, command, and coordination the system should always be responsive. However, the situation on the ground is different. Most hospitals are caught up in times of disasters which end up making the already bad situation worse. The main challenge lies with developing and implementing the required preparedness action. Among the greatest challenges in hospice organizations is a surge in capacity. Most hospitals in the densely populated areas operate at or near full capacity. Consequently during disasters, the hospitals are seriously limited on their expansion capability (Kaji & Lewis, 2004 ). Some of the surveys done, for example, have found that availability of beds, ventilators, isolation beds, and drugs are insufficient in times of large scale disaster. Another challenge is the lack of a good communication network. There is a need to put more emphasis on the importance of a good flow and channel of communication. It’s a fact that communication assists in ensuring victims are directed to the most appropriate facilities. Besides, hospitals have a prior alert on the number of victims to expect and the type of response is required. According to Niska and Burt (2005), very few hospitals have a provision for their bioterrorism response plan at 72% . Hence, it can be stated that the communication systems for most hospitals are considerably weak. Similarities Between the Municipal and Hospital Preparedness The teams tasked with the tackling emergencies in cases of a disaster are the municipal and the healthcare workers. Both teams share a lot when it comes to disasters management. The municipal team for instance provides emergency plan templates training and exercises development and facilitation of the same. In addition, the municipal enhance information sharing with the different hospitals; creating situational awareness on the primary care needs before and after a disaster. In conclusion, the mutual partnership between healthcare providers and the local authorities is imperative and more resources should be channeled to enhance this cooperation. The management of hospitals around the country should come up with realistic policies that can be implemented to make sure disasters and emergencies are averted in the shortest possible time. References Kaji, A. H., Langford, V., & Lewis, R. J. (2008). Assessing hospital disaster preparedness: A comparison of an on-site survey, directly observed drill performance, and video analysis of teamwork. Annals of emergency medicine, 52(3), 195-201.doi: 10.1016/j.annemergmed.2007.10.026. Niska, R. W., & Burt, C. W. (2005). Bioterrorism and mass casualty preparedness in hospitals: United States, 2003. Emmitsburg, MD: National Emergency Training Center. Rand Corporation. (2004). RAND study shows compensation for 9/11 terror attacks tops $38 billion. Businesses Receive Biggest Share. Retrieved from http://www.rand.org/news/press.04/11.08b.html Student 2 post: Hospital preparedness especially when it comes to disasters is a common requirement that should be taken seriously. Majority of hospitals in the urban and rural sectors do not use disaster preparation techniques in managing disasters (Beitsch et al,2006). This usually results to most of them failing when a disaster takes place. It is essential that hospitals should always be prepared in handling these situations since they handle the lives of people. There are many challenges that make it difficult for hospitals to either develop or implement their preparedness plans; this paper will discuss some of them. Budgets are some of the leading problems that affect planning an implementation of preparedness plans. The hospital sector will always require enough financial allocations for buying emergency types of equipment that will help in rescuing people from arising dangers. In some cases, the hospitals may be forced to spend too much on patients' recovery. This, therefore, means that there should always be money that is available to take care of this. Some finances can be used for other preparations and the training of staff. Some hospitals face problems with the administration; The administrators do not consider emergencies when they are planning for or allocating the available resources. This, therefore, leads to the misuse of resources that would have instead been used for preparing for disasters. Training of staff is a requirement that should be accomplished in every hospital so that they are able to deal with emergencies (Leinhos et al, 2014). Emergencies in the health-care sector cannot be handled by just anyone, special knowledge is required so as not to cause more harm. There is also a lack of enough guidelines to provide direction to the staff; this can help in avoiding switching of roles. Communication is another important factor that is not taken seriously in health care preparedness. Through good communication, the nurses and other staff are informed of their roles beforehand so they know what to do, this avoids any sort of confusion. Communication is important in ensuring there is coordination. Coordination is also another problem that affects the development and implementation of preparedness plans in the hospital setting. Coordination between different sectors such as wards and the administration help in ensuring a hospital is fully prepared. The above-explained factors help in showing that indeed there is a difference between the municipal preparedness and the hospital preparedness for an emergency. The hospital, for instance, requires qualified staff that are fully trained on how to handle emergency situations (CAUDLE, 2009). The hospital setting is more important hence requires more attention. The importance is derived from its ability to also treat the affected people from any emergency situation. It is also important to remember that both sectors are similar in a way; they both deal with emergency and require revenue. This, therefore, means that financial allocation affects all of them. In summary, emergency services are always important since they ensure any disaster or sudden occurrence is controlled properly. It is clear that capital is important in planning for control of such situations. Training of the staff is also another factor that helps in the efficiency of the operation. The management in hospitals and the municipal sectors are also expected to be qualified so that they can do their work as required and for proper use of resources. They should also ensure that they work with all sectors to enable the process of emergency control. Through communication, every staff will be made aware of the situation whenever it comes about. The hospitals should also contain the emergency department section with the teams who work together in controlling disasters. This can help in specialization in this sector so that it is remembered when funds are being allocated. References Beitsch, L., Kodolikar, S., Stephens, T., Shodell, D., Clawson, A., Menachemi, N., & Brooks, R. (2006). A State-Based Analysis of Public Health Preparedness Programs in the United States. Public Health Reports (1974-), 121(6), 737-745. CAUDLE, S. (2009). AN OPTION FOR HOMELAND SECURITY PREPAREDNESS REQUIREMENTS: Consensus Management System Standards. Public Performance & Management Review,33(1), 141-155. Leinhos, M., Qari, S., & Williams-Johnson, M. (2014). Preparedness and Emergency Response Research Centers: Using a Public Health Systems Approach to Improve All-Hazards Preparedness and Response. Public Health Reports (1974-), 129, 8-18. DISASTER MEDICINE/ORIGINAL RESEARCH Assessing Hospital Disaster Preparedness: A Comparison of an On-Site Survey, Directly Observed Drill Performance, and Video Analysis of Teamwork Amy H. Kaji, MD, MPH Vinette Langford, RN, MSN Roger J. Lewis, MD, PhD From the Department of Emergency Medicine, Harbor–UCLA Medical Center, Los Angeles, CA (Kaji, Lewis); David Geffen School of Medicine at UCLA, Torrance, CA (Kaji, Lewis); Los Angeles Biomedical Research Institute, Torrance, CA (Kaji, Lewis); The South Bay Disaster Resource Center at Harbor–UCLA Medical Center, Los Angeles, CA (Kaji); and MedTeams and Healthcare Programs Training Development and Implementation, Dynamics Research Corporation, Andover, MA (Langford). Study objective: There is currently no validated method for assessing hospital disaster preparedness. We determine the degree of correlation between the results of 3 methods for assessing hospital disaster preparedness: administration of an on-site survey, drill observation using a structured evaluation tool, and video analysis of team performance in the hospital incident command center. Methods: This was a prospective, observational study conducted during a regional disaster drill, comparing the results from an on-site survey, a structured disaster drill evaluation tool, and a video analysis of teamwork, performed at 6 911-receiving hospitals in Los Angeles County, CA. The on-site survey was conducted separately from the drill and assessed hospital disaster plan structure, vendor agreements, modes of communication, medical and surgical supplies, involvement of law enforcement, mutual aid agreements with other facilities, drills and training, surge capacity, decontamination capability, and pharmaceutical stockpiles. The drill evaluation tool, developed by Johns Hopkins University under contract from the Agency for Healthcare Research and Quality, was used to assess various aspects of drill performance, such as the availability of the hospital disaster plan, the geographic configuration of the incident command center, whether drill participants were identifiable, whether the noise level interfered with effective communication, and how often key information (eg, number of available staffed floor, intensive care, and isolation beds; number of arriving victims; expected triage level of victims; number of potential discharges) was received by the incident command center. Teamwork behaviors in the incident command center were quantitatively assessed, using the MedTeams analysis of the video recordings obtained during the disaster drill. Spearman rank correlations of the results between pair-wise groupings of the 3 assessment methods were calculated. Results: The 3 evaluation methods demonstrated qualitatively different results with respect to each hospital’s level of disaster preparedness. The Spearman rank correlation coefficient between the results of the on-site survey and the video analysis of teamwork was – 0.34; between the results of the on-site survey and the structured drill evaluation tool, 0.15; and between the results of the video analysis and the drill evaluation tool, 0.82. Conclusion: The disparate results obtained from the 3 methods suggest that each measures distinct aspects of disaster preparedness, and perhaps no single method adequately characterizes overall hospital preparedness. [Ann Emerg Med. 2008;52:195-201.] 0196-0644/$-see front matter Copyright © 2008 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2007.10.026 INTRODUCTION A disaster may be defined as a natural or manmade event that results in an imbalance between the supply and demand for resources.1 Events of September 11, 2001, and the devastation from Hurricanes Katrina and Rita have recently Volume , .  : September  highlighted the importance of hospital disaster preparedness and response. Previous disasters have demonstrated weaknesses in hospital disaster management, including confusion over roles and responsibilities, poor communication, lack of planning, suboptimal training, and a Annals of Emergency Medicine 195 Assessing Hospital Disaster Preparedness Editor’s Capsule Summary What is already known on this topic Extremely little is known on how to objectively and accurately rate hospital disaster preparedness. Scales and measurements have been developed but not extensively validated; most evaluations are highly subjective and subject to bias. What question this study addressed At 6 sites, 3 evaluation methods, an onsite predrill survey, a real-time drill performance rating tool, and a video teamwork analysis, were used and correlations among evaluation methods examined. What this study adds to our knowledge The 3 methods produced disparate evaluations of preparedness, suggesting that the instruments are flawed, they are measuring different things, or both. How this might change clinical practice Better assessment tools for hospital disaster preparedness need to be developed, perhaps beginning with the careful definition of what aspects of preparedness are to be measured. lack of hospital integration into community disaster planning.2 Despite The Joint Commission’s emphasis on emergency preparedness for all hospitals, including requirements for having a written disaster plan and participating in disaster drills, there is currently no validated, standardized method for assessing hospital disaster preparedness. This lack of validated assessment methods may reflect the complex and multifaceted nature of hospital preparedness. To be prepared to care for an influx of victims, a hospital must have adequate supplies, equipment, and space, as well as the appropriate medical and nonmedical staff. Survey instruments, either self-administered or conducted on site, may be used to assess these resources. Although surveys and questionnaires attempt to capture a hospital’s level of preparedness through quantifying hospital beds, ventilators, isolation capacity, morgue space, available modes of communication, frequency of drills, and other aspects of disaster preparedness,3-8 it is unclear whether they are reliable or valid predictors of hospital performance during an actual disaster, or even during a drill. In contrast to surveys, which assess hospital resources and characteristics during a period of usual activity, disaster drills make use of moulaged victims to gauge hospital preparedness and assess staff interactions in a dynamic environment in real time. Although hospitals routinely conduct after-drill debriefing sessions, during which participants discuss deficiencies warranting improvement, there is no commonly used and 196 Annals of Emergency Medicine Kaji, Langford & Lewis validated method for evaluating hospital performance during disaster drills. To address this gap, the Johns Hopkins University Evidence-based Practice Center, with support from the Agency for Healthcare Research and Quality (AHRQ), developed a hospital disaster drill evaluation tool.9 The tool includes separate modules for the incident command center, triage area, decontamination zone, and treatment areas. In a recent study, conducted in parallel with the study reported here, we described the AHRQ evaluation tool’s internal and interrater reliability.10 We found a high degree of internal reliability in the instrument’s items but substantial variability in interrater reliability.10 Recently, evidence has suggested that enhancing teamwork among medical providers optimizes the provision of health care, especially in a stressful setting, and some experts working in this area have adopted the aviation model as a basis for designing teamwork programs to reduce medical errors.11 In 1998, researchers from MedTeams, a research corporation that focuses on observing and rating team behaviors, set out to evaluate the effectiveness of using aviation-based crew resource management programs to teach teamwork behaviors in emergency departments (EDs), conducting a prospective, multicenter, controlled study.12 The MedTeams study, published in 2002, demonstrated a statistically significant improvement in the quality of team behaviors, as well as a reduction in the clinical error rate, after completion of the Emergency Team Coordination Course.12 Because effective teamwork and communication are essential to achieving an organized disaster response, assessing teamwork behavior may be a key element in a comprehensive evaluation of hospital disaster response. Evaluating teamwork behaviors involves the assessment of the overall interpersonal climate, the ability of team members to plan and problem-solve, the degree of reciprocity among team members in giving and receiving information and assistance, the team’s ability to manage changing levels of workload, and the ability of the team to monitor and review its performance and improve its teamwork processes.12 In addition to observing team members in real time, MedTeams researchers routinely review videotaped interactions among team members as a method of quantifying teamwork behaviors. The objective of our study was to determine the degree of correlation between 3 measures of assessing hospital disaster preparedness: an on-site survey, directly observed drill performance, and video analysis of teamwork behaviors. MATERIALS AND METHODS Six 911-receiving hospitals, participating in the annual, statewide disaster drill in November 2005, agreed to complete the site survey and undergo the drill evaluation and video analysis. The selection of the sample of hospitals and their characteristics has been described previously.10 The drill scenario included an explosion at a public venue, with multiple victims. To preserve the anonymity of the hospitals, they are designated numerically 1 through 6. Because all data were Volume , .  : September  Kaji, Langford & Lewis deidentified and reported in aggregate, our study was verified as exempt by the institutional review board of the Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center. We used an on-site survey (included in Appendix E1, available online at http://www.annemergmed.com), which included 79 items focusing on areas previously identified as standards or evidence of preparedness.1-3,13-28 The survey was a modification of an instrument we used in a previous study.8 Compared with the original survey instrument, the number of items was reduced from 117 to 79 by the study investigators to eliminate items that had limited discriminatory capacity and to reduce redundancy and workload. Survey items included a description of the structure of the hospital disaster plan, modes of intra- and interhospital communication, decontamination capability and training, characteristics of drills, pharmaceutical stockpiles, and each facility’s surge capacity (assessed by monthly ED diversion status, number of available beds, ventilators, negative pressure isolation rooms, etc). Because a survey performed in 1994 demonstrated that hospitals were better prepared when the medical directors of the ED participated in community planning,27 we also assessed whether each hospital participated in the local disaster planning committee. Additional survey items examined mutual aid agreements with other hospitals and long-term care facilities; predisaster “preferred” agreements with medical vendors; protocols for canceling elective surgeries and early inpatient discharge; the ability to provide daycare for dependents of hospital staff; the existence of syndromic surveillance systems; ongoing training with local emergency medical services (EMS) and fire agencies; communication with the public health department; and protocols for instituting volunteer credentialing systems, hospital lockdown, and managing mass fatality incidents. The survey was distributed by electronic mail, and between June 2006 and June 2007, the disaster coordinators at each of the 6 hospitals completed the survey. The on-site “inspection” to verify the responses to the 79 item survey was performed by a single observer (A.H.K.) between June 2006 and June 2007. During the visit, necessary clarification of responses to the survey items was obtained, followed by an examination of the hospital disaster plan, the decontamination shower, the personal protective equipment, communication systems (eg, walkietalkies and radio system), Geiger counters, the ED, the laboratory, the pharmacy, and the designated site of the incident command center. The possible answers for 71 of the 79 survey items were assigned a point value. Depending on perceived importance, items were allocated zero to 1 point, zero to 3 points, or zero to 5 points, with a higher score indicating better preparedness. For example, for the question, how many patients could you treat for a nerve agent exposure? the answer “fewer than 10” would be given a score of zero, the answer “10 to 20” would be given a score of 1, “20 to 30” would be given a score of 2, and “greater Volume , .  : September  Assessing Hospital Disaster Preparedness than 30” would be given a score of 3. There were also 8 of 79 questions to which no point value was assigned because the item was not designed to discriminate between levels of preparedness. For example, no point value was assigned to the question, have you ever had to truly implement the incident command structure? A summary score for overall preparedness was calculated by summing each of the item scores. The maximum possible score was 215 (see Appendix E1, available online at http://www.annemergmed.com). As described in our recent study and companion article evaluating the reliability of the drill evaluation tool, 32 trained medical student observers were deployed to the 6 participating hospitals to evaluate drill performance using the AHRQ instrument.9 Two hundred selected dichotomous drill evaluation items were coded as better versus poorer preparedness by the study investigators.10 An unweighted “raw performance” score was calculated by summing these dichotomous indicators. Although the drill evaluation instrument assesses multiple areas of the hospital, including triage, decontamination, treatment, and incident command, we chose to consider only those items related to the performance of the incident command center because it was the only drill evaluation module that was applied at all 6 hospitals, as described in the companion article.10 Moreover, the MedTeams evaluation (see below) was based on video analysis of the incident command center. We also believed that a high level of performance in the incident command center would be correlated with high levels of performance elsewhere in the hospital. There were 45 dichotomous items evaluating the incident command center that could be dichotomously coded as indicating better or worse preparedness. Examples of drill evaluation items included whether the incident command center had a defined boundary zone, the incident commander took charge of the zone, the incident commander was easily identifiable, the hospital disaster plan was accessible, and whether the noise level in the incident command center interfered with effective communication. Because of the limited number of observers, 2 hospitals had 1 observer deployed to the incident command center, whereas 4 hospitals had 2 observers. When 2 observers were available, the average of the 2 scores was calculated. A professional video company was employed to film activities at each of the hospitals on the day of the disaster drill. Although various areas of the hospital were filmed, the predominant focus was on the incident command center and capturing the interactions among its members. The videos were edited, transferred to DVDs, and sent to MedTeams, whose staff were blinded to the drill and site survey results, for analysis and scoring of teamwork behaviors. To assess teamwork behaviors, MedTeams uses a team dimension rating scale based on the 5 team dimensions of the behaviorally anchored rating scales and an overall score, which is a mean of the 5 team dimensions. The range of possible scores for each of the team dimensions was 1 to 7. “Team dimension Annals of Emergency Medicine 197 Assessing Hospital Disaster Preparedness rating” is the term applied to the process of observing team behavior and assigning ratings to each of the 5 behaviorally anchored rating scale team dimensions.29 Each team dimension has specific criteria that are used for scoring purposes. The first team dimension assesses how well the team structure was constructed and maintained. For example, the observer is asked to rate how efficiently the leader assembled the team, assigned roles and responsibilities, communicated with each of the team members, acknowledged contributions of team members to team goals, demonstrated mutual respect in all communications, held everyone accountable for team outcomes, addressed professional concerns, and resolved conflicts constructively.29 The second team dimension assesses planning and problemsolving capability. Observations include whether team members were engaged in the planning and decisionmaking process, whether protocols were established to develop a plan, whether team members were alerted to potential biases and errors, and how errors were avoided and corrected.29 The third team dimension evaluates team communications. Observations include whether situational awareness updates were provided, whether a common terminology was used, whether the transfer of information was verified, and whether decisions were communicated to team members.29 The fourth team dimension assesses the management of team workload. The observer records whether there was a teamestablished plan to redistribute the workload, integrating individual assessments of patient needs, overall caseload, and updates from actions of team members.29 The final team dimension describes team improvement skills. Recorded observations include whether there were shift reviews of teamwork, whether teamwork considerations were included in educational forums, and whether situational learning and teaching were incorporated into such forums.29 Although behaviorally anchored rating scale descriptions specify distinct clusters of teamwork behaviors, there is some inevitable overlap across the 5 team dimensions. The behaviorally anchored rating scale describes concrete and specific behaviors for each team dimension and provides anchors for the lowest, middle, and highest values (standards of judgment). Additionally, the behaviorally anchored rating scale delineates criteria for assigning a numeric value to the rater’s judgment, and each of the 5 dimensions is rated on a numeric scale of 1 to 7, in which 1 is very poor and 7 is deemed superior.29 Primary Data Analysis Data obtained from the on-site survey and drill evaluation tool were recorded on data collection forms. All data were stored in an Access database (Access 2003; Microsoft Corporation, Redmond, WA). The database was translated into SAS format using DBMS/Copy (DataFlux Corporation, Cary, NC). The statistical analysis was performed using SAS, version 9.1 (SAS Institute, Inc., Cary, NC), and Stata, version 9.2 (StataCorp, College Station, TX). 198 Annals of Emergency Medicine Kaji, Langford & Lewis Table. Results of 3 methods of assessing hospital disaster drill performance. Hospital Number* On-site Survey (1–215) (%)† Modified AHRQ Score in ICC (1–45) (%)† MedTeams ICC Score (1–7) (%)† 1 2 3 4 5 6 155 (72) 155 (72) 186 (87) 159 (74) 166 (77) 152 (71) 31 (69) 19 (42) 27 (60) 34 (76) 24 (53) 26 (58) 5 (71) 4 (57) 4.8 (69) 5 (71) 4.2 (60) 5 (71) ICC, Incident command center. *Note that there was only 1 observer deployed to the ICC at hospitals 1 and 4, whereas the remaining 4 hospitals had 2 observers simultaneously deployed to the ICC, and the score represents the average of the 2 scores. † Percentage of maximum possible score for that assessment method. Because the results from each of the 3 evaluation methods could not be assumed to be normally distributed, pair-wise nonparametric Spearman rank correlation coefficients were calculated to assess the relationship between the results of the on-site survey, the drill evaluation tool, and the video analysis of teamwork behaviors. RESULTS The summary on site survey scores is shown in the Table. All hospitals had a disaster plan that was based on the Hospital Incident Command System, a policy to cancel elective surgery and for early discharge to make room for incoming disaster victims. Five of the 6 (83%) hospitals had a protocol for hospital lockdown, involved the local police department in the plan, and had a volunteer credentialing policy. Only 3 of the 6 (50%) had a protocol to provide daycare for children of hospital staff, as well as a designated overflow area for victims in the plan. Although all hospitals had mutual aid or “preferred” agreements with vendors, only 2 of the 6 hospitals (33%) had a mutual aid agreement with a long-term care facility, whereas 5 of 6 (83%) had agreements with other hospitals. In terms of surge capacity, 5 of the 6 (83%) had a licensed bed capacity greater than 200 and the ability to create isolation beds, and only 1 (17%) stated that they were on ambulance diversion greater than 20% of the time. Yet, 3 (50%) hospitals stated that they had fewer than 10 isolation rooms, and 4 (67%) were affected by the nursing shortage. All the hospitals had EMScompatible radios, walkie-talkies, availability of HAM radios, level C personal protective equipment, a warm water decontamination shower, Geiger counters, and an antibiotic stockpile. Five (83%) had greater than 3 days’ worth of hospital supplies, a chemical antidote stockpile, and a surveillance system in place. Four hospitals (67%) stated that they would be able to obtain 5 more ventilators and had greater than 20 ventilators on hand. All hospitals stated that they conducted drills with multiple agencies, and 5 (83%) conducted at least biannual decontamination training for staff. The raw drill performance scores for the incident command center ranged from 19 of 94 (20%) to 34 of 94 (36%). The Volume , .  : September  Kaji, Langford & Lewis Assessing Hospital Disaster Preparedness Figure. Pair-wise comparisons of the 3 methods of disaster preparedness. Note the expanded scales used for each preparedness measure. various scores of each of the hospitals are listed in the Table. The MedTeams team dimension rating overall average scores ranged from 4.2 to 4.8. The specific team dimension rating range for each of the 5 dimensions was as follows: 3 to 6 for maintaining team structure and climate, 3 to 6 for planning and problem-solving ability, 4 to 6 for team communications, 4 to 5 for workload management, and 4 to 5.8 for the ability to improve team skills (Table). Pair-wise comparisons for the 3 evaluative methods are shown in the Figure. Spearman correlation results for the pairwise comparisons were as follows: 0.14 (between the on-site survey and the drill evaluation tool), ⫺0.33 (between the onsite survey and the video analysis), and 0.82 (between the drill evaluation tool and the video analysis). Although we believe our general observation that there is highly variable correlation between results from the 3 methods for assessing hospital preparedness, we cannot define the pair-wise correlations with much precision, given our limited sample size of hospitals. hospital preparedness, we could not define the pair-wise correlation coefficients with much precision. Our revised 79-item survey instrument has not been validated, although the questions were created from a review of the existing literature and had been used previously. The survey results depend on the accuracy of the disaster coordinators, and there is a possibility that the respondents answered in such a way to appear better prepared. However, we believe the on-site verification of survey results diminishes this possibility. The AHRQ disaster drill evaluation tool also has not been validated against hospital performance in a real disaster, and its interrater and internal reliability have only been assessed in our previous investigation.10 Finally, the results from the drill evaluation and the video analysis were focused only on the incident command center because we assumed that a high level of performance in the incident command center would be correlated with high levels of performance elsewhere in the hospital. DISCUSSION LIMITATIONS Our study has a number of limitations. The sample size of 6 hospitals is small, and self-selection bias is likely.10 The survey was conducted in Los Angeles County, with its unique hazards, which limits the generalizability of the results. Because of the small sample size, confidence intervals for the Spearman rank correlation coefficients could not be determined, and thus, although we believe our general observation that there is limited correlation between the results of 3 methods for assessing Volume , .  : September  There is no standard evaluation method for assessing hospital disaster preparedness. Despite The Joint Commission requirement for hospital drills to be conducted yearly, there is no evidence demonstrating that a certain type of drill, or that practicing drills at all, improves hospital preparedness.30 Our results demonstrate highly variable correlations between 3 evaluative methods, and this suggests that each method may be assessing different dimensions of hospital disaster preparedness. The video analysis focuses on evaluating teamwork behaviors, Annals of Emergency Medicine 199 Assessing Hospital Disaster Preparedness whereas the on-site survey emphasizes whether a hospital has the appropriate supplies, equipment, and staff. The drill evaluation tool incorporates items that attempt to assess the teamwork behaviors of drill participants, as well as the adequacy of supplies, equipment, and staff at the hospital. The correlation between the drill evaluation instrument results and the video analysis was the highest of the 3 pair-wise comparisons. Perhaps this is because both of these instruments assess aspects of communication and teamwork behaviors, whereas the survey instrument focuses on quantifying the supply, equipment, and personnel resources of the hospital. The 3 evaluative methods also demonstrate limited discriminatory capability to assess disaster preparedness. In fact, 3 hospitals obtained the same overall score by the MedTeams evaluator. Identical scores were also obtained when the complete on-site survey was used to assess preparedness.8 The drill evaluation tool appeared to have the best discriminatory capability, at least in that there were no identical scores. All our hospitals are in the same geographic area, and there are likely regional standards that are common to all. This may make consistent discrimination difficult. Given the lack of standards for preparedness, developing a universally accepted tool to assess hospital disaster preparedness is a daunting task. Perhaps our findings can be used as a basis for a more comprehensive approach that reflects both communication and teamwork behaviors, as well as a quantitative assessment of surge capacity, supplies, and equipment. The correlation analysis suggests that the video analysis and drill evaluation tool had the greatest degree of similarity. One solution may therefore be to combine items from the tools with the least redundancy, such as the drill evaluation tool and the written on-site survey or the sitesurvey and the video analysis, to create a multidimensional, comprehensive evaluation instrument. Future study will be necessary to determine which items have the greatest internal reliability and interrater reliability, after which the tool will require pilot testing and validation. Among a cohort of 6 hospitals in Los Angeles County, CA, participating in a regional disaster drill, an on-site survey, the AHRQ disaster drill evaluation tool, and the MedTeams video analysis of teamwork behavior demonstrated little consistency, suggesting that each may measure a different aspect of hospital preparedness. We wish to thank the following personnel and entities for support of this work: Agency for Healthcare Research and Quality grant 1 F32 HS013985; Emergency Medical Foundation Research Fellowship Grant; an unrestricted grant from ARCO Corporation; the hospital disaster coordinators from each participating hospital, and the members of Amy Kaji’s epidemiology doctoral dissertation committee for their guidance: Robert Kim-Farley, MD, MPH; Jorn Olsen, MD, PhD; and Scott Layne, MD. MedTeams is a registered trademark of Dynamics Research Corporation, Andover, MA. 200 Annals of Emergency Medicine Kaji, Langford & Lewis Supervising editor: Jonathan L. Burstein, MD Author contributions: AHK and RJL conceived and designed the study and obtained research funding. AHK and RJL supervised the conduct of the data collection. AHK undertook recruitment of participating centers and managed the data. AHK and RJL analyzed the data from the on-site survey and the disaster drill. VL analyzed the data for teamwork behaviors from the video. AHK drafted the article, and all 3 authors contributed substantially to its revision. All authors had full access to the data and take full responsibility for the integrity of the data and the accuracy of the data analysis. AHK takes responsibility for the paper as a whole. Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Publication dates: Received for publication August 11, 2007. Revision received October 4, 2007. Accepted for publication October 29, 2007. Available online January 11, 2008. Reprints not available from the authors. Address for correspondence: Amy H. Kaji, MD, MPH, Department of Emergency Medicine, Harbor–UCLA Medical Center, 1000 West Carson Street, Box 21, Torrance, CA 90509; 310-222-3500, fax 310-782-1763; E-mail akaji@emedharbor.edu. REFERENCES 1. Noji E. Disaster epidemiology. Emerg Med Clin North Am. 1996; 14:289-300. 2. Waeckerle J. Disaster planning and response. N Engl J Med. 1991;324:815-821. 3. Higgins W, Wainright C, Lu N, et al. Assessing hospital preparedness using an instrument based on the Mass Casualty Disaster Plan checklist: results of a statewide survey. Am J Infect Control. 2004;32:327-332. 4. Agency for Healthcare Research and Quality. AHRQ unveils hospital bioterrorism preparedness tool. Available at: http://www.ahrq.gov/news/press/pr2002/bioterrpr.htm. Accessed July 19, 2007. 5. Greenboro MO, Jurgens SM, Gracely EJ. Emergency department preparedness for the evaluation and treatment of victims of biological or chemical terrorist attack. J Emerg Med. 2002;22:273-278. 6. Treat KN, Williams JM, Furbee PM, et al. Hospital preparedness for weapons of mass destruction incidents: an initial assessment. Ann Emerg Med. 2001;38:562-565. 7. Ghilarducci DP, Pirrallo RG, Hegman KT. Hazardous materials readiness in the United States level 1 trauma centers. J Occup Environ Med. 2000;42:683-692. 8. Kaji AH, Lewis RJ. Hospital disaster preparedness in Los Angeles County. Acad Emerg Med. 2006;13:1198-1203. 9. Agency for Healthcare Research and Quality. Evaluation of hospital disaster drills: a module-based approach. Prepared for the Agency for Healthcare Research and Quality, contract No. 290-02-0018, and prepared by the Johns Hopkins University Evidence-based Practice Center, the Johns Hopkins University Bloomberg School of Public Health, and the Johns Hopkins University Applied Physics Laboratory. Volume , .  : September  Kaji, Langford & Lewis 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Available at: http://www.ahrq.gov/research/hospdrills/hospdrill.htm. 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Hsu EB, Jenckes MW, Catlett CL, et al. Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review. Prehosp Disaster Med. 2004;19:191-199. Murphy JK. After 9/11: priority focus areas for bioterrorism preparedness in hospitals. J Healthc Manag. 2004;49:227-235. Quarantelli EL. Delivery of Emergency Medical Care in Disasters: Assumptions and Realities. New York, NY: Irvington Publishers; 1983. Wetter D, Daniell W, Treser CD. Hospital preparedness for victims of chemical or biological terrorism. Am J Public Health. 2001;91: 710-716. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41:457-462. Volume , .  : September  Assessing Hospital Disaster Preparedness 21. Bissell RA, Becker BM, Burkle FJ Jr. Health care personnel in disaster response: reversible roles or territorial imperatives? Emerg Med Clin North Am. 1996;14:267-288. 22. Greenberg MO, Jurgens SM, Gracely EJ. Emergency department preparedness for the evaluation and treatment of victims of biological or chemical terrorist attack. J Emerg Med. 2002;22: 273-278. 23. Treat KN, Williams JM, Furbee PM, et al. Hospital preparedness for weapons of mass destruction incidents: an initial assessment. Ann Emerg Med. 2001;38:562-565. 24. Levitin HW, Sieglson HJ. Hazardous materials. Disaster medical planning and response. Emerg Med Clin North Am. 1996;14:327348. 25. Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness. I: The emergency department and hospital. Emerg Med Clin North Am. 2002;20:437-455. 26. Ridge T. The critical role of hospitals involved in national bioterrorism preparedness. J Healthc Prot Manage. 2002;18:39-48. 27. Landesman LY, Markowitz SB, Rosenberg SN. Hospital preparedness for chemical accidents: the effect of environmental legislation on healthcare services. Prehosp Disaster Med. 1994; 9:154-159. 28. Keim ME, Pesik N, Twum-danso NA. Lack of hospital preparedness for chemical terrorism in a major US city: 19962000. Prehosp Disaster Med. 2003;18:193-199. 29. Barrett J, Bondaruk J. MedTeams Performance Evaluation Course Guide TDR/BARS. Andover, MA: Dynamics Research Corporation; 2004. 30. Jasper E, Sweeney B, Williams E, et al. Value of an unannounced drill in preparing hospitals for a terrorism attack or other mass casualty event [abstract]. Acad Emerg Med. 2004;11:562. Annals of Emergency Medicine 201 APPENDIX E1. Hospital disaster preparedness survey with point values. 201.e1 Annals of Emergency Medicine Volume , .  : September  Volume , .  : September  Annals of Emergency Medicine 201.e2 201.e3 Annals of Emergency Medicine Volume , .  : September  Volume , .  : September  Annals of Emergency Medicine 201.e4 201.e5 Annals of Emergency Medicine Volume , .  : September  Volume , .  : September  Annals of Emergency Medicine 201.e6 201.e7 Annals of Emergency Medicine Volume , .  : September  49. How many negative pressure isolation beds do you have at your hospital? a. None - 0 b. 1-10 - 1 c. 10-20 - 2 d. >20 - 3 e. Don’t know- . f. Missing - . 50. How would you rate your hospital laboratory’s ability to identify specimens of bioterrorism? NO SCORE a. very poor b. poor c. fair d. good e. very good f. don’t know/missing 51. How would you rate your hospital’s ability to manage victims of bioterrorism? NO SCORE a. very poor b. poor c. fair d. good e. very good f. don’t know/missing 52. How would you rate your hospital’s ability to manage victims of disasters, in general? NO SCORE a. very poor b. poor c. fair d. good e. very good f. don’t know/missing 53. What is your average daily in-patient census? NO SCORE a. less than 50 b. between 50-200 c. between 200-400 d. between 400-600 e. greater than 600 f. don’t know/missing 54. How many employees does your hospital have? NO SCORE a. less than 200 b. between 200-500 c. between 500-2000 d. greater than 2000 e. don’t know/missing Volume , .  : September  Annals of Emergency Medicine 201.e8 201.e9 Annals of Emergency Medicine Volume , .  : September  Volume , .  : September  Annals of Emergency Medicine 201.e10 201.e11 Annals of Emergency Medicine Volume , .  : September  Volume , .  : September  Annals of Emergency Medicine 201.e12
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