2019 International Conference on Disaster Medicine and Hurricane Resiliency Presentation by Mary Russell, EdD, MSN Emergency Nurse, Boca Raton General Hospital; Past Chair, Healthcare Emergency Response Coalition of Palm Beach County

1. Strengthening Preparedness,
Response & Recovery
Healthcare Emergency Response
Coalitions
Mary Russell EdD MSN
HERC, PBC Florida
ASPR TRACIE SME
Center for Disaster Healthcare Preparedness
University of South Alabama

2. Objectives
 Explain incentives to establish & sustain a
Healthcare Emergency Response Coalition
 Present real-world case studies & challenges
addressed by Healthcare Emergency
Response Coalitions
 Describe available professional resources
for multidisciplinary emergency management
 Define Disaster Core Competencies for
Healthcare Providers & Agencies

3. What is a Healthcare Coalition (HCC)?
Formal collaboration among healthcare
& response organizations & public &
private sector partners in a defined
geographic location that is organized to
develop capabilities to prepare for &
respond to an emergency, mass casualty
or catastrophic health event as part of a
healthcare delivery system.
3
Goal: Ensure a Disaster system of care

4. Why are Coalitions needed?
To address emergency preparedness,
response and recovery challenges that
cannot be addressed by individual
institutions acting alone
4
A “Whole Community” approach will provide
advanced capabilities and resources.

5. Disaster Categories
Small-scale mass injury/illness events
 Bus crash, tornado, outbreaks, shootings
Large-scale natural disasters
 Hurricanes, moderate earthquake, flooding
Complex mass casualty events
 MCI shooting/bombing, burn, chem, rad, lethal or
contagious infectious disease
Catastrophic health events
 Nuclear, severe pandemic, major earthquake

6. Need for a Scalable Response to All-Hazards
Emergency
•Infrastructure
intact
•Sustainable
•Standard of care
•No deaths*
Disaster
•Infrastructure
damaged
•Temporarily
Sustainable
•Sufficient care
•Few deaths*
Catastrophe
•Infrastructure
disabled
•Evacuation
•Basic care
•Many deaths
possible*
*Deaths directly related to impact of event or ability to care for those ill or injured
STANDARDS OF CARE
Conventional Contingency Crisis

7. Local disasters provide wake-
up calls & lessons learned
7

8. Lots of lessons learned….
FL: Focus for preparedness was on annual hurricane risk vs. all-hazards8

10. Hurricane Andrew 1992
• Catastrophic level event
• Significant community infrastructure damage
including to healthcare agencies, employee
homes & businesses
• Patient evacuation was extensive
• Mutual aid was needed for months
• Recovery process took years
10

12. Lessons Learned: Katrina 2005

13. Disaster Response in Florida
• Bio agents: Influenza, norovirus, cyclospora, anthrax, dengue, west nile,
chikungunya, zika
• Hurricanes: Andrew, Frances, Jeanne, Ivan, Charley, Katrina, Rita,
Wilma, Fay, Gustav, Ike, Florence, Harvey, Irma, Matthew, Michael
• Tornadoes
• Mass Wildfires
• Mass Events: Superbowls, Mass Migration, Shootings, Protestors
• Mass Transportation Incidents marine, rail, vehicular,
air, space
Surge types present different challenges

14. Definition of Preparedness
Maximizes the ability to:
 Identify and mitigate hazards
 Respond appropriately to threats
 Recover and prepare again
14

15. Florida & the Caribbean are “international” destinations
with the potential for global threats.

16. Haiti 1/14/10/ Getty
46,000 – 85,000 fatalities

17. Haiti 1/14/10/ AP

18. Evacuation or Shelter-In-Place?

21. 21
The impact can be widespread.
Planning cannot occur in isolation.

23. Epidemiologist from PB
DOH attends & reports
at our coalition meeting
Evacuee concerns:
• Zika
• Leptospirosis

24. 24

25. 10/4/01
The day all the beepers went off…
25

26. 26
First Anthrax Fatality
Weaponized Agent

27. HERC is born…
It became clear that hospitals needed more support:
• Portable Decon units
• Hazmat PPE for hospital ED’s
• Communications equipment
• Training for healthcare professionals
• Development of common protocols
27

28. HERC VISION
To develop and promote the healthcare
emergency preparedness, response, and
recovery capabilities of Palm Beach County,
Florida
28

29. • Provide a forum for the healthcare community to
interact with one another & other response agencies at
a county, regional & state level to promote emergency
preparedness
• Coordinate & improve the delivery of healthcare
emergency response services
• Foster communication between local, regional & state
entities on community-wide emergency planning,
response & recovery
• Ensure overall readiness through coordination of
community-wide training & exercises
• Promote preparedness in the healthcare community
through standardized practices & integration with other
response partners
HERC Purpose
29

30. Major Difference in Disaster Medicine
Conventional
Medicine
Individual Patients
Disaster Medicine
Large Populations
of Patients

31. 31

32. HCC Disaster Capabilities
 Strong foundation for health care & medical
readiness
• Includes strong administrative & financial
backing for disaster planning efforts
 Health care & medical response coordination
• Each partner has a role to support response
 Continuity of healthcare service delivery
 Planning for medical surge

33. Medical Surge
• Ability to provide adequate medical evaluation &
care during events that exceed the limits of the
normal medical infrastructure of an affected
community.
• Ability of healthcare system delivery to survive
a hazard impact & maintain & rapidly recover
operations that were compromised (medical
system resiliency).

34. Medical Surge: Target Capability
• Outcomes:
– Injured/ill are rapidly & appropriately cared for
– Continuity of care is maintained for non-incident
related illness or injury
• Includes levels of care & continuum of care
Used to be considered similar to an MCI;
Now viewed as a throughput challenge.

35. Surge Capacity
• Potential patient beds or available space for
patients to be triaged, managed, vaccinated,
decontaminated, or simply located; space
• Available personnel of all types; staff
• Necessary medications, supplies & equipment;
stuff
• Legal capacity to deliver health care under
situations which exceed authorized capacity;
structure

36. Casualty Severity – what we know
• The majority of casualties can be treated &
released on an outpatient basis (± 85%)*
- Behavioral health support will be needed for all
• A smaller number will require admission (<15%)
• The majority will arrive as self-rescues
* Exceptions are bombings/major burn incidents/mass shootings

37. Triage Tags
Efficiently sort,
separate, stage &
treat medical &
psychological
casualties
Four Levels of Triage:
• Red Immediate/Critical
• Yellow Delayed/Stable
• Green Minor
• Black Deceased/ Expectant
Hospitals need to support
the red/yellow casualties
as a priority

38. MCI Acuity Level Calculator- it depends on the MCI!
Hosp
Bed Size
MCI Pts
20% bed size
Peds Pts
20%
Red
20%
OR
10%
Yellow
30%
Green
50%
100 20 4 4 0 6 10
200 40 8 8 1 12 20
300 60 12 12 1 18 30
400 80 16 16 2 24 40
20% conventional MCI surge
Doesn’t work for penetrating injury traumas or
the location of your hospital to an incident site.

39. Minimizing mortality
& morbidity is time-sensitive
Is your healthcare delivery system ready?

40. Fear Factor
…can cause a surge PRE & Post event

41. Public Assumptions
 Health care will be delivered using
established standards of care
 Resources & facilities needed to support
delivery of care will be available

42. Surge- the realities
• ED’s/Hospitals operate at/over staffed bed
capacity daily
• Most hospitals cannot not easily manage a 10%
acute increase in patients at once or over a short
period of time
• Critical care services are limited
• Numbers of patients, severity
of illness & potential contagion
may require modified standards
of care

43. Coalition Building
• Regular meetings build trust
• It takes one event to see the value of coalitions
– Power Failures
– Water Pressure Failures
– Hospital Evacuations
– Vulnerable Population Sheltering
– Critical Supplies (Blood products, Meds, Fuel)
– Critical Services (Oxygen, Dialysis)

44. Coalition Infrastructure
Boundaries Mission/Vision/Goals
Membership Strategic planning
Meeting structure Communications
Leadership Common Protocols
Risk assessment Joint Training/Exercises
Governance Joint planning
MOU’s/MOA’s Resources & assets
Gap Analysis Operating Guidelines

45.  Hospitals (Acute, Subacute &
Specialty)
 LTC: SNF’s/ALF’s/RTC’s
 Outpatient Providers
 Health Dept.
 Health Care District
 Medical Society
 Healthcare Foundations
 Hospital Association
 Veterinary Association
 Division of Emerg Mgt/EOC
 School District
 Home Health
 Supply Chains: DME, Pharma
 Law Enforcement
 Fire-Rescue & EMS
 Regional Reps
 Red Cross
 Mental Health
 Universities
 Blood Banks
 Dialysis
 Business Partners
 Others: Utilities
(electric, water,
waste, fuel), ME, MRC
etc)
HCC Membership

46. Healthcare System Delivery
 Levels of care:
Acute care
Specialty care
Subacute care
Rehab Centers
 Urgent care
 Surgicenters
 Health Clinics
 Other Providers: Hospice, Renal Services,
Home Health

47. Healthcare Service Delivery Assets
• LTC Capacity & Capability
• Outpatient Providers:
• Urgent Care
• Clinics
• Ambulatory Surgical Care Centers
• Dialysis Centers
• Mental Health Providers
• DME & Supply Chain Providers
• Pharmacies

48. • Essential Partners:
– Designated Representatives
– Alternate Representatives
– Infection Prevention Practitioners
• Interested Parties
HERC Agency Membership
48
“3 deep” ICS key personnel
recommendation

49. Coalition Leadership
• Chairperson
• Officers
• Steering Committee
• Standing Committees
• Workgroups / Task Forces
49
The work is shared!

50. • Communications
• Training & Exercises
• Syndromic Surveillance
• Public Affairs
• Finance
HERC Committees
Report
50

51. • Sheltering
• At-risk population needs
• Evacuation
• Patient tracking & movement
• Alternate Care Sites
• Event Management Software
• Utilities
• Fatality Management
• Active Shooter
HERC Workgroups
Report
51

52. Communications
• Meetings
• Email distribution Lists (24/7)
• Weekly roll calls using emergency radios
• Threat notification
• Mass notification
• Event management software
• Websites (Coalition, EOC, Health Dept)
• Conference Calls
• Publications Annual Reports, Newsletters, Press
Releases
52

53. 53
Redundancy is needed

54. Healthcare Facility
Email Alert Example:
“Dear Directors of
Healthcare Facilities”
54

55. Mutual Aid MOU
• Signed by member partners
• Provides framework for the healthcare system
to support each other and work together
• Voluntary agreement
• Supplements, but does not replace, each
facility’s existing emergency disaster plan
55

56. Mutual Aid MOU
• Addresses transfer & reimbursement for
loaned personnel
• Sets procedures for transferring patients
& evacuating a facility
• Outlines how facilities will track resources
• Addresses reimbursement for transferred
pharmaceuticals & supplies
56

57. Resources/Assets Identification
• Plans & procedures
• Space
• Staffing
• Equipment & supplies
• Skills & expertise
• Services

58. Resources & Assets
• Evacuation equipment
• Western Shelter ACS
• Pharmaceuticals
• Durable Medical Equipment
• Dialysis providers
• Blood supplies
• Morgue capacity
Individual organizations & regional assets
58

59. Medical Surge Capability

60. Incentives for Coalition Participation
 Situational Awareness
 Joint Hazard Vulnerability Analysis
 Multidisciplinary Training Opportunities
 Joint Exercise Participation & AAR’s
 Joint Disaster Planning
 Mutual Aid & Resources Support
 Shared Protocols
 Communications
 Economic Incentives

61. Coalition Benefits: Training
• Basic Awareness & Operations Level
• Chemical Terrorism
• Catastrophic Incident Response
• Comprehensive Emergency Management Planning
• Critical Infrastructure Hazard Vulnerability Assessments
• Hospital Emergency Management
• Basic Disaster Life Support; Advanced Disaster Life Support
• Incident Command System
• Infectious Substances: Packing & Shipping
• Medical Reserve Corps
• Pandemic Flu
• Radiological Training
• Response to Terrorism; Bombs, Burns, Blasts
• MCI Response Training 61

62. Incentives
• Specialty Expertise
• Common Issues & Emerging Threats
• Support for new & existing members
• Turnover of healthcare leadership
• Sharing of Lessons learned
• Trust Building
• Networking
• Management of major/catastrophic disasters
• Purchasing of shared equipment
• Cost savings 62
Meet disaster
partners
before disasters

63. Coalition Cost Savings: Example
• Tangible Cost Savings:
– Annual Membership: $500
– Trainings: $18,629/24 $ 776
– Exercises: $50,000/24 $ 2,083
– ReadyOp System:$33,000/11 $ 3,000
– PAPR’s: $49,462/12 $ 4,121
– P25 Radio Upgrade: $137,648/13 $ 10,588
Total: $ 20,568
• Intangible Cost Savings: Priceless!
Return on Investment = (Gain from Investment – Cost of Investment)
(Cost of Investment)
= $20,568 - $500
500
For every $1 spent on member dues, $40.13 was returned
63

65. ASPR Technical Resources, Assistance
Center, and Information Exchange
asprtracie.hhs.gov
1-844-5-TRACIE (toll-free)
askasprtracie@hhs.gov

66. ABOUT ASPR TRACIE
Technical Resources, Assistance Center &
Information Exchange
66
• A healthcare emergency preparedness
information gateway for stakeholders at any level
• No cost, online access to information &
resources
• NIH/NLM funded- access to complete DisasterLit
database: >8000 records; >700 organizations
• 57 Topic Collections completed; each topic has
key resources targeted for health & medical
preparedness
Officially launched September, 2015

67. ASPR TRACIE: Three Sections
67
Self-service collection of SME-reviewed
“Topic Collections” & peer-reviewed
materials with tools & experiences
Personalized support & responses to
requests for information & technical
assistance
Area for password-protected discussion
among vetted users in near real-time.
Can support chats & the peer-to-peer
exchange of user-developed templates,
plans, and other materials

68. Technical Resources Categories
 Must Reads
 Articles
 Guidelines and Strategies
 Hazard-Specific Planning
 Plans, Tools, and Templates
 Studies and Reports
 Toolkits, Templates
 Webinars
68

69. Topic Areas (a sampling)
Emergency
Management
Response
Planning
Healthcare
Coalitions
Decontamination Infectious
Disease
Exercises &
Evaluation
Recovery Communications Specific Hazards
Crisis Standards
of Care
Fatality
Management
Mental &
Behavioral Health
Medical
Countermeasures
Patient
Movement &
Tracking
Responder Safety
& Health
IT/EHR Pre-Hospital Pharmacy
Regulatory/Legal Disaster Ethics Vet Issues
69Also Hurricanes, Peds, Zika, Supply Chains, Disaster Ethics, FAC’s etc

70. Assistance Center
Person to person direct assistance with
specialists who have a background in
healthcare & public health preparedness
• No-cost to requesters. Can help with
providing additional resources on a specific
topic area, research help, developing new
documents, hosting a webinar, or facilitating a
meeting with ASPR TRACIE SME Cadre
members.
Open Monday-Friday, 9am-5pm ET,
1-844-5-TRACIE or askasprtracie@hhs/gov
70

71. Information Exchange
Peer to peer online discussion board
TRACIE TA Specialists moderate and monitor
conversations to identify potential resources
to share with others/ request to be part of
Resource Library
TA Specialists monitor all the domains if there
are any “trending” or unusual topics/ issues
that are being searched in the Resource
Library, asked through the Assistance Center,
and/or talked about in the Information
Exchange
71

72. National Incident Management System
(NIMS)
 Common all-hazards approach to enable the whole
community to work together, regardless of cause,
size, location, or complexity.
 Incorporates lessons learned from exercises and real-
world incidents, best practices, and changes in policy.
 Organized into 4 elements: Fundamentals &
Concepts, Resource Management, Command &
Coordination, & Communication & Information
Management.
https://www.fema.gov/nims-doctrine-supporting-guides-tools

73. Highly Pathogenic Infectious Disease Planning
 National Ebola Training and Education Center
(NETEC) & ASPR have partnered on webinars:
 Overview of exercise templates & unique
planning considerations
 Exercise planning for frontline facilities &
regional transport
 Templates for HCC exercises- all free &
customizable
Source: https://netec.org
Special Pathogens Planning for EMS, HCC’s
& healthcare facilities

74. PEDIATRIC RESOURCES
 ASPR TRACIE Pediatric Topic Collection
www.asprtracie.hhs.gov/technical-resources/31/pediatric/27
 American Academy of Pediatrics Children and
Disaster's website
www.aap.org/en-US/advocacy-and=policy/aap-health-
initiatives/Children-and-Disasters/Pages/default.aspx
 National Center for School Crisis and Bereavement
www.schoolcrisiscenter.org

75. 75
 A person can die from blood loss in 5 minutes
 In most cases, direct pressure can control
hemorrhage Can also use a finger or a knee
 Terrorist bombings require fast action for
potentially more severe injuries than civilian
trauma
 Consider Healthcare Coalition project for
responders, receivers & immediate bystanders
https://www.dhs.gov/stopthebleed

76. 76
 Hemorrhage control is vital.
 Prepositioned kits will help:
Emergency Responders
Community buildings: Kits with AED’s
Hospital ER’s: Kits with Crash Carts

77. 77
Disaster Core Competencies
 Require a unique set of knowledge, skills & abilities
 Enable staff to function efficiently & effectively in
their assigned disaster roles with less stress & more
resilience
 Increases consistency of training per level
 Emphasizes teamwork to manage a response for all-
hazards
 Assists in meeting emergency management
standards
Competencies are performance based for
specific capabilities

78. Disaster Core Competencies
Source: http://www.floridahealth.gov/programs-and-services/emergency-
preparedness-and-response/healthcare-system-
preparedness/_documents/corecompetenciesupdatedspring.pdf

79. 79
Disaster Core Competencies
Align with emergency management categories:
 General
 Communication
 Resources & assets
 Security & safety
 Staff
 Utilities
 Patient support

80. 80
Three Levels of Facility Preparedness
 Awareness Level: All Personnel
 Personal preparedness
 Role within department
 Mid-Level: Builds on awareness competencies
 Leadership level within department
 Department role within hospital
 Advanced Level: Builds on awareness & mid-
level competencies
 Leadership level, Specialty Teams; SME’s
 Facility role within community

81. 81
Awareness Level Competencies
Examples:
 Demonstrate how to access department & facility
disaster plans
 Complete a personal preparedness plan
 Describe department response for an event
 Identify department disaster resources
 Define communication process: notification &
updates
 State who to report to during an event & where
 State primary & cross-trained role & responsibilities
to internal or external notification of an event
 State employee hotline number

82. Personal Preparedness
82
Get a Kit
Make a Plan
Be Informed
Samples available at:
• http://www.redcross.org/prepare/
• http://www.floridadisaster.org
• http://www.ready.gov
• http://www.bt.cdc.gov/preparedness/

83. 83
Mid-Level Competencies
Examples:
 Describe the facility's Emergency Operations
Plan (EOP) - all hazards & hazard-specific
 State how to operationalize EOP & lead staff
in department implementation
 Describe how to operationalize immediate
actions & precautions to protect staff, facility
& patients from harm

84. 84
Advanced-Level Competencies
Examples:
 Explain process for facility to receive official
notification of public health or emergency threats
or events;
 Demonstrate successful communication of
messaging to staff throughout the organization
internally & externally through mass notification
mechanisms & hotlines;
 Demonstrate successful staffing callback rates
from drills & events;

85. 85
Advanced-Level Competencies
Examples:
 Demonstrate access to 24/7 list of critical
contacts for organization, community partners &
external authorities;
 Demonstrate ability to contact vendors for
essential supplies, services & equipment during
an emergency;

86. 86
Competency Checklists
 Intended to be performance based
 Completion to be monitored by department &
for the hospital overall
 Competencies are tied to training & exercises
 Staff are encouraged to advance their level of
competency over time

87. What does all this mean for you?
• Establish/Join your local HCC
• Increase your own awareness of threats
• Have a personal preparedness plan
• Take advantage of training
• Participate in exercises
• Know your facility’s plan
• Build your own resilience

88. Coalition Value
• Improve community & healthcare system
preparedness for disasters & public health
emergencies
–Improve system surge capacity
–Address gaps in preparedness & response
88

89. Outcomes are measured by the
ability to respond to a public health
emergency or disaster event
Time-sensitive concerns
Performance Measurement
89
Minimize morbidity & mortality from an event
ARE YOU READY TO RESPOND??

90. Questions?
HERC, Palm Beach County http://www.pbcherc.org
Mary Russell drmaryrussell@yahoo.com