After-Action Report/Improvement Plan June 2018 Rev. 2017 508 HSEEP-IP01
EXERCISE OVERVIEW Exercise Name Exercise Date April 5, 2018 Scope Hospital Preparedness Program (HPP) Capabilities 1 Objectives Scenario Sponsor This functional exercise was planned for four hours at three evacuating hospitals and the King County Disaster Medical Control/Coordination Center (DMCC). Additional exercise play occurred at receiving facilities across the healthcare coalition, as well as within receiving facilities located outside of the healthcare coalition. Exercise play incorporated healthcare coalition partners across King, Kitsap, and Pierce counties. Evacuating patients were placed in healthcare facilities across Washington, as well as in some facilities located in California, Oregon, Idaho, and Utah. Capability 1: Foundation for Health Care and Medical Readiness Capability 2: Health Care and Medical Response Coordination Capability 4: Medical Surge 1. Evacuating hospitals and coalition partners rapidly activate. 2. Evacuating hospitals contact appropriate partners quickly upon identifying need to evacuate. 3. Coalition (with the DMCC) communicates and coordinates quickly to find and match available beds and transportation resources for evacuating patients. 4. Hospitals perform tasks without excessive guidance or prompting. 5. Healthcare Emergency Coordination Center (HECC) disseminates situational awareness notification to non-hospital healthcare facilities. 6. Non-hospital healthcare facilities conduct and provide bed count of available bed space to notionally receive evacuating patients. This exercise did not utilize a scenario. Three hospitals were asked to respond as if they needed to evacuate all patients within four hours. Evacuating hospitals were informed that transportation and all forms of communication were available. Northwest Healthcare Response Network (NWHRN) 1 2017-2022 Health Care Preparedness and Response Capabilities, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, November 2016.
Exercise Name Participating Organizations Point of Contact Please see Appendix B for the full list of participating organizations Nancy Blanford, MPH Training and Exercise Coordinator Northwest Healthcare Response Network nancy.blanford@nwhrn.org 425-988-2898 office 206-718-8589 cell
ANALYSIS OF HPP CAPABILITIES Aligning exercise objectives and HPP capabilities provides a consistent taxonomy for evaluation that transcends individual exercises to support preparedness reporting and trend analysis. Table 1 includes the exercise objectives, aligned HPP capabilities, and performance ratings for each HPP capability as observed during the exercise and determined by the evaluation team. Objective Evacuating hospitals contact appropriate partners quickly upon identifying need to evacuate. HPP Capability HPP Capability 1 HPP Capability 2 Performed without Challenges (P) Performed with Some Challenges (S) S Performed with Major Challenges (M) Unable to be Performed (U) Evacuating hospitals and coalition partners rapidly activate. HPP Capability 1 HPP Capability 2 S Coalition (& DMCC) communicates and coordinates quickly to find and match available beds and transportation resources for evacuating patients. HPP Capability 2 HPP Capability 4 S Hospitals perform tasks without excessive guidance or prompting. HPP Capability 1 S HECC disseminates situational awareness notification to nonhospital healthcare facilities. HPP Capability 1 HPP Capability 2 S Non-hospital healthcare facilities conduct and provide bed count of available bed space to notionally receive evacuating patients. HPP Capability 1 S Table 1. Summary of HPP Capability Performance Ratings Definitions: Performed without Challenges (P): The targets and critical tasks associated with the HPP capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. Analysis of HPP Capabilities 3 Northwest Healthcare Response Network
Performed with Some Challenges (S): The targets and critical tasks associated with the HPP capability were completed in a manner that achieved the objective(s) and did not negatively impact the performance of other activities. Performance of this activity did not contribute to additional health and/or safety risks for the public or for emergency workers, and it was conducted in accordance with applicable plans, policies, procedures, regulations, and laws. However, opportunities to enhance effectiveness and/or efficiency were identified. Performed with Major Challenges (M): The targets and critical tasks associated with the HPP capability were completed in a manner that achieved the objective(s), but some or all of the following were observed: demonstrated performance had a negative impact on the performance of other activities; contributed to additional health and/or safety risks for the public or for emergency workers; and/or was not conducted in accordance with applicable plans, policies, procedures, regulations, and laws. Unable to be Performed (U): The targets and critical tasks associated with the HPP capability were not performed in a manner that achieved the objective(s). The following sections provide an overview of the performance related to each exercise objective and associated HPP capability, highlighting strengths and areas for improvement. Analysis of HPP Capabilities 4 Northwest Healthcare Response Network
Objective 1: Evacuating hospitals contact appropriate partners quickly upon identifying need to evacuate. Strengths The partial capability level can be attributed to the following strengths: Strength 1: Notifications from all three evacuating facilities to the HECC occurred in a timely fashion. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: Evacuating facility contact information for some partners was outdated. Analysis: Several evacuating facilities discovered contact information documented for regional partners in their Emergency Operating Procedures (EOPs) was outdated. Some of this outdated information resulted in delays in alerting and notifying partners. Recommendation: Routine drills to test communications and contact information for partners would ensure hospitals maintain the most accurate emergency contact information. Objective 2: Evacuating hospitals and coalition partners rapidly activate. Strengths The partial capability level can be attributed to the following strengths: Strength 1: All three evacuating hospitals activated well within the 60-minute notice period. Strength 2: King County DMCC, Pierce County DMCC, Seattle Fire Department (SFD), Kitsap Health Department, Tacoma Pierce County Health Department (TPCHD), Public Health Seattle & King County (PHSKC), Seattle OEM, and the HECC were notified and requested to activate. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: Requests for the DMCC and SFD to activate occurred, but with some prompting from assessors. Analysis: All three evacuating facilities notified the DMCC and SFD of their hospital evacuation with some prompting from exercise controllers. In a real-world situation, delays in notifying the DMCC or SFD of a hospital evacuation may postpone the availability of resources to support a hospital evacuation. Analysis of HPP Capabilities 5 Northwest Healthcare Response Network
Recommendation: Facilities may ensure that all facility-level procedures explicitly include instructions to notify the DMCC and the local fire department once a hospital considers the need to evacuate. Ensure facility staff are trained to these procedures and test regularly. Objective 3: Coalition (& DMCC) communicates and coordinates quickly to find and match available beds and transportation resources for evacuating patients. Strengths The partial capability level can be attributed to the following strengths: Strength 1: The DMCC received patient census information from all three evacuating facilities within 90-minutes. Strength 2: Evacuating hospitals immediately discharged 221 patients upon identification of the need to evacuate their patients. Strength 3: The DMCC placed 70.5% of all evacuating patients in other hospitals in the coalition within 90 minutes. Strength 4: Receiving hospitals conducted their hospital census and consolidated census data to support the DMCC. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: Hospitals did not receive confirmation of evacuating patient destinations from DMCC. Analysis: Within the time constraints of the exercise, the DMCC did not have the opportunity to communicate back to evacuating facilities the destinations of their evacuating patients. In a realworld scenario, the DMCC would likely be able to confirm where evacuating patients will go with evacuating facilities. Recommendation: This observation appears to be the result of the exercise time limit rather than a planning and/or training issue. DMCCs should continue to regularly conduct staff training to sustain level of response. Area for Improvement 2: Several evacuating facilities attempted to place patients on their own, creating a redundancy of efforts with the DMCCs. Analysis: One facility attempted to place patients within their own hospital system prior to reporting the number of patients requiring evacuation to the DMCC. This redundant effort delayed sharing patient census information with the DMCC; additionally, this effort resulted in some patients being "placed" in hospitals that were evacuating their own patients. Another hospital also attempted to place specialty patients out-of-state, which, although successful, still risked redundant efforts with the DMCC. Analysis of HPP Capabilities 6 Northwest Healthcare Response Network
Recommendation: Additional regional and facility-level training on patient movement procedures between hospitals and DMCCs would clarify the delineation of roles and responsibilities in terms of identifying patient destinations during a hospital evacuation. Area for Improvement 3: Players from evacuating facilities indicated confusion regarding which organizations would be responsible for coordinating transportation for evacuating patients. Analysis: During the facilitated discussion, several players indicated confusion regarding which agencies and/or organizations would be responsible for coordinating transportation for evacuating patients. According to the Regional Patient Movement Response Plan, during a hospital evacuation, the evacuating facility is responsible for requesting transportation support, in addition to designating a transportation liaison to co-locate and communicate with on-scene emergency medical services (EMS) Medical Transportation liaisons and the DMCC concerning patient needs, destination, and transportation assets. Recommendation: Further regional and facility-level training on patient movement with hospitals, non-hospital healthcare facilities, DMCCs, and transportation agencies would clarify the delineation of roles and responsibilities, especially within the context of coordinating transportation resources for evacuating patients. Objective 4: Hospitals perform tasks without excessive guidance or prompting. Strengths The partial capability level can be attributed to the following strengths: Strength 1: Evacuating facility staff conducted patient censuses without excessive guidance. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: Some evacuating facility staff received just-in-time training from assessors regarding incident command system (ICS) roles. Analysis: Assessors were available to provide valuable just-in-time training for evacuating facility staff. Some of this training was conducted to refresh some staff on assuming specific roles within ICS. Recommendation: Continue to provide ICS or hospital incident command system (HICS) training to facility staff to ensure those responsible for supporting an emergency response maintain proficiency in activating in support of a HICS/ICS structure. Objective 5: HECC disseminates situational awareness notification to nonhospital healthcare facilities. Analysis of HPP Capabilities 7 Northwest Healthcare Response Network
Strengths The partial capability level can be attributed to the following strengths: Strength 1: The HECC successfully disseminated WATrac notifications and Flash Reports to all partners, including non-hospital healthcare facilities. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: Some Long Term Care (LTC) partners indicated that they did not receive situational awareness updates in a timely fashion. Analysis: Some LTC partners indicated they would prefer to receive situational awareness updates from the HECC quicker. Since most LTC partners do not have WATrac accounts, they would not receive WATrac text notifications. Many LTCs can only receive information via reports disseminated by e-mail, which require constant monitoring to receive timely updates. Recommendation: NWHRN is in the process of identifying an alternative and/or redundant method to notify partners of an incident beyond disseminating e-mails. Additional discussion with LTCs are required to determine the most appropriate method of communicating with nonhospital partners during an emergency. Area for Improvement 2: Some contact information for LTC partners was outdated. Analysis: The LTC Response Team discovered some contact information for LTC facilities was outdated. As a result, the LTC Response Team was unable to contact some LTC partners to find available bed space for evacuating patients. Recommendation: HECC preparedness activities should include regular outreach to LTC partners to ensure contact information remains accurate and up-to-date. Objective 6: Non-hospital healthcare facilities conduct and provide bed count of available bed space to notionally receive evacuating patients. Strengths The partial capability level can be attributed to the following strengths: Strength 1: This exercise presented an opportunity to pilot the LTC Response Team, which identified 182 available beds in LTC facilities to receive patients from evacuating hospitals. Areas for Improvement The following areas require improvement to achieve the full capability level: Area for Improvement 1: More planning is needed to further develop the LTC Response Team. Analysis: The LTC Response Team demonstrated to be an asset in terms of supporting hospital evacuations to non-hospital facilities; however, this asset has not yet been documented in plans. Analysis of HPP Capabilities 8 Northwest Healthcare Response Network
Recommendation: Continue to convene LTC partners to discuss and develop plans for building and incorporating a LTC Response Team into HECC operations. Analysis of HPP Capabilities 9 Northwest Healthcare Response Network
Appendix A: IMPROVEMENT PLAN This IP has been developed as suggested recommended actions for Northwest Healthcare Response Network and partners of the coalition as a result of conducted on April 5, 2018. HPP Capability Capability 1: Foundation for Health Care and Medical Readiness Capability 2: Health Care and Medical Response Coordination Issue/Area for Improvement 1. Outdated partner contact information Recommended Action Routine drills to test communications and contact information for partners would ensure hospitals maintain the latest accurate emergency contact information. 2. HICS training Continue to provide ICS or HICS training to facility staff to ensure those responsible for supporting an emergency response maintain proficiency in activating in support of a HICS/ICS structure. 1. Alerts and notifications to partners 2. Patient placement redundancy 3. Coordination of patient transportation Ensure hospital emergency response plans include steps to contact all response partners (e.g., DMCC, local fire department, NWHRN). Additional regional and facility-level training on patient movement between hospitals and the DMCC would clarify the delineation of roles and responsibilities in terms of identifying patient destinations during a hospital evacuation. Further regional and facility-level training on patient movement with hospitals, non-hospital healthcare POETE Element (Plans, Organization, Equipment, Training, Exercise) Training, Exercise Plans, Training, Exercise Plans, Training, Exercise Plans, Training, Exercise Plans, Organization, Equipment, Training, Exercise Proposed Responsible Organization(s) All coalition partners Coalition hospitals Coalition hospitals Coalition hospitals and DMCCs Coalition hospitals, patient transport, and DMCCs Appendix A: Improvement Plan A-1 Northwest Healthcare Response Network
facilities, DMCCs, and transportation agencies would clarify the delineation of roles and responsibilities, especially within the context of coordinating transportation resources for evacuating patients. Continue to convene LTC partners to discuss and develop plans for building and incorporating a LTC Response Team into HECC operations. LTC Response Team would be involved in the coordination of patient movement from evacuating hospitals to non-hospital healthcare facilities. 4. LTC Response Team development Plans, Organization, Equipment, Training, Exercise LTC partners, HECC Appendix A: Improvement Plan A-2 Northwest Healthcare Response Network
APPENDIX B: EXERCISE PARTICIPANTS Participating Organizations Coalition Partners American Medical Response King County Office of Emergency Management Kitsap Public Health District Northwest Healthcare Response Network Pierce County Office of Emergency Management Public Health Seattle & King County Seattle Fire Department Seattle Office of Emergency Management Tacoma Pierce County Health Department Evacuating Hospitals Seattle Children s Hospital Swedish Medical Center First Hill Campus University of Washington University of Washington Medical Center Receiving Hospitals CHI Harrison Medical Center CHI Highline Medical Center CHI St. Francis Hospital CHI St. Joseph Medical Center Doernbecher Children s Hospital EvergreenHealth Medical Center EvergreenHealth Monroe Fairfax Behavioral Health Kaiser Permanente Madigan Army Medical Center Mary Bridge Children s Hospital MultiCare Auburn MultiCare Good Samaritan Hospital (Pierce County DMCC) MultiCare Tacoma General Oregon Health & Science University Hospital Overlake Medical Center Providence Everett Medical Center Providence Portland Medical Center Providence Sacred Heart Medical Center Randall Children s Hospital Smokey Point Behavioral Health Snoqualmie Valley Hospital Appendix B: Exercise Participants B-1 Northwest Healthcare Response Network
Stanford University Medical Center Swedish Medical Center Ballard Campus Swedish Medical Center Cherry Hill Campus Swedish Medical Center Edmonds Campus Swedish Medical Center Issaquah Campus University of California San Francisco Children s Hospital University of Washington Harborview Medical Center (King County DMCC) University of Washington Northwest Hospital & Medical Center University of Washington Valley Medical Center Virginia Mason Medical Center Virginia Mason Memorial Yakima Valley Non-Hospital Healthcare Partners Ashley House Avalon Care Center of Federal Way Bayview Benson Heights Rehabilitation Center Columbia Lutheran Home Genesis HCC Linden Grove Genesis HCC Orchard Park Health & Rehab Kline Galland LifeCare Center of Puyallup Mirabella Seattle Retirement Community Northwest Eye Surgeons Northwest Kidney Centers Park Rose Care Center Providence Marianwood Renton Nursing and Rehabilitation Seattle Medical Post Acute Care Skyline at First Hill Tacoma Lutheran Tacoma Nursing and Rehabilitation Center VA Puget Sound Health Care System Washington Veteran s Home Appendix B: Exercise Participants B-2 Northwest Healthcare Response Network
AAR AMR DMCC EMS EOP HECC HICS HPP HSEEP ICS IP LTC NWHRN OEM PHSKC SFD TPCHD Acronym APPENDIX C: ACRONYM LIST Definition After-Action Report American Medical Response Disaster Medical Control/Coordination Center Emergency Medical Services Emergency Operating Procedures Healthcare Emergency Coordination Center Hospital Incident Command System Hospital Preparedness Program Homeland Security Exercise and Evaluation Program Incident Command System Improvement Plan Long Term Care Northwest Healthcare Response Network Office of Emergency Management Public Health Seattle & King County Seattle Fire Department Tacoma Pierce County Health Department Appendix C: Acronym List C-1 Northwest Healthcare Response Network