These presenters have nothing to disclose L8: Emergency Preparedness North Shore LIJ Health System Mark J. Solazzo Executive Vice President Chief Operating Officer James Romagnoli Vice President Protective Services Mary Mahoney, NP Director Planning & Preparedness Mark Jarrett, MD Senior Vice President Chief Quality Officer December 8, 2013 1 Session Objectives Discuss planning, training, and resource commitments needed for a comprehensive emergency management program Describe the steps necessary to ensure the safety of patients, employees, and the community during an incident Discuss vital components of a business continuity plan Discuss the all hazards planning and preparedness concept and how it can be applied to healthcare 2 1
Program Agenda 1. A Senior Leader s Perspective on Emergency Management About NSLIJ and why it s well positioned for a robust emergency management program NSLIJ s emergency preparedness philosophy 2. Building & Maintaining a Robust Emergency Preparedness Program The structure, fundamentals and essentials of emergency preparedness Interactive case studies 3. Making Critical Clinical Decisions during a Major Emergency Evacuating versus sheltering-in-place The needs of an evacuated hospital Employee resilience Interactive case studies 3 A Senior Leader s Perspective on Emergency Management Mark J. Solazzo Executive Vice President Chief Operating Officer 4 2
North Shore LIJ Health System: At a Glance 5 Critical Assets of the North Shore LIJ Health System Integrated Distribution Center / Warehouse C.L.I nationally recognized corporate university The Center for E.M.S. Group Purchasing Organization Geographically spread-out North Shore LIJ Medical Group Public / Private Partnerships 6 3
The Philosophy Manage an incident, not just treat it A robust emergency preparedness/management program allows the health system to maintain a safe and effective environment of care during natural, technological and man-made hazards. 7 Synergy with our Mission, Vision & Values Quality Operational Performance Emergency Preparedness ensures continuity of NSLIJ s mission during emergencies Community Health Service Excellence Source: NSLIJ Mission Statement 8 4
The Joint Commission EM.01.01.01: The hospital conducts a hazard vulnerability analysis to identify potential emergencies that could affect the need for its services or its ability to provide these services EM.02.01.01: The hospital develops and maintains a written Emergency Operations Plan that describes the preparedness activities that will organize and mobilize essential resources EM.03.01.01: The hospital conducts drills regularly to test emergency management Source: The Joint Commission Emergency Management Standards 9 Fundamentals of Emergency Preparedness The people Abundant training Emergency Management professionals who are subject matter experts Multidisciplinary team The planning Continuous assessment of threats, weaknesses and problems Top-down approach to incident command education Creating a culture comfortable with emergencies The resources Investments driven by past experiences Technology Mobility 10 5
Building & Maintaining a Robust Emergency Preparedness Program James Romagnoli Vice President Protective Services & Mary Mahoney, NP Director Planning & Preparedness 11 Emergency Management Program Organization Source: The Center for Domestic Preparedness FRAME educational materials 12 6
Structure / Components of Emergency Management Source: U.C. Davis Emergency Management & Mission Continuity Program 13 Overview of Emergency Preparedness Efforts 1997: Integrated system-wide emergency preparedness efforts In the same year, directive given to make emergency preparedness training part of leadership core competency Expanded system emergency management to include expert assistance and subject matter experts Currently provide training in Health Care Emergency Management, Incident Command, and Crisis Intervention as a designated Learning Center for the Center of Domestic Preparedness NSLIJ Emergency Management and Business Continuity Plans were a key component of the National Quality Forum Award for Quality and was recognized as best practice by the Joint Commission 14 7
The Development of the Emergency Management Division 1997 1999 2001 2003 Integrated System Wide Emergency Management EM becomes division of E.M.S A centralized, system EOC is constructed in Syosset, NY A corporate director is hired to oversee EM Corp. Security and EM becomes a separate and distinct division of NSLIJ 15 Timeline of Major Emergencies WMD Conference Northeast Blackout SARS Outbreak H1N1 Outbreak Hurricane Irene 9/11 Anthrax AA Flight 587 crash NYC Transit Strike Christmas Blizzards Hurricane Sandy Y2K Hurricane Floyd 16 8
Successes During Major Events Provided Emergency Response assistance to local OEMs during major events (i.e. Great Neck Tornado in 2010, preventing the unnecessary evacuation of multiple skilled nursing facilities) Managed the Flu Vaccination Program for Nassau County during the H1N1 Outbreak, establishing and overseeing points of distribution (PODS) Established an Alternate Care Site at LIJ Medical Center for the sole treatment of flu patients, which saw over 300 additional patients per day Successfully evacuated approximately 950 patients during Hurricane Irene Successfully completed rapid assessment and discharge of approximately 2,391 patients during Hurricane Sandy. All NSLIJ facilities remained fully operational throughout event. 17 The People 18 9
The Network Emergency Management Team The Team Members: 10 healthcare professionals with diverse backgrounds in emergency services Are all paramedics, RNs or NPs Are drawn from the ranks of the NYPD, NCPD, FDNY, Nassau County Fire Chiefs and Company Commanders, FEMA USAR Team & DMAT Team Advantages: Advanced Incident Command experience Ability to adapt quickly to evolving situations Connections with outside agencies and ability to speak the same language 19 NSLIJ Leadership & Staff Strategically picked leadership and staff trained in Incident Command and other core competencies Supported by a site-designated Emergency Management Coordinator who is positioned to provide guidance Multi-disciplinary team participates on the emergency management committee and consults the Network Emergency Management team, they include: Quality Procurement Facilities Finance Clinical Leadership IT 20 10
Learning / Training Opportunities Leadership and Staff throughout the health system participate in joint exercises every year. This includes classroom learning, table top exercises, and functional and full-scale drills. The following classes are also available for employees: -Hazmat for Healthcare Employees Awareness/Operations -Standardized Awareness Training AWR 160 - Healthcare Incident Commander Development - Incident Command System 300 -Incident Command System 400 -Weapons of Mass Destruction Radiological/Nuclear Awareness -MGT 341 -Disaster Preparedness for Hospitals and Healthcare Organizations -Framework for Healthcare Emergency Management (FRAME) -Hospital 21 The Boston Marathon Bombing 2 explosions 3 dead 264 injured 27 local hospitals received patients 22 11
2010 Times Square Bombing Attempt 23 Case Study: Learning From Current Events A bomb explodes during a high school football championship game, leaving hundreds dead and thousands injured, frantically seeking emergency care. The police suspect the bomb was dirty, containing lethal chemicals and radioactive material. The question is: is your organization ready? 24 12
Training Video 25 The Planning 26 13
An Organization Comfortable with Emergencies Our definition of an Emergency --- Any deviation from normal operations Frequently using the incident command / emergency management system hardwires the process for leadership and staff across the system and allows for smoother operations during major emergencies. Network Emergency Management responds to over 200 emergencies every year. 27 An Organization Comfortable with Emergencies Incident Type Summary YTD October 2013 28 14
Multi-Disciplinary Planning NSLIJHS Emergency Management Structure Administrative Steering Committee M. Solazzo Clinical Advisory Committee L. Smith Network Emergency Management System Emergency Preparedness Committee Jim Romagnoli 29 Critical Focus Areas Utilities EOC Operations Security and Safety Critical Areas of Focus Communications Resource Management Patient Care 30 15
Situational Awareness Weather Health System Status Real-Time Monitoring Local & National Incidents National & Global Disease Patterns 31 Situational Awareness: Cascading Information Incident Progression Intel received by emergency management staff -Evaluated - Reformatted - Disseminated Facility receives intel from EM staff -Evaluates impact to services -Goes on HICS as needed Employees -Receive specific, verified information 32 16
Employee Mass Communication Network e-mail accounts Intranet MIR3 mass notification software Site leadership 33 After-Action Analysis Carefully review and hot wash each emergency Quality Assurance process conducted by Quality Management, not Emergency Management 34 17
Public Private Partnerships Regular intelligence and planning meetings with the surrounding municipal and governmental agencies. They are a resource to us, and we are a resource to them. New York State Department of Health Nassau County Office of Emergency Management Suffolk County Office of Emergency Management New York City Office of Emergency Management Nassau County Police Department Suffolk County Police Department New York City Police Department New York City Fire Department Nassau County Fire Commission 35 Hazard Vulnerability Analysis (HVA) Each phase of Comprehensive Emergency Management (CEM) incorporates the goal of managing the variety of hazards that may adversely impact the facility HVA is key to developing a risk-based, all-hazard emergency management plan Identifies the potential emergencies that may prevent or negatively affect the ability of the facility to deliver its normal services Drives the emergency planning process Source: The Center for Domestic Preparedness FRAME educational materials 36 18
Hazard Vulnerability Analysis (HVA) Healthcare facilities have unique characteristics that add to their vulnerability: Heavily occupied 24/7/365 Patients are vulnerable Complex buildings combining functions similar to hotels, offices, labs and warehouses Supplies and records may not be available in an emergency Facilities contain controlled substances and hazardous materials Utilities and communications are vital to their functioning Destination during major events in the community Source: The Center for Domestic Preparedness FRAME educational materials 37 Business Continuity Employees Resiliency Ability to be redeployed / work off-site Resources Information/IT recovery Ability to be redeployed Redundancies Finance Careful accounting of expenditures throughout event 38 19
Case Study # 1: H1N1 Outbreak 39 Case Study: H1N1 Outbreak April 2009 As of May 12, 2009, WHO reported 5,266 cases in 30 countries with 61 deaths United States: 2,600 cases 3 deaths Canada: 330 cases 1 death Mexico: 2,059 cases -- 56 deaths Spain: 95 cases --no deaths 40 20
H1N1 The First Human Case April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 Earliest human case of A/H1N1 Swine Influenza appears in Mexico in late March, or early April. 41 H1N1 The Rise April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 Mexican media begins reporting a sharp rise in respiratory illness in a small coastal region in central Mexico. 42 21
H1N1 The Rise April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 New York State DOH briefs Health System s Emergency Management on the presence of an outbreak in N. America. NSLIJHS Emergency Management moves to a heightened state of epidemiology surveillance. 43 H1N1 Crosses the Boarder April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 CDC confirms swine flu cases in California (4/15,17) and Texas (4/22). Number of illnesses reported in Mexico grows rapidly. 44 22
H1N1 April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 Mexico's Minister of Health confirms 20 deaths from swine flu, 40 other fatalities were being probed, and at least 943 nationwide were sick from the suspected flu. Mexico City shuts down schools, museums, libraries, and state-run theaters across the capital. 45 H1N1 Hits Home April S M T W T F S 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 26 27 28 29 30 Friday evening: noted surge in patients with flu-like presentation in the emergency department at Long Island Jewish Medical Center. St. Francis Prep students begin posting on Facebook that they have swine flu and that their classmates should go to Schneider Children s Hospital. 46 23
Discussion Topic What are you thinking and doing? 47 NSLIJ The First 24 Hours Friday, April 24th Network Emergency Management is notified by Long Island Jewish / Schneider emergency department that they are seeing a surge in patients presenting with flu-like symptoms. Pattern begins to develop of patients in the LIJ / SCH emergency department many of the students have travelled to Mexico within the last week. Friday, April 24 Saturday, April 25 10:00 pm 12:00 am 48 24
NSLIJ The First 24 Hours Saturday, April 25th National & local media begin to report on suspicious flu-like cases appearing in metro NY. Investigation reveals that most of the patients who have been arriving at the pediatric emergency department are students at St. Francis Preparatory in Fresh Meadows. 8:00 am NYC DOH/MH issues their first bulletin on the potential of a swine flu connection between these students and Mexico. NSLIJ Senior Administrative / Clinical Leadership are kept abreast of the developing situation. Friday, April 24 Saturday, April 25 49 NSLIJ the first 24 hours Saturday, April 25th Activated initial phases of Health System s Biological Response Plan (modification of triage, inventory of medication and personal protective equipment reviewed). Friday, April 24 Saturday, April 25 10:00 am 50 25
NSLIJ the first 24 hours Saturday, April 25th News Media are beginning to report that there is a local outbreak centered around St. Francis Prep. NSUH, Forest Hills, Franklin Hospitals are beginning to see students and increased publicity is adding to the surges. Friday, April 24 Saturday, April 25 1:00 pm 51 St Francis Prep North Shore University Long Island Jewish Forest Hills Franklin 52 26
Media Reports: April 24 th, 7:00pm 53 Discussion Topic Now what are you thinking? 54 27
NSLIJ The First 24 Hours Saturday, April 25th Situation now being handled as a regional emergency for the Health System due to multiple sites being impacted. Emergency Management is in constant contact with Health System Leadership, New York State, New York City, and Nassau County Departments of Health and Offices of Emergency Management. Friday, April 24 Saturday, April 25 4:00 pm + 55 H1N1 - Long Island Jewish Medical Center ED Volume April S M T W T F S 19 20 21 22 23 24 25 26 27 28 29 30 450 400 62% Increase in total volume Saturday, May 2: 11 % drop from previous Saturday 350 300 Pediatrics Adults 250 200 150 100 50 04/23 4/24 4/26 4/27 4/28 4/29 4/22/09 4/23/09 4/24/09 4/25/09 4/26/09 4/27/09 4/28/09 4/29/09 4/30/09 5/1/09 5/2/09 5/3/09 56 28
H1N1 On-going Operations The Health System s Emergency Operations Center (EOC) is opened. Daily Operational briefing including situational update of disease surveillance of all hospitals are reviewed. Daily conference calls with clinical staff, site leadership, and health officials from state, city & county. Network Clinical Advisory Committee updated and issued clinical guidance to faculty physicians, voluntary physicians, and Employee Health Services. Proactive supply chain control by Materials Management leading to adequate levels of pharmaceuticals and protective equipment. Implemented Core Lab surge capacity plan expanding virology capability. Sunday, April 26 8:00 am 57 H1N1 Emergency Response Site visit by NYS DOH/MH, refer to NSLIJHS as the benchmark organization for event response 1. Communications External demands Internal need for information 2. Operations ED surge Increased lab volume Supply needs: masks, medications 3. Planning Alternative care sites 4. Clinical CDC/DOH conflicting messages Employee health concerns 58 29
Case Study # 2: Super Storm Sandy 59 Case Study: Super Storm Sandy October 2012 60 30
Case Study: Super Storm Sandy October 2012 61 Case Study: Super Storm Sandy October 2012 A Look Back System Emergency Operations Center (EOC) officially activated Monday, Oct 22, 2012 Rapid assessment and discharge occurred prior to the hurricane; approximately 2,391 patients discharged from Friday, Oct 26 th Sunday, Oct 28 th Modified evacuation of Staten Island University Hospital and Southside Hospital: Oct 26 th Oct 27 th All facilities remained fully operational, including 3 facilities in flood zones Several hundred nursing home patients from 10 different facilities in the Rockaways and Long Beach were accepted and transported by NSLIJ NSLIJ received a total of 139 patients from NYU Medical Center, Bellevue Hospital, and Coney Island Hospital 62 31
Case Study: Super Storm Sandy October 2012 A Look Back NSLIJ System EOC facilitated NY and Nassau County OEM s request for the accommodation of dialysis and psych patients from the Rockaways, South Nassau, and Bellevue Hospital A large number of the worried well presented at North Shore-LIJ hospitals Assisted with municipal special need shelters and general population shelters Operated NSLIJ fueling stations and transportation alternatives for health system employees Created the Employee Assistance Resource Center for health system employees who suffered catastrophic damages from the storm Community outreach & support 63 North Shore University Hospital EOC 64 32
NSLIJ Centralized EOC 65 Rockaway, Queens 66 33
Rockaway, Queens 67 Long Beach, NY 68 34
NSLIJ Temporary Special Needs Shelter 69 NSLIJ Mobile Van Operation Goal: Provide resources from NSLIJ Health System to those most affected by Hurricane Sandy Humanitarian effort No insurance asked No billing Simple paper records Sites based on needs assessment 70 35
Topic for Discussion 1. When would you start canceling your elective surgery cases? 1. How many days can your hospital/health system go without a delivery of supplies? 1. When do you evacuate? 71 Super Storm Sandy Video 72 36
Making Critical Clinical Decisions during a Major Emergency Mark Jarrett, MD Senior Vice President Chief Quality Officer 73 Case Study # 3: Hurricane Irene 74 37
Case Study: Hurricane Irene August 2011 75 Hurricane Irene Video 76 38
Early Warning & Planning Tuesday 8/23/2011 0800 hrs. System Administration is notified of an increasingly high probability of a hurricane landfall on Long Island System Administration authorizes that an advisory notice be sent to all employees Emergency Management establishes conference calls with all critical infrastructure divisions. Emergency Management briefs the following entities: Executive Directors Department Heads of Materials Management, IT & Telecommunications, Facilities & Engineering, Risk Management All departments are to begin activating emergency plans 77 96 Hours to Landfall: Actions Begin Wednesday 8/24/2011 0800 hrs. 24/7 surveillance of weather & hurricane 4-hour weather updates are issued Critical infrastructure departments are briefed twice daily Hospital evacuations are under evaluation Emergency purchasing and leasing begins System Administration places the Health System on a Level 1 HICS Health System EOC is opened Rapid discharge and surge plans are under review Employee advisories are upgraded to alerts Employees are advised to begin personal readiness actions 78 39
72 Hours to Landfall Thursday 8/25/2011 0800 hrs. HICS Level 2 is ordered and all weather reports are confirming a L.I. -NYC landfall Evacuations appear likely to occur at SIUH North and South sites All critical infrastructure needs and requests are being filled All municipal emergency management agencies are consulted EOC initiates 24/7 staffing model Facilities leadership orders a stop work order on all construction sites All sites are to be secured within 24 hrs Union labor issues are considered Vendors and contractors are asked to provide their staffing models Employee alerts are increased to twice per day Executive conference calls occur every 4 hrs 79 48 Hours to Landfall Friday 8/26/2011 Decision has been made to evacuate SIUH North & South and begin evacuating Southside Hospital, as well Emergency purchases begin to arrive at system hospitals and Emergency Management Headquarters in Syosset Emergency generators are disbursed based on assessments by facilities and engineering leadership Hospitals are asked to prepare staffing models and submit them to Emergency Management Hospitals are instructed to begin rapid discharges and surge plans are to be activated Executive leadership have suspended all elective surgeries through Tuesday 80 40
24 36 Hours to Landfall Final checks are being made with all system partners at our sites All equipment requested by the sites have been delivered A decision has been made to evacuate Southside Hospital Many nursing homes and area hospitals are seeking assistance in evacuations NS-LIJ staff is sent to these facilities to coordinate, evaluate and facilitate evacuations and/or sheltering 81 12 Hours Out SIUH evacuations are completed Resources had been shifted east earlier as the need declined in Staten Island Southside evacuations completed NSLIJ begins to take additional evacuees from nursing homes in Nassau and Queens NSLIJ coordinates additional evacuations in Rockaways and to sites outside the Health System NSLIJ begins to take patients who refuse special needs sheltering Patient tracking and patient medical evaluations are the primary operations sector duties 82 41
During the Storm All transportation services and deliveries are suspended Facility damage assessments are conducted regularly Monitoring of utilities is constant, many facilities go to generator power Staff attendance shows no significant absentee rates No facilities are closed to emergencies, including the evacuated facilities Patients continue to arrive in Emergency Departments All NSLIJ Hospitals are reporting normal operations 83 Summary 947 patients were evacuated from Southside Hospital and Staten Island University Hospital All evacuated inpatients were safely transported prior to the storm Southside Hospital and SIUH both continued to keep their Emergency Departments open throughout the storm Post storm, all of the evacuated patients were safely discharged or transported back to their original facility depending on their medical condition 70 nursing home patients from seven different facilities in the Rockaways and Long Beach were accommodated at: North Shore University Hospital s Stern Center for Extended Care and Rehabilitation in Manhasset Long Island Jewish Medical Center Franklin Hospital 84 42
Ensuring the Safety of Patients, Staff and the Community 85 Shelter in Place Pros Less logistically challenging Less of a load on network Mitigate risks associated with transfers and handoffs Cons Obvious risk to patients in extreme circumstances Most complicated moment is in the thick of the event (i.e. last minute evacuations during Hurricane Sandy) Pearls Staff at 150% Key medical staff in-house for the duration of event Evacuate most critically ill, when possible Create clinical redundancies in-house 86 43
Evacuate Pros Mitigate risk associated with staying in the danger-zone The complicated portion of this task is done in normal conditions/pre-hazard Cons Logistically challenging Creates capacity issues for surrounding/receiving hospitals More hand offs are possible patient safety issues Pearls Preexisting relationships and plans with surrounding facilities Expanded stay-teams to support the community Predetermined structure for handoffs and communication of PHI and equipment in emergency situations 87 Video 88 44
Evacuation Processes during Irene Stay Teams To address concerns that area residents may seek shelter and medical care during the storm, Stay Teams were expanded to include sufficient clinical staff to provide patient care, if needed Dietary, sleeping, and parking arrangements were made to accommodate staff 89 Evacuation Processes during Irene Effective Strategies/Best Practices Coordinated effectively with the System to secure appropriate beds and transportation for all patients Patient relations created an effective chain of communication between hospital and patient family/friends Utilizing social networking, hospital website and HICS hotline to communicate scheduling decisions with staff Patient safety was maintained throughout the evacuation process No patient or staff injuries Efficiently distributed four day supply of medication to transferred patients 90 45
Evacuation Processes during Irene Opportunities for Improvement Gaps in communication in patient transfer process Infrequent communication updates with on-duty staff No process in place to inform family members that were present during evacuation Improved tracking process for equipment loaned to other facilities The Main Conference Room at North Site was not conducive to implementation of Incident Command System Incident Command structure was not fully developed Key HICS roles were not assigned No order of succession designated for relief of individuals in key roles Better communication with departments about labor pool use/function Better utilize staff support function as described in HICS structure 91 Evacuation Processes during Irene Recommendations Make better use of radio and Spectralinkphones to communicate vertically among all levels of staff Better utilize technology to track patients and equipment Expedite relocation of Primary EOC to McGinn Education Center Incorporate a family reception/information area into the evacuation plan Designate areas for HICS Sections with communication capabilities for each section Develop the role of EOC Manager to coach the Command staff during plan activations 92 46
Evacuation Processes during Irene Recommendations Resume ongoing education on the incident command structure for hospital leadership Provide more frequent communication updates with on-duty staff Provide education to unit staff regarding evacuation, triage and transport needs Establish mechanism to assign physician and PCUM teams to expedite evacuation process Train staff on new processes and evaluate effectiveness in an exercise 93 94 47
Employee Assistance Post-Sandy Established 0% interest loans with local banks, making $900,000 available to eligible employees Created ride-sharing programs and discounts with local car dealerships NSLIJ provided $400,000 in direct financial assistance System-sponsored temporary housing for 260 employees and their families Established a Employee Emergency Resource Center (EERC). The EERC fielded 4,600 phone calls and the website had 14,000 visits Employee Assistance Paid time off exchange resulting in 7,000 hours of PTO being distributed to employees in need 95 Employee Resilience and Assistance Employee Resilience is key to business continuity; and it s the right thing to do! 96 48
Q & A 97 49