Our Healthcare Preparedness columnist picks the brains of three highly experienced hospital emergency managers about the whens, whys, hows and how-not-tos of healthcare disaster exercises.

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• Charlotte S. Clark, A.S., CHSP, CHEC-III is the emergency manager, Regional Coordinating Hospital - Region D, Grady Memorial Hospital, Atlanta.
• Rick Davis is the manager for environmental health and safety at Kaiser Permanente Riverside Medical Center, Riverside, Calif.
• Bonnie Kaido, MS, is the director of emergency preparedness for Bassett Healthcare, Cooperstown, N.Y.

Do you use live or simulated victims?

Davis: It depends. Typically, you have to move patients at least once a year in a drill to meet regulatory standards. In our countywide drill, we’ll move patients. This gives us more lifelike scenarios. In those, we dress victims up, give them victim cards, etc.

Charlotte S. Clark, A.S., CHSP, CHEC-III

Kaido: It depends on the exercise. We recently purchased inflatable disaster mannequins, as it is often difficult to obtain live victims. Our emergency management software generates the victim tags and injuries for us with a couple of keystrokes.

Clark: Grady is a Level 1 trauma center, and we see large amounts of patients in our emergency room at any hour of the day. Because of this, we don’t use live patients. We use simulated patients "on paper." We have far too much going on in the ER, and live patients would simply clog it up. Role-playing is performed using pieces of paper and victim cards.

How do you select objectives?

Davis: This comes from the after-action plans from previous exercises and drills.

Bonnie Kaido, MS

Kaido: We are in a state of continuous improvement and are always looking for ways to test our learning and our ability to translate that learning into real changes in our plans and policies.

Clark: We build upon problems identified from previous exercises. The Joint Commission requires us to identify and fix things. Objectives have to incorporate things that happened in a prior exercise. We did this, for example, with the recent Bluffton University bus accident. [This was a mass-casualty accident that occurred during the early morning hours of March 2, 2007, on I-75 in Atlanta.] You need to show after-action reports.

How are the objectives linked to the master sequence of events list?

Davis: You write your master sequence of events on a timeline to include what you want to happen. If your hospital generators aren’t working right, for example, you have to give staff time to fix them. So your decision-makers have to do planning in between on how to message and communicate how to fix things, what engineers need to get involved, etc.

Kaido: We determine what we want to test and then build the scenario around them. The scenario needs to be “real” enough to engage the participants, but not to the point where normal operations are challenged, unless that is one of the objectives.

Clark: Injects and objectives are part of the master sequence of events list. The inject is a role-playing tool or script. Objectives call for us to write the injects. The objectives dictate how we write the scripts.

How do you use the exercise to meet your Joint Commission standards?

Davis: Our drills are all documented for review by the Joint Commission. Our evaluators are looking for activities that include standards from the Joint Commission. We have forms to assist with this process to ensure compliance is reached.

Kaido: Our observers/evaluators monitor each of the areas that the Joint Commission requires, and our post-exercise plans include the identification of deficiencies and opportunities for improvement. We then modify our plans based upon our experience.

Clark: The standard requires exercises twice a year. One must be with a community partner, which can be a tabletop exercise. Both don’t need to be separated by any length of time.

How have the exercise competencies compared to real incidents?

Davis: We actually perform better during real incidents because in exercises, everyone knows what’s coming ahead of time. All of our departments rally and come together well during live events. Exercises give people an outline of how to perform in a real-life scenario.

Kaido: We have tested our response to a severe weather emergency only to have a blizzard appear within days of the exercise. The same has been true in other scenarios. We tested our multi-casualty incident response and within hours had a real one. Staff thought we were engaged in another drill.

(WakeMed Health & Hospitals, Raleigh, N.C.)

Clark: We have so many. A few times we’ve had very small exercises only involving the ER. The exercises have showed us how to improve our response in real emergencies.

Should there be a standardized approach to writing and deploying exercises?

Davis: Yes. It would make it easier for everyone. But this is where Web-based emergency management programs can help.

Kaido: We have found that most hospitals are not used to the HSEEP program and that becoming proficient takes time, effort and follow-up. We sent our trauma nurse coordinator to Master Exercise Practitioner <www.training.fema.gov/emiweb/cec> training so that we would have an in-house expert to help guide our progress.  Many hospitals will not have the luxury of doing this.

Clark: There is a standardized approach already, and that’s the HSEEP protocols. All of the county and state agencies are required to follow it, and now most of the hospitals have also adopted it.

Can you describe an actual event and how exercises have improved your response competencies?

Davis: About six months ago, the City of Riverside lost complete power to the city. All the signals went out, traffic snarled, and some communication systems outside of the hospital went down. Our backup generators allowed normal operations within the hospital. But in our clinics, where we have minimal power, we had minimally operational elevators, and little or no lighting.

Our challenge was how to notify patients who had appointments that day. Having been through a drill that simulated losing power gave us good insights. For example, we immediately started monitoring the elevators we did have and routing people where they needed to go.

Kaido: Our experience in the Northeast is with severe winter weather. Our exercises and real events have allowed us to change our approach to winter weather emergencies and to encourage staff to prepare at home so that they can report to work. With 28 health centers, we also have needed to develop plans for each of them so that we can transfer staff from an affected center to one that is less so. We also have developed plans for contacting patients and making determinations as to whether they will make appointments, offering them an immediate opportunity to reschedule within a few days. Safety of staff, patients and visitors is our priority.

Clark: The Bluffton University bus accident is a good example. The biggest lesson we learned was we needed a better tracking system for incoming patients. Two months after the accident, we staged an exercise that improved our competencies in many areas. In the actual bus incident, we had 17 injured patients coming in, and we knew nothing about many of them, because they were wearing sweats at the time and weren’t carrying any identification. The accident taught us we needed to have a system in place to track the movement of anonymous patients once they arrived in the hospital.

Our previous methods of identifying victims required too much information and were causing confusion. So we streamlined the process by simplifying our disaster packs and developing all the paperwork needed for admissions that had patient record numbers on them. In the exercise following the accident, we had dummy patients come through, and we made sure that hospital staff knew what they were supposed to do ahead of time once the patient came through the door.

The author's closing comments
Thanks to all of our contributing experts for their responses. In all cases, the need to develop a long-term exercise program that builds on competencies and improve the overall hospital emergency management program is clear. Each contributor identified improvement during actual events, reducing injuries and increasing their ability to maintain services during any hazard. It is comforting to know there are dedicated experts such as Rick, Bonnie and Charlotte who are working hard to ensure our care and safety when needed most.

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