Hospital Disaster Drill

[Chieko Boteler]

TheCalifornia Statewide Medical and Health Exercise Program (SMHE), utilizing HSEEP and aligning with PHEP and HPP grant requirements, offers customizable exercise templates for jurisdictions, organizations, and facilities.

Updated annually, the program provide objectives, scenarios, and focus regions for participation in the yearly exercise. Facilitated by CDPHi and the California Emergency Medical Service Authority, SWMHE aligns with state-level engagement and grant requirements, though local jurisdictions have the option to conduct their own exercises.

ShakeOut is an annual earthquake drill and preparedness activity that promotes earthquake preparedness and safety. Originating in Southern California in 2008, ShakeOut has since expanded to other regions and countries around the world.

ShakeOut drills are designed to raise awareness about earthquake risks and encourage individuals, organizations, and communities to take proactive measures to reduce their vulnerability to earthquakes and their potential impact.

The Homeland Security Exercise and Evaluation Program (HSEEP) is a capabilities and performance-based exercise program that provides a standardized methodology and terminology for exercise design, development, conduct, evaluation, and improvement planning.

The Homeland Security Exercise and Evaluation Program (HSEEP) constitutes a national standard for all exercises. Through exercises, the National Exercise Program supports organizations to achieve objective assessments of their capabilities so that strengths and areas for improvement are identified, corrected, and shared as appropriate prior to a real incident. To learn more about the HSEEP program, click on the About HSEEP tab above.

There are 7 types of exercises. Exercises are either discussion based, or operations-based. Discussions-based exercises familiarize participants with current plans, policies, agreements and procedures, or may be used to develop new plans, policies, agreements, and procedures. Discussion-based Exercises include the following:

Operations-based Exercises validate plans, policies, agreements and procedures, clarify roles and responsibilities, and identify resource gaps in an operational environment.Operations-based exercises include the following:

Hospitals must be prepared to respond to public health emergencies that may create a sudden demand on services. Disaster drills allow hospitals to test response capabilities to these emergencies in real time.

AHRQ has developed this Tool for Evaluating Core Elements of Hospital Drills. This tool can be used by hospitals to identify the most important strengths and weaknesses in disaster drills. The results can be applied to training and drill planning.

Consistent with the blanket waiver request submitted by the American Hospital Association (AHA), the Federal Communication Commission has adopted an order which permits the use of HAM radios during hospital disaster drills. The Commission determined that amateur radio operators play a critical role during disasters and that amateur radio operators should be permitted to participate in disaster drills regardless of whether they are employed by the entity conducting the drill.

Hospital disaster preparedness has therefore taken on increased importance at local, State, and federal levels. Hospitals themselves are taking renewed interest in disaster preparedness, reexamining their disaster plans, and conducting disaster exercises. Preparing for MCIs is a daunting task, as unique issues must be considered with each type of event. For example, the systemic stress of a biothreat is entirely different from that of a chemical disaster or any other acute onset disaster. These differences hold challenging implications for preparedness training.

The current evidence report updates the evidence report Training of Clinicians for Public Health Events Relevant to Bioterrorism Preparedness2 and focuses specifically on the effectiveness of hospital disaster drills, computer simulations, and tabletop or other exercises in training hospital staff to respond to an MCI. The following key questions were addressed:

Paired investigators reviewed the abstracts of citations located by the search to identify pertinent articles. Exclusion criteria were: not written in English; no human data; no original data; meeting abstract (no full article for review); did not include hospital staff; did not include response to an MCI or a disaster; did not include training or education; no evaluation of the training; or did not apply to any of the key questions.

Paired reviewers evaluated study quality in terms of the representativeness of the targeted hospital staff, potential bias and confounding, description of the intervention, assessment of outcomes, and analysis. The reviewers then extracted information on the studies (e.g., geographic location, MCI type, training intervention, hospital staff targeted, other entities involved, objectives, evaluation methods, and results).

The reviewed studies represented a heterogeneous body of literature. They ranged from descriptions of local drills, including transportation incidents, fires, and radiological exposures, to sophisticated telecommunication exercises, such as a large regional drill involving multiple agencies.22

Studies also varied in terms of targeted staff, learning objectives, identified outcomes, and evaluation methods. Because of the wide range of foci for the studies, it was difficult to draw definitive conclusions about the most effective approaches for training hospital staff to respond to an MCI. However, some potentially valuable points could be identified in the literature:

Due to the heterogeneity of the evaluation methods and the lack of data on their validity and reproducibility, the evidence was insufficient to support any firm conclusions about the usefulness of reported evaluation methods.

Hospital disaster drills, computer simulations, and tabletop and other exercises are designed to test the hospital's disaster plan and to allow employees to become familiar with disaster procedures. Based on the review of the literature, discussion with experts, and analysis of disaster response plans,24 the EPC team identified several important aspects of hospital disaster response that may be useful to evaluate. Most of the lessons learned relate to one or more of the following aspects of disaster response:

Enough studies were available to suggest that hospital disaster drills can help to identify problems with incident command, communications, triage, patient flow, security, and other issues. Evidence also indicated that computer simulations and tabletop and other exercises may help to train key decisionmakers in disaster response. The studies demonstrated that different types of training exercises may have different roles to play in educating hospital staff in disaster response. However, the evidence was insufficient to support firm conclusions about the effectiveness of specific training methods because of the marked heterogeneity of studies, weaknesses in study design, and the limited number of exercises that have been reported in the literature. Future disaster preparedness efforts would benefit from increased reporting of hospitals' experiences in disaster response training.

A toolkit was developed to support health care facilities and health departments conduct similar drills to identify areas for improvement and enhance readiness at a critical point of entry into the health care system. This toolkit could be useful for other jurisdictions.

Exercises were designed in accordance with the U.S. Department of Homeland Security Exercise and Evaluation Program (1). Scenarios were developed in collaboration with a stakeholder advisory group and consisted of a person simulating a patient entering the ED and reporting recent fever and either 1) respiratory symptoms and recent travel to the Middle East (i.e., possible MERS) or 2) a rash after traveling to Europe (i.e., possible measles). A red maculopapular measles-like rash was simulated on the neck or upper extremities of the person in the role of the measles patient using a commercially available moulage kit (Figure 1). Based on previously provided ED guidance (2), the expectation was that once the patient was identified as being at high risk for having a communicable disease with a potential for respiratory transmission, he or she would be asked to don a mask and would be placed into an airborne infection isolation room.

EDs and their associated waiting areas have been shown to facilitate the transmission of infections, such as measles and severe acute respiratory syndrome, to patients and health care workers, leading to spread within hospitals and surrounding communities (3,4). This mystery patient drill program provided an opportunity to examine real-world implementation of infectious disease-related screening and isolation of potentially high-risk patients in EDs across New York City. It also provided a reasonable baseline for expectations of ED staff member practices regarding control of highly infectious diseases at this entry point to the hospital system. Based on these findings, performance goals of 1 minute from entry to masking and 10 minutes from entry to isolation will be adopted for evaluating similar drills in the future. In addition, the overall median time from entry to isolation achieved in this study (8.5 minutes) is comparable to times achieved in an earlier Ebola drill analysis (9 minutes) (5).

Although the majority of drills were completed successfully by masking and isolating the patient, approximately 40% of hospitals failed at least one drill, and there was considerable variation in the length of time each hospital took to perform these steps. It is possible that measles cases were recognized to be an infectious risk more quickly, as the rash was a clearer objective finding. However, the higher percentage of mask provision and patient isolation in MERS scenarios suggests that a history of travel to the Middle East might be more recognizable as a high-risk exposure than history of travel to Germany in the measles scenario; it was noted on multiple drill reports that staff members were unsure if travel to Europe constituted a risk. The finding that masking and isolation occurred significantly more frequently in situations where a travel history had been elicited suggests that routinely inquiring about recent travel could prevent exposures to infectious patients at critical entry points to the health care system.

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