After Action Report / Improvement Plan

Transcription

1 After Action Report Improvement Plan April 18, 2013 Consolidated 1 Page

2 ADMINISTRATIVE HANDLING INSTRUCTIONS 1. The title of this document is The "Harmful Haze - A Healthcare Coalition Exercise" After Action Report. 2. The information gathered in this AAR/IP is classified as For Official Use Only (FOUO) and should be handled as sensitive information not to be disclosed. This document should be safeguarded, handled, transmitted, and stored in accordance with appropriate security directives. 3. At a minimum, the attached materials will be disseminated only on a need-to-know basis and when unattended, will be stored in a locked container or area offering sufficient protection against theft, compromise, inadvertent access, and unauthorized disclosure. Points of Contact: Hospital: Tami Wood Hays Medical Center (Office) ( ) tami.wood@haysmed.com Exercise Director: Chris Floyd Disaster Resistant Communities Group LLC (Office) ( ) chrisfloyd@drc-group.com 2 Page

3 CONTENTS ADMINISTRATIVE HANDLING INSTRUCTIONS... 2 CONTENTS... 3 EXECUTIVE SUMMARY... 4 SECTION 1: EXERCISE OVERVIEW... 5 Exercise Details... 5 Participant Information... 5 SECTION 2: EXERCISE DESIGN SUMMARY... 7 Exercise Purpose and Design... 7 Exercise Objectives, Capabilities and Activities... 7 Scenario Summary... 8 SECTION 3: ANALYSIS OF CAPABILITIES... 9 SECTION 4: CONCLUSION APPENDIX A: IMPROVEMENT PLAN APPENDIX B: PARTICIPANT FEEDBACK (3 THUMBS UP 3 THUMBS DOWN).. 55 APPENDIX C: ACRONYMS Page

4 EXECUTIVE SUMMARY Harmful Haze - A Healthcare Coalition Exercise was designed and facilitated to assess hospital capabilities in regards to responding to a hazardous materials incident resulting in the evacuation of the Emergency Department along with the coordination and collaboration with the various emergency response agencies. The purpose of this report is to analyze exercise results, identify strengths to be maintained and built upon, identify potential areas for further improvement, and support development of corrective actions. Incorporated in Section 3: Analysis of Capabilities of this After Action Report is a comprehensive listing of each Target Capability with its associated Major Strengths, Primary Areas for Improvement and Improvement 4 Page

5 Exercise Details SECTION 1: EXERCISE OVERVIEW Exercise Name: Type of Exercise: Harmful Haze - A Healthcare Coalition Exercise Tabletop Exercise Start Date: April 18, 2013 Duration: Location: Sponsor: Three Hours Hospital throughout Northwest Kansas Northwest Kansas Regional Healthcare Coalition Program: To assist hospitals to assess their plans and procedures regarding a hazardous materials incident. Purpose: The purpose of the exercise was to test hospital evacuation plans, coordination and agreements with outside agencies. Mission: To provide exercise participants from various agencies the opportunity to work together as a unified team in support of a hospital s response to a hazardous materials incident. Scenario Type: Hazardous Materials Incident Participant Information Participant Location Decatur County Hospital Goodland Regional Medical Center Gove County Hospital Graham County Hospital Grisell Memorial Hospital Hays Medical Center Logan County Hospital 5 Page

6 Ness County Hospital Norton County Hospital Phillips County Health Systems Rawlins County Health Center Rooks County Health Center Rush County Memorial Hospital Russell Regional Hospital Sheridan County Health Complex Number of Participants Page

7 SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design The purpose of the exercise was to assess hospital capabilities in regards to responding to a hazardous materials incident resulting in the evacuation of the Emergency Department along with the coordination and collaboration with the various emergency response agencies. Exercise Objectives, Capabilities and Activities Capabilities-based planning allows for the exercise planning team to develop exercise objectives and observe exercise outcomes through a framework of specific action items that were derived from the Target Capabilities List (TCL). The capabilities listed below form the foundation for the organization of all objectives and observations in this exercise. Additionally, each capability is linked to several corresponding activities and tasks to provide additional detail. Based upon the identified exercise objectives below, the exercise planning team decided to demonstrate the following capabilities during this exercise: Communications Activity Target Capability # 1 Initial Incident Communication # 2 Hospital Command Center Activation and Management # 3 Notification and Coordination with Outside Partners # 4 Return to Normal Operations Evacuation and Shelter-In-Place Activity Target Capability # 1 Evacuate Patients in Affected Area of Facility # 2 Continue Patient Care HazMat Response and Decontamination Activity Target Capability # 1 Limiting Access to Hospital # 2 Decontamination 7 Page

8 Scenario Summary It is a warm spring day in April with low humidity and mild breeze out of the west. At 4:30PM a tanker tractor-trailer carrying hazardous materials is cut off by a mini-van driven by a distracted teenager, who was carrying his three younger siblings. The tractor-trailer hit the mini-van and swerved into a ditch, tipping on its side and spilling its contents. 8 Page

9 SECTION 3: ANALYSIS OF CAPABILITIES Communications Performance [OVERALL] Target Capability Activity # 1: Initial Incident Communication Associated Critical Tasks Task # 1.1: Have understanding of response agency notifications. Goodland Regional Medical Center Participants knowledgeable of subject. Logan County Hospital All players recognized availability and use of redundant forms of communication. More players from different entities would help to clarify what systems they have in place. Norton County Hospital New nurses learned the county emergency manager, learned to notify administration for large events. Such as administrator, safety officer. Need to train more nurses. Hays Medical Center Good pre-event monitoring systems in place thru monitoring 800MHz radios in both the Emergency Department and the Security Department. Both areas are able to monitor when EMS, Fire and Law enforcement are dispatched to an event. Not clear how information gets passed on to other areas of the hospital or hospital leadership or how / when EMS notifies ED of patient transports or if they notify ED if no patient transports are required Establish written notification protocols between EMS and the 9 Page

10 Emergency Department regarding Hazardous Materials Events and Mass Casualty events so that preparation time is increased. Weak Rooks County Health Center The participants did a good job knowing what agencies needed to respond and did so in a timely manner. The team needs to improve on who will be in charge of contacted the agencies and relaying information. Phillips County Health System After discussion with other partners were able to identify what agencies needed notified Will schedule time in staff meetings to have discussions with staff to make them more familiar with the inter relationship of agencies and how to notify them. Russell Regional Hospital The participants did extremely well in determining which agencies would need to be involved and notified and discussed various methods of notification such as call down lists, ADT notification system, EMSystems, radio and cell phone use. Complete the emergency Response Plan update and include a listing of radio frequencies and phone contacts. Decatur County Hospital Rawlins County Health Center Discussion held regarding agencies notified by dispatch, EMS, law enforcement, Emergency Management, Health Department; how many patients, what kind of chemical, staffing issues. 10 Page

11 Know the roles and limitations of outside agencies. Obtain agreement with dispatch (or PD, EMS, Sheriff, FD, ect.) to notify hospital as soon as it appears they have someone who will require treatment or may exceed hospital capabilities. Ness County Hospital Everyone was aware of flip index that contain agency contact information. Keep flip indexes updated. Any uncertainties were clarified. Graham County Hospital Upon initial 911 call the Graham County Sheriff Department, Graham County EMS, Graham County Fire Department and Graham County Hospital were notified. Sheridan County Health Complex Hospital was aware of the different ways to communicate with all emergency response agencies. More staff needs to learn the different methods to communicate with emergency responders and area hospitals. Policies are being written and they know the means of communication with emergency responders. There were some agencies however that were not considered necessary to contact, for example public health. It was discussed further of what their role would be in the aftermath of the event. In addition the use of the EOC was referenced several times and utilizing a Joint Information Center. Consider having area agencies contact information easily accessible and recognizable to staff. 11 Page

12 Gove County Hospital It is understood which agencies would be involved (LE, EMS, Fire, City, Hospital) although there is not a formal written agreement as such. Group unsure why Health Department would be involved because "it is not an infectious disease." Infuse into EOP policies / procedures importance of working with area agencies in Emergency Response. Stress importance of working with Incident Commander on scene of incident. Task # 1.2: Communications between the field and the hospital. Goodland Regional Medical Center Logan County Hospital There were two players from EMS and they verbalized communications. Common knowledge dictates that since communications systems seem to be fairly uniform in the county the hospital will be able to at the least hear communications from the scene. Not enough outside players were involved to judge how communications would occur. Norton County Hospital EMS and nursing will communicate by phone and 800MHz for follow up. Hays Medical Center Pretty good communication channels from Emergency Department and Ellis County EMS. Need improvement between other EMS agencies and Hays Medical Center. Establish written protocols between EMS and the Emergency 12 Page

13 Department regarding Hazardous Materials and Mass Casualty events so that preparation time is increased. Weak Rooks County Health Center The team needed to have better communication with the field; there was no information relayed from the field to the hospital. The hospital was relying solely on information from dispatch regarding the accident. Have someone in charge of giving a report to the hospital that is in the field. Phillips County Health System Russell Regional Hospital Discussed the various methods of communications that would be used. Complete the Emergency Response Plan update and include a listing of radio frequencies and phone contacts Decatur County Hospital Rawlins County Health Center Discussion of how hospital would be notified, directly or indirectly by overhearing EMS being dispatched. Non-Existent of outside agencies have identified the need to notify hospital of hazardous incident resulting in patients. As independent agencies, practice communication between EMS, PD, FD or SO and the hospital when a routine call results in patients being transported to hospital. 13 Page

14 Ness County Hospital New 800MHz radio system has been installed and the hospital is still learning. Weak Discuss at LEPC that issues with 800MHz radio system knowledge could hinder communications between entities. Law enforcement did not seem to understand the importance of quick notification to the hospital. Not a priority for them. Timely notification is essential in this type of situation due to staffing needs and decon set-up time. Graham County Hospital Upon receiving the initial 911 call the dispatcher asks for the tanker placard number so the chemical can be identified. When this information is received it will be shared with the hospital so they can begin preparations for treatment of the victims. The first responders will also notify the hospital of number of victims and the extent of their injuries. Be as timely with this information as possible. Sheridan County Health Complex Stated that the communication between responders and hospital was by cell phone mainly. All agencies need to be educated better on how to communicate with the VHF and 800MHz radios. Understand that cell phone service may not work all the time. They have a scanner that dispatch utilizes to notify them on what is occurring. EMS also has cell phones that they can utilize. The pathways are in place however in our community there are several different radio systems. With the three different systems continuity of communication is a problem. Nurses noted that they may hear some of the radio traffic but other traffic they cannot hear and that information could help 14 Page

15 them in planning for their next steps. Weak Recommend that the community continue to do community exercises together and target communications as specific exercise possibly within the LEPC. Gove County Hospital It is "understood" that the hospital will be contacted when EMS is out on a patient call; similar to all patient runs. The hospital will receive a patient report when EMS is in route. Hospital can also monitor radio traffic. Hospital gets formal incoming phone call with patient report when the patient "is two minutes out." No policy / procedure for law enforcement to notify hospital when they are on scene of possible patient / incident. There was conversation that the hospital would not be an initial point of contact from the scene about possible contamination / mass casualty. Continued discussion between all capabilities identified need for better notification to establish readiness. Promote open communication lines between all capabilities. Establish contact points for all capabilities to eliminate confusion. For example, designate points of contact for Hospital, EMS, Fire, Health Department, Law Enforcement, etc. These points of contact should be published for all capabilities to refer to and updated judiciously. Performance Target Capability [OVERALL] Activity # 2: Hospital Command Center Activation and Management Associated Critical Tasks Task # 2.1: Established protocols for activating the Hospital Command Center. Weak Goodland Regional Medical Center Need additional planning and training. Logan County Hospital 15 Page

16 ICS was activated immediately. Norton County Hospital Reviewed the HICS policy and went through the steps. More nurses need to be trained in IC. Supervisors also need to be trained in IC. Hays Medical Center Protocols are established. Security Department aware of procedures, however there is weakness in other departments regarding Command Center operations. Provide additional ICS training opportunities for Hays Medical Center associates, and include more associates in exercise training. Rooks County Health Center An incident commander was in place, but policies and procedures need to be updated. Update policies and procedures and review them throughout the year. Phillips County Health System Russell Regional Hospital This was discussed and an ICS type flow chart described. Assure that this is included in the update of the Response Plan and identify positions and backup positions. Would suggest that they are referred to as positions and not get too wrapped up about names for each position, but ICS positions should be identified by hospital positions and their backup and not necessarily name as some people might be gone when this happens. Decatur County Hospital 16 Page

17 Rawlins County Health Center Charge nurse notifies Director of Nursing who determines need for incident command. HIC and IC clear, it is clear when to notify IC, and IC then made the decision how much response was needed and how much staff to bring in. Re-evaluate the HICS assigned positions. Non-essential staff could be utilized for non-nursing roles such as decon. Ness County Hospital All staff aware of command chain. Continual training to all staff. Roles are understood, the hospital will use HICS to navigate the incident Graham County Hospital The HCC will be established when there is a possibility of more than four victims being brought to hospital. The calling tree will be initiated to increase staffing. Weak Increase staff awareness of need for HCC Sheridan County Health Complex Very little understanding of what the HCC was. Unsure of what roles would be part of the HCC. Review the ICS with employees. Recommend doing small exercises in county to get better 17 Page

18 understanding of the roles played in ICS. Weak When they need to contact staff they have a good system in place with their ADT alert system. The HICS system which they are beginning to use more is a great resource for managing and tracking staff. They knew that they needed to call the administrator on call however on what type of triggers was not clear. A more formalized plan with trigger points needs to be put in place. Gove County Hospital HICS was activated after Code Orange had been activated, hospital was in lock down, the hazardous chemicals were identified, and six patients were on route to the facility. HICS activated too late in the incident. Operational HICS was not a thought until prompted by scenario questions. Write into EOP trigger points for HICS activation. HICS activation procedure should streamline for all events. Empower employees in IC positions to recognize trigger points and activate HICS. Task # 2.2: Hospital Command Center is adequately staffed. Goodland Regional Medical Center Weak Logan County Hospital There is simply not enough staff to fill all positions. In this size of an incident they seemed to manage well but some personnel did have to where multiple titles. Norton County Hospital Went through the different jobs and who could be assigned and 18 Page

19 why. Need to drill on this. Hays Medical Center Staffing is adequate, however not enough associates are familiar with Command Structure to determine if Command Center is staffed appropriately for every event. Provide additional ICS training opportunities for Hays Medical Center associates, and include more associates in exercise training. Rooks County Health Center The team called in additional staff to aid at the hospital's ER and with the decontamination unit. Phillips County Health System Russell Regional Hospital Fairly well thought out. Considered what other agencies might need to be involved. Make sure the plan shows backup positions to cover when some are gone or if the incident goes past one operational period to allow for shifts to maintain the continued operations. Decatur County Hospital Rawlins County Health Center Hospital staff notified through the Emergency Preparedness Phone Out System. Update Emergency Preparedness Phone Out System with current employees. 19 Page

20 Most of HICS team was present and knew their roles without fighting the scenario. Need to have attendance of safety and security or have them send a replacement. Ness County Hospital Licensed staff would be needed to treat patients. Weak Make sure non-licensed staff is trained to assume command positions. Recognition that some of the command positions are also personnel needed on floor. Think through the personnel and the roles. Graham County Hospital The Incident Commander will be the RN in charge until arrival of the administrator or the DON if they are not initially available. A Logistics Manager, Liaison Officer and PIO were all designated. Weak Increase staff awareness of duties of HCC Sheridan County Health Complex Smaller hospital, many staff played several different rolls. Train appropriate staff to the different positions of the HCC. Explain that not all positions have to be filled for every situation. They have staff with the appropriate ICS courses and level within the hospital identified for the positions and has enough to staff them. Weak A better understanding of ICS needs to occur. Utilizing the HICS system more often will assist in this. Gove County Hospital 20 Page

21 Identified that due to staffing the ICC will normally function as a "skeleton crew." Recognized that is how it would function in an event and that is how it should be drilled. Group identified need for IC and IC requested a scribe. Recognized need for PIO late in the drill. HICS IC and PIO would be the same person for this event. Questioned late in the drill if Security Officer needed but individual was not assigned. Group did acknowledge the person recognizing the event (nurse) would be IC until relieved by assigned HICS staff. Group did not recognize that medical staff would be concentrated on medical care and could not fully function as IC staff for a great length of time. Group discussion identified no need to designate Safety Officer. Group did not discuss need for Hazmat Branch officer for this Hazmat incident. Drill and practice Incident Command activation and staffing with available positions with staff. Recognize partial goal of IC is to relieve and support hospital functions during an emergency. Position of Safety Officer should always be designated in an event. This position ensures someone is watching out for the safety of staff at all times. The Safety Officer can stop operations at any time if safety of staff is compromised. For any HazMat incident, a HazMat Branch Officer will oversee decon procedures and communicate workings of the HazMat team to IC. Staff needs refreshed on HICS positions and duties. Task # 2.3: Hospital Command Center is able to receive requests for resources / information and dispatch accordingly. Goodland Regional Medical Center Logan County Hospital 21 Page

22 Norton County Hospital The safety officer and DON know who to contact to request these needs. More administration needs to learn these steps. Hays Medical Center Command Center staff aware of who to contact for requests / resources, but not all Command Center staff aware of processes for requests or notifications. Additional exercises to allow Command Staff opportunity to practice procedures. Rooks County Health Center The hospital was able to receive requests and hear what dispatch was reporting over the radio, however, there was not a designated person in charge of receiving these requests or relaying information. Weak Have a designated person. Phillips County Health System Staff unsure of how this process is to occur. Continue to have discussions with staff regarding how to obtain resources during an incident. Staff familiar with normal resource requests but unsure how to adapt to emergency response. Russell Regional Hospital Talked of methods to request different types of resources. Local Mutual Aid, State assets and federal assets. The response plan was not referred to as it is incomplete. Need to finish the plan and make sure all partners are involved in the planning process and or at least review what their agencies (other partners) roles and responsibilities are in the updated plan. Decatur County Hospital 22 Page

23 Rawlins County Health Center Hospital has agreements with other agencies for needed resources. Central Dispatch handles EMS, FD, PD and SO and is also expected to receive and send communication to hospital. Have representative from dispatch who may be able to offer suggestions to facilitate communication between agencies without taxing their position. Ness County Hospital Graham County Hospital Additional sources of extra supplies were identified as the hospital disaster trailer, Northwest Kansas Disaster Trailer located at EMS, and the Graham County Health Department. Non-Existent Increase staff awareness of these resources. Sheridan County Health Complex The utilization of the emergency operations center during this event was discussed and how the liaison officer and the utilization of the HICS system would play into the event. 23 Page

24 Therefore the liaison could act as a means to request resources or information. The structure was discussed, several staff where not real familiar the way that it would occur in our community. Key stakeholders such as EMS, Fire, Emergency Management and Public Health offered their input as to how they would play a role in the event. Non-Existent Make sure that decision makers are aware of the process. Gove County Hospital HICS was not fully developed to witness exchange of information with scene IC or internally. Practice and drill use of HICS. Task # 2.4: Significant events or developments are communicated to the HCC in a timely fashion. Goodland Regional Medical Center Logan County Hospital Very small hospital so communication is done with relative ease. Norton County Hospital The hospital has adequate amount of portable radios. Hays Medical Center Information communicated, however not all staff were aware of HICS hierarchy and how to make communications. Provide additional ICS training opportunities for Hays Medical Center associates, and include more associates in exercise training. 24 Page

25 Rooks County Health Center The team did a good job of utilizing the information they received from the field, new developments within the hospital, and actions from the public and notified the HCC quickly. Weak Have someone in charge of reporting information, do not rely on just listening to dispatch. Phillips County Health System Since seldom use the HCC in normal emergency responses staff unsure how to handle messages and needs during an emergency that stretches normal responses. Continue to practice the HCC and discuss its functions during meetings and continue to provide educational opportunities to all staff. Russell Regional Hospital Good discussion and identification of who needs to know what. Decatur County Hospital Rawlins County Health Center Good communication within the hospital. Identify need for tracking patients, influx of patients. Ness County Hospital 25 Page

26 Weak Graham County Hospital First responders will notify when HazMat teams are available and will be transporting victims. Discussion was held regarding additional ambulances from surrounding counties to transport victims which would not be contaminated at the scene. Establish agreements with surrounding counties for availability of ambulances. Sheridan County Health Complex Non-Existent Many in the room were aware of the chain of command and utilizing the EOC as a central hub, however there was still some un-clarity on how the HCC would function. This simply is because of unfamiliarity with the system. It was stated that they utilize ICS in the hospital all the time it is just not formal and in the same format. Therefore, they just need to be able to frame it in structure of the HICS system and continue to practice. Therefore, they just need to be able to frame it in structure of the HICS system and continue to practice. Gove County Hospital HICS was not fully developed to witness communication with scene IC or internally. Practice and drill use of HICS. Performance Target Capability [OVERALL] Activity # 3: Notification and Coordination with Outside Partners 26 Page

27 Associated Critical Tasks Task # 3.1: Maintain communications with outside partner agencies. Weak Goodland Regional Medical Center Communicating with EOC is very important. Some thought of communicating with dispatch instead of EOC. Unsure Logan County Hospital Typically in real scenarios communications occurs however only EMS and Health Department were represented in this exercise. Communication training exercises with outside partners would be beneficial. Norton County Hospital Liaison officer was assigned and worked with outside agencies. Training with Liaison officer needs to be done. Hays Medical Center Good Communication links between EMS and Emergency Department Staff, Good communication links between Law enforcement and Security, good communication links between command center and emergency management. Additional exercises to allow Command Staff opportunity to practice procedures. Rooks County Health Center The team used EMResource, contacted and informed mutual aid of any changes, and used the ADT alert system well. Weak Phillips County Health System Staff unsure how this is handled during emergencies and functions of PIO, Liaison and other agencies 27 Page

28 Provide opportunities to discuss these positions and the whole HCC process so allow staff to become more familiar with everyone's responsibilities and roles Russell Regional Hospital Again, talked about various methods of getting information out. Finish the plan and identify the contact info. Decatur County Hospital Rawlins County Health Center Team aware of methods to communicate with other agencies. Weak Observed lack of accessing policy and procedures manual for review of written procedures Poor communication between hospital and outside agencies. Establish mutual protocols for communicating expected hospital needs between outside agencies. Ness County Hospital Everyone was aware that outside agencies need to be kept up to date. Weak Agencies appeared to be focused only on their own issues. Graham County Hospital Graham County Sheriff Office will request support from Kansas Highway Patrol. Northwest Kansas Regional Emergency Management will be contacted for resources. 28 Page

29 Graham County Health Department will be contacted for more resources. Weak Increase awareness of availability of these resources Sheridan County Health Complex Weak Weak Understanding the trigger points for when other agencies such as public health or emergency management to be notified were not real clear to staff. Continue to involve staff in local exercises and trainings in community to expose them to the partners and their functions. Gove County Hospital Identified need for Law Enforcement to function as hospital security if need arose. Identified who do we tell if the ED is contaminated? Identified multiple means to communicate this --- EMS by calling dispatch or use the radio, NIMS system on the computer, verbally to the on-scene incident commander, public notification by security personnel, by radio, or TV, and total notify (but could only utilize this to hospital staff). The Health Department designee identified that the PIO has the responsibility to communicate with the community how events affect the hospital's function. The tabletop discussion gave actions to take but there was not a policy to reference. Ensure there is a policy and procedure for communications with outside agencies. The policy will direct staff whom to communicate with and how to communicate in the event. This ensures any person in IC has written instructions to follow. Performance Target Capability [OVERALL] Activity # 4: Return to Normal Operations 29 Page

30 Associated Critical Tasks Task # 4.1: Communicate return of normal operations to all parties involved. Goodland Regional Medical Center No specific policy or training in place for actual role out. Logan County Hospital Norton County Hospital Used reverse 911, TV interruption, radio station for announcements with the EM. Hays Medical Center Command staff aware of need to debrief. ED and Security staff aware of need to implement their departmental protocols to return to normal duty. Additional exercises to allow Command Staff and other department to review and practice return to normal procedures. Rooks County Health Center The team used the ADT alert system, EMResource as well as dispatch to relay the change in operations. Phillips County Health System Russell Regional Hospital Discussed use of media and PIO to inform residents and responders. 30 Page

31 Decatur County Hospital Rawlins County Health Center Hospital staff notified, debriefing held, communication using the EMSystem. Refer to and review policy and procedure manual during exercise to identify areas of improvement. Decon ED, debriefing staff and public, restocking supplies, proper disposal of contaminated clothing and supplies, restocking PPE. Acknowledge HIC may decrease in size, but remain in effect for many days / months / years, and the need to continue to track man hours, supplies, and treatment regarding the event. Ness County Hospital Remind staff that all parties need to be notified. Graham County Hospital Discussion was held regarding decon of ER department and resupplying. Weak Know where to find professional decon companies. Sheridan County Health Complex No understanding of how to let all parties involved know that the hospital was back to normal operations. 31 Page

32 Unsure of how to communicate with public to let them know hospital was back to normal operations. Improve communications with all emergency agencies. Implement a policy into the EOP on who should communicate with appropriate agencies. They were aware of the means of communication to use such as the EMResource system and the Emergency Manager to return to normal. Gove County Hospital Identified need to decon hospital before resuming normal operations but no policy / guidelines referenced. Group questioned length of time it would take to get hospital decontaminated. There was discussion of need to check on staff and perform a debriefing. Health Department identified in their policy to include Behavioral Health Counseling at the conclusion of an event. Group discussed procedure for coming off diversion and a return to EMS systems. Group identified need to perform an After Action Report. There was no discussion on how to make the public aware of return to normal function or how to identify and utilize community resources to support the community after an event. There was no discussion about how this event changes the functionality or image of the community and hospital. The Health Department stated their responsibility would be to monitor public effects of the hazardous materials. Establish written policy / protocols for returning to normal function after an event. This can be referenced for all events. Evacuation and Shelter-In-Place Performance [OVERALL] Target Capability Activity # 1: Evacuate Patients in Affected Area of Facility 32 Page

33 Associated Critical Tasks Task # 1.1: Review established evacuation plan. Logan County Hospital Players were unsure where to re-locate to but it was quickly discovered. The hospital ER is quite small so it was determined that if the ER was to be evacuated it was likely the whole hospital would need to be evacuated. It was not clear how the exposure actually occurred. Familiarizing everyone with location of alternate care sites. Norton County Hospital Discussed alternate care site, mobilization, equipment and what is expected at the site. Need to do a mock drill. Rooks County Health Center The team evacuated the patients and hospital as soon as it was discovered to be contaminated. Have a plan of action as to the mode of transportation for the patients. Phillips County Health System Russell Regional Hospital Concentrated on Shelter in Place which was appropriate do to the conditions and talked about what resources might be needed if full evacuation became necessary. Rawlins County Health Center Evacuation plan was reviewed. ER would be quarantined, staff assessed. DON to notify Incident Command. 33 Page

34 Weak Review partial and full evacuation plans with hospital staff. Chose to "evacuate" to another portion of the hospital. Know limitations within event and recognize when it is appropriate to evacuate to alternate care site. Ness County Hospital Staff is very aware of plan. Weak Decatur County Hospital Full evacuation was performed with temporary ER set up outside existing ER entrance. Define indoor locations that a temporary ER can be setup and operated. Set need criteria for doing a full evacuation a partial may have been plenty for this scenario. Knowledge of the plan is strong although evacuation drills would be a benefit. Weak Graham County Hospital Discussion was held about facilities in community which would be big enough with proper services available. The bed spaces available in surrounding hospitals could be found on the statewide EMS website. The possible shortage of ambulances was discussed and use of alternate transportation such as school buses. Have agreements in place with these facilities for their use and with the school district for use of buses. Sheridan County Health Complex Not stated clearly in EOP on how to evacuate patients / residents if need did arise. 34 Page

35 Weak Update EOP for hospital and county on how to evacuate patients / residents and families. I noticed that they did have MOA s in place with the Methodist Church, High School and Heartland Christian School in the event that they needed to set up an alternative care site. Also, they have and evacuation plan in place. However general staff are not aware of the components of the plan. I would suggest that they review the current plan and make any revisions needed. In addition the staff needs to be trained on its components. Gove County Hospital There was a decision to evacuate the Emergency Department due to contamination and the decision was to "Go Outside." ly decontaminate patients and staff would resume medical care on the hospital unit. supplies would be available. No formal evacuation plan was referenced. Write, review, and drill an Evacuation Policy. Identify trigger points for an evacuation. Expand the Overwhelming Patient Emergency policy to include an Alternate Care Site. Task # 1.2: Determine need for outside assistance in evacuation. Logan County Hospital Norton County Hospital Would ask for assistance through EM. Need to drill on this. Rooks County Health Center An additional HazMat team was requested as well as the need 35 Page

36 for transportation. Phillips County Health System Russell Regional Hospital Considered what resources might be available or needed. Develop checklists or triggers of when to evacuate or how. Rawlins County Health Center Emergency Management to divert incoming EMS. Did not discuss total notify and did not designate the need for the task to be assigned to the Planning Section Chief. Verbalize understanding of the policy in response to total notify and how staff will be utilized. Ness County Hospital Staff discussed the need for more wheel chair type transportation. Discuss with LEPC. Decatur County Hospital County handicapped bus, school buses, ambulances from other counties, personal vehicles and law enforcement were identified as outside assistance sources. Formal MOU's with outside assistance defined in observations. Staffing call in procedure is strong. 36 Page

37 Graham County Hospital The need for area EMS and their ambulances was discussed. Have mutual aid agreements for these services in place. Sheridan County Health Complex Made known resources that could be used in case of evacuation. Need to update MOU's with appropriate agencies for use of vehicles / buses and other forms of transportation and keep them updated yearly. There was a lot of communication about what was available in the area with regards to resources and that the Thomas County Emergency Manager is the first call that needs to be made when requesting outside resources. There was in-depth discussion about the need to track what resources are being requested and that in order to be reimbursed later it must be requested through the county EM. Make sure that all staff is aware of the avenues of requesting outside resources. Gove County Hospital The group identified there would be a need for assistance to evacuate. They identified the need for transportation - police, ambulance, transport van and school buses. The city office and public works could assist with crowd control. The Emergency Manager offered assistance from the Alternate Care Site trailers. On-site daycare said they would need additional staff to care for an influx in staff's children. The group identified they would need to include Bluestem Medical Clinic in their diversion / evacuation / lock down policies. Include in an Evacuation Policy the support functions needed and contact persons for those functions. 37 Page

38 Performance Target Capability [OVERALL] Activity # 2: Continue Patient Care Associated Critical Tasks Task # 2.1: Procedures are established for alternative care for patients arriving at the ED. Logan County Hospital The hospital would have been evacuated so the group determined that the patients would be sent to the ACS and triaged there. It was an assumption that LE would be able to set up road blocks to divert patients but again without participation from other entities it was difficult to determine how or if this would or could happen. Norton County Hospital Discussed diverting patients to alternate care site by directions from staff at the hospital. Rooks County Health Center The team chose to use an internal security system to lead the patients arriving via personal vehicle to one entrance into the hospital to avoid possible contamination. They also relayed information to dispatch to place the hospital on bypass so the ambulance crews new to take additional patients to another facility when possible. Have someone in charge of directing facilities outside the immediate county to avoid transfers to the facility when possible. If they are on a different frequency, your dispatch is not necessarily heard. Phillips County Health System 38 Page

39 Russell Regional Hospital There is a policy or procedure in place with the hospital region, but not an MOU. MOU with outside resources is needed. Rawlins County Health Center Arriving patients to be decontaminated at hospital site then triaged and relocated to other facilities. Contaminated ED moved to Cardiac Rehab. Recognize quickly the capacity for patient surge in this event and to safeguard existing staff and patients by moving the treatment to an alternate care site for victims of chemical exposure. Ness County Hospital Staff discussed setting up alternate triage site. Weak Decatur County Hospital Ambulance barn, Family Practice Clinic, churches, school gym and the Gateway were identified as alternate care sites. Plans and procedures need to be developed to address alternate care sites. MOU's to use identified alternate care sites. Discussed ER becoming a hot zone and an alternate in house ED. Need to think through procedure for changing to alternate site. Graham County Hospital 39 Page

40 Notify the EOC of the possible need to arrange for transport of noncritical patients or stable inpatients to make more room available. Weak Better plan for the logistics of transportation. Sheridan County Health Complex Not enough staff to run an ACS. Had an RN outside ED to triage patients. Little communication with EMS to divert ambulances if needed. Train more staff to assist in running an ACS. They are in the process of their written plan for alternative care. As mentioned earlier they have their alternative care locations identified, the regional trailer is housed at their facility and they have resources available through the region. After final plan is in place ensure that training occurs with staff so they are aware of where they can find it and the basic components of it. Gove County Hospital It was the group s discussion to decon all incident patients and package them for transport to surrounding hospitals. Also, all non-contaminated patients would be diverted to another hospital since this facility was contaminated. There was not discussion for full evacuation of this facility. It was deemed that only the ER as contaminated so the rest of the facility could function. A developed Alternate Care Site policy and procedure can direct functions for care of patients that present to the ED. Task # 2.2: Hospital directs patients seeking care to adequate community resources or alternatives. Logan County Hospital PIO statement. 40 Page

41 Weak Norton County Hospital Discussed using EM for community resources Did not discuss directing patients to the resource, but county health talked about helping with community notification with EM. Rooks County Health Center Staff informed patients of the alternative site set up in the community as well as nearby hospitals that are available. Phillips County Health System Russell Regional Hospital Discussed needs and available facilities. Need MOU with other agencies that may be available as a resource. Rawlins County Health Center Will still need to receive patients in triage area, decontaminate, ID patients. Use Tag System? Not Applicable Implement plan to ID patients in receiving / triage area. No alternative treatment centers in our community. Ness County Hospital Discussed different agencies that could help set up. Decatur County Hospital Identified the need to remain open and accessible to the public. Also identified need to direct patients to other facilities as 41 Page

42 required based on conditions of patients. Not Applicable Define plans and procedures for handling patients when and if facility is operating at minimum capability. This would also include what equipment / supplies would be needed at temp location and how needed equipment / supplies would be transported. Non-Existent Graham County Hospital The need to ask patient to go to surrounding hospitals for treatment was discussed. The hospital may need to be put on diversion status via the state EMS system. Good communication with area hospitals regarding the status of the incident and their needed involvement. Sheridan County Health Complex Weak They discussed the process of determining that they could no longer accept patients. It was still unclear on the process if patients show up to the other clinic in town. This is something that needs further thought. The EMs system will be utilized to ensure that other hospitals and EMS is alerted that they are at capacity. It was identified that EMS and the health department needs to get login access to the EMs system. Gove County Hospital Group discussion was to divert people seeking medical care to other hospitals. The Health Department would monitor public effects of the 42 Page

43 contaminate. Behavioral Health Counseling would be offered to the community according to the Health Department's policy. Hospital would offer mental health counseling for employees through High Plains Mental Health. Identify all resources that could be utilized after a mass casualty or emergency even the American Red Cross, local aid organizations and sheltering facilities then incorporate them into the Alternate Care Site policy. HazMat Response and Decontamination Performance [OVERALL] Target Capability Activity # 1: Limiting Access to Hospital Associated Critical Tasks Task # 1.1: Hospital understands and has ability to implement a limited access Goodland Regional Medical Center Norton County Hospital Has participated in decon training and has trained for set up also. Need to have mock drills. Hays Medical Center Security, ED and command staff understood the need to restrict access. Additional exercises to allow more associates to practice procedures. Logan County Hospital Very early in the exercise the hospital discussed and implemented lock down of the facility. 43 Page

44 They also notified the health department and the clinic as they are all encompassed in the same facility. The health department discussed the need to develop signs to place on doors and lock down as well. It was also discussed whether or not the nursing home should be included in lock down. They are not attached to the hospital however they are hospital owned so some concern that the worried well may end up the manor was discussed. They are also in need of signage. Communicating with all of the entities could be difficult. In an exercise it is easy to address this need however in a true scenario it could easily be overlooked. Continual training to staff of departments that need to be kept aware of the situation is of utmost importance. Rooks County Health Center The hospital has a policy for who locks which doors during an emergency and implemented that policy to avoid multiple entrance possibilities. Phillips County Health System Russell Regional Hospital The hospital does have staff trained in decon and HazMat procedures but does need to rely on outside assistance from Hazmat Response Teams etc. and from other hospitals to assist. Develop MOU with partner agencies. Train and equip more personnel. Rawlins County Health Center Staff would secure all entrances, using only ER entrance, and set up security perimeters on hospital campus. Would need assistance from law enforcement, fire department and / or other agencies. 44 Page

45 Recognized early the need to lockdown and limit accessibility to hospital, as well as to provide security representatives at each entrance so access could not be breached. Restricted entrance to ED to safeguard staff and patients already in hospital. Decatur County Hospital Limited access to the facility from ER was priority one when event was first announced. Security secured the facility and limited access to building thru ER. Evaluate and incorporate outcome into policy how / where staff will enter building. Currently staff comes to the front door and to the front lobby. It was suggested that the back door be used with staff reporting to front lobby. for capabilities. Weak Graham County Hospital The hospital would go into lockdown. The keys to lock all doors are located at nurses station. The maintenance department is responsible for seeing this is done. The ER doors would be the only access to get into hospital. Recognize need to do this in the very early stages of the incident. Sheridan County Health Complex Noted that most doors of hospital were locked all the time. Noted that two doors are open during certain hours and one of those doors is accessible all the time by using a code to get in. Need to update policy on how to lock down hospital if needed. Need to appoint a department to stand at doors if in lockdown. 45 Page