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DISASTER PREPAREDNESS FOR HEALTHCARE PROVIDERS

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DISASTER PREPAREDNESS FOR HEALTHCARE PROVIDERS

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    1. DISASTER PREPAREDNESS FOR HEALTHCARE PROVIDERS California Preparedness Education Network Revised January 2008 Funded by ASPR Grant T01HP01405 *CORE SLIDE Ch*CORE SLIDE Ch

    2. Outline What is a disaster? Disaster response locally and nationally NIMS training ICS 100 Institutional disaster preparedness Triage Resources Straight forward. We are just reviewing the course of the lecture When compared to the old, we now have NIMS and ICS 100 compliance. Disaster medicine, which is now too broad for one small section, has been changed to triage for this portion. We have other parts, including decontamination and PPE, in other modules to round out disaster medicine. Straight forward. We are just reviewing the course of the lecture When compared to the old, we now have NIMS and ICS 100 compliance. Disaster medicine, which is now too broad for one small section, has been changed to triage for this portion. We have other parts, including decontamination and PPE, in other modules to round out disaster medicine.

    3. WHAT IS A DISASTER? Let’s start off just talking about what is a “disaster”? Let’s start off just talking about what is a “disaster”?

    4. Earthquakes Photo of San Francisco after Bay area earthquake – Can get similar photos of other California disasters from California OES website (image library) or Google image search. Note to Faculty: In this section, we have included only a few slides of photos. We expect you to pick your own photographs and information based on your experiences and local learner’s preference. You can include as many as you like to drive home the point that disasters are very broad and local (this is why we kept the last slide of the MVA)Earthquakes Photo of San Francisco after Bay area earthquake – Can get similar photos of other California disasters from California OES website (image library) or Google image search. Note to Faculty: In this section, we have included only a few slides of photos. We expect you to pick your own photographs and information based on your experiences and local learner’s preference. You can include as many as you like to drive home the point that disasters are very broad and local (this is why we kept the last slide of the MVA)

    5. The major purpose of this slide is to lead into the definition of a disaster, more practically that when a system is “overwhelmed” in terms of resources and response. If you chose, you can change this slide but please bring this point up for the local planning ascpet. Some disasters are not so obvious – may not be as widespread as we would expect. Even a relatively small number of patients could overwhelm a smaller facility. For example, a small accident near a rural clinic with a relatively small number of patients could overwhelm that system and constitute a ‘disaster’. This clearly sets the example that it is overwhelming of the system, not the absolute number, that makes the difference.The major purpose of this slide is to lead into the definition of a disaster, more practically that when a system is “overwhelmed” in terms of resources and response. If you chose, you can change this slide but please bring this point up for the local planning ascpet. Some disasters are not so obvious – may not be as widespread as we would expect. Even a relatively small number of patients could overwhelm a smaller facility. For example, a small accident near a rural clinic with a relatively small number of patients could overwhelm that system and constitute a ‘disaster’. This clearly sets the example that it is overwhelming of the system, not the absolute number, that makes the difference.

    6. WHAT IS A DISASTER? Webster’s def: “any happening that causes great harm or damage; calamity.” Practical def: any situation where the numbers of patients or severity of illness exceeds the ability of the facility or system to care for them, requiring external assistance. *CORE SLIDE “Disaster” means different things to different people. Private parties to government entities all have a different view of a disaster. Webster’s definition is more of a layperson’s def. This implies great damage, loss of life, etc. – in this def the magnitude simply defines the disaster. But, for our purposes it is best to define a disaster in the context of our system. A disaster is really anything that overwhelms the system – therefore causing a disruption of normal activities and need for external assistance. For example in the UC Davis ED large pile-up on the freeway with 30 patients arriving may constitute a disaster. In a small clinic, two patients arriving with organophosphate poisoning may be a disaster. *CORE SLIDE “Disaster” means different things to different people. Private parties to government entities all have a different view of a disaster. Webster’s definition is more of a layperson’s def. This implies great damage, loss of life, etc. – in this def the magnitude simply defines the disaster. But, for our purposes it is best to define a disaster in the context of our system. A disaster is really anything that overwhelms the system – therefore causing a disruption of normal activities and need for external assistance. For example in the UC Davis ED large pile-up on the freeway with 30 patients arriving may constitute a disaster. In a small clinic, two patients arriving with organophosphate poisoning may be a disaster.

    7. Disaster Events “All Hazards” Disasters can come in a lot of flavors. Just a list of some, but not all of potential disasters. You may want to encourage the audience to add a few, see if they are thinking. Disasters can come in a lot of flavors. Just a list of some, but not all of potential disasters. You may want to encourage the audience to add a few, see if they are thinking.

    8. “ALL HAZARDS” APPROACH Principles of preparation for human-made or natural disasters overlap with those of dealing with a chemical or biological event. We have discussed that disaster risk is out there. Introduce the importance of being prepared. Disaster planning and preparedness should use an all hazards approach. Because CBRNE is now “popular”, we may want to use this as a catalyst for getting prepared, but we should plan for all potential disasters when we plan. Plan for “all hazards”. Some examples here include: Preparedness for anthrax improved SARS response nationally Pandemic Influenza preparedness will enhance response to BT and emerging infectious diseases Earthquake preparedness and principles assisted with wildfire responseWe have discussed that disaster risk is out there. Introduce the importance of being prepared. Disaster planning and preparedness should use an all hazards approach. Because CBRNE is now “popular”, we may want to use this as a catalyst for getting prepared, but we should plan for all potential disasters when we plan. Plan for “all hazards”. Some examples here include: Preparedness for anthrax improved SARS response nationally Pandemic Influenza preparedness will enhance response to BT and emerging infectious diseases Earthquake preparedness and principles assisted with wildfire response

    9. *CORE SLIDE The role of preparedness in the medical community has grown greatly over the last few years with funding and outreach. However, many assumptions remain. Most notably is the link between first responders, the public health community, and the medical community. The medical community does not have the experience and expertise routinely seen in the fire, law, and military sector. However, we are expected to interact and respond and cannot just focus on our facility alone. Just look at Charity Hosptial in NO during Katrina. *CORE SLIDE The role of preparedness in the medical community has grown greatly over the last few years with funding and outreach. However, many assumptions remain. Most notably is the link between first responders, the public health community, and the medical community. The medical community does not have the experience and expertise routinely seen in the fire, law, and military sector. However, we are expected to interact and respond and cannot just focus on our facility alone. Just look at Charity Hosptial in NO during Katrina.

    10. AUM SHINRIKIYO Shoko Asahara Shoko Asahara = leader of Aum cult. He is blind. They feel that end of world is coming and their job to make it happen. Also have directed attacks against judges/politicians with views contrary to their interests.Shoko Asahara = leader of Aum cult. He is blind. They feel that end of world is coming and their job to make it happen. Also have directed attacks against judges/politicians with views contrary to their interests.

    11. TOKYO MARCH, 1995 In March 1995 cult members boarded several Tokyo subway trains with plastic bags containing sarin, an organophosphorus agent. At approximately the same time the bags were placed on the floor and punctured with umbrellas. The idea in this attack was to contaminate several subway cars that were all headed to the center of Tokyo. This was supposed to create a very large-scale attack in the center of Tokyo. Luckily the dispersal devices weren’t that effective. They depended on vapor action. Still 12 were killed and 5,500 injured. A local hospital (St Luke’s) saw 641 patients within the first 2 hours after the attack. Can you imagine being on-duty in an ED and having 641 patients show up all at once? Talk about a disaster (or a bad day at work).In March 1995 cult members boarded several Tokyo subway trains with plastic bags containing sarin, an organophosphorus agent. At approximately the same time the bags were placed on the floor and punctured with umbrellas. The idea in this attack was to contaminate several subway cars that were all headed to the center of Tokyo. This was supposed to create a very large-scale attack in the center of Tokyo. Luckily the dispersal devices weren’t that effective. They depended on vapor action. Still 12 were killed and 5,500 injured. A local hospital (St Luke’s) saw 641 patients within the first 2 hours after the attack. Can you imagine being on-duty in an ED and having 641 patients show up all at once? Talk about a disaster (or a bad day at work).

    12. LESSONS FROM TOKYO Coordinated terrorist attack on 5 subway cars with sarin gas 12 persons killed, more than 5,500 affected 641 seen in nearest ER Most were “walk-ins” 2 deaths, 4 severe cases, 107 moderate cases Ann Emerg Med 1996; 28: 129 Vast majority of patients presented within first hours after attack Only 20% of patients seen in ED were decontaminated in the field. (80% walk-ins) This is very consistent with past experiences with HAZMAT events. Most patients find their way to the ED, hospital, clinics Any healthcare facility in proximity to the event (ground zero) may become the “emergency room” and is likely to be overwhelmed. Confusion is great among patients/victims Only planning may help prevent similar confusion among healthcare providers – ensure functional responseVast majority of patients presented within first hours after attack Only 20% of patients seen in ED were decontaminated in the field. (80% walk-ins) This is very consistent with past experiences with HAZMAT events. Most patients find their way to the ED, hospital, clinics Any healthcare facility in proximity to the event (ground zero) may become the “emergency room” and is likely to be overwhelmed. Confusion is great among patients/victims Only planning may help prevent similar confusion among healthcare providers – ensure functional response

    13. PUBLIC HEALTH EMERGENCY We will often be the first presenting facility, regardless of facility We can become the disaster We may go to the disaster Facilities are likely to be overwhelmed and communication with local response teams essential We are accustomed to outside coordination and internal emergency response *CORE SLIDE These are the lessens supported from Tokyo and much of Katrina. You can make a link to Katrina as well if needed. The biggest thing is we may be the frist palce of the disaster response, we may become the disaster (as happened in tokyo and katrina), or we may go to the disaster as in San diego wildfires. Outside communication, the ability to create a command and control staff, and communication to the outside world is a big issue. This is one of the weakest links for us still. *CORE SLIDE These are the lessens supported from Tokyo and much of Katrina. You can make a link to Katrina as well if needed. The biggest thing is we may be the frist palce of the disaster response, we may become the disaster (as happened in tokyo and katrina), or we may go to the disaster as in San diego wildfires. Outside communication, the ability to create a command and control staff, and communication to the outside world is a big issue. This is one of the weakest links for us still.

    14. DISASTER RESPONSE In order to know our place in the event of a disaster, we need to know something about how disasters are handled ….. In order to know our place in the event of a disaster, we need to know something about how disasters are handled …..

    15. CALIFORNIA IS A NATIONAL MODEL We have disasters (lead the nation) “All disasters are local” mantra has been adopted nationally Standardized Emergency Management System (SEMS) is California creation the led to… National Incident Management System (NIMS) *CORE SLIDE Everyone knows that California is different – but beyond all the other things that make us unique – the way we handle disasters is unique. First of all we are a large state and we do have disasters. At any given time we are actively running several disasters (you can look at the California OES website and see the disasters we are managing in California on any day – usually several on any day) Sometimes we are called the “Disneyland of disasters.” Something on the order of 20-30% of federal disasters occur in California. Disasters here are managed from the local level up. This is unique. Local responders and governments are in control unless they ask for help or to turn over the disaster. The state’s role is to help provide resources and support to those agencies working locally. Everyone in our state used SEMS which was developed here in order to improve disaster management in the state. Our experience with wildfires in California has really shaped the way we handle disasters in this state. SEMS developed in the Oakland Hills fires in 1991. After these fires it was recognized that we needed a better system for managing large emergencies (disasters) in our state. We found that mutual aid wasn’t good and resources didn’t flow well – we had a problem. This caused the development of SEMS which is the management tool we use in California for disaster management and NIMS was modeled after this. Our long experience with disasters have led to our influence on national planning, with SEMS acting as a template for the National Incident Management System on the federal level. *CORE SLIDE Everyone knows that California is different – but beyond all the other things that make us unique – the way we handle disasters is unique. First of all we are a large state and we do have disasters. At any given time we are actively running several disasters (you can look at the California OES website and see the disasters we are managing in California on any day – usually several on any day) Sometimes we are called the “Disneyland of disasters.” Something on the order of 20-30% of federal disasters occur in California. Disasters here are managed from the local level up. This is unique. Local responders and governments are in control unless they ask for help or to turn over the disaster. The state’s role is to help provide resources and support to those agencies working locally. Everyone in our state used SEMS which was developed here in order to improve disaster management in the state. Our experience with wildfires in California has really shaped the way we handle disasters in this state. SEMS developed in the Oakland Hills fires in 1991. After these fires it was recognized that we needed a better system for managing large emergencies (disasters) in our state. We found that mutual aid wasn’t good and resources didn’t flow well – we had a problem. This caused the development of SEMS which is the management tool we use in California for disaster management and NIMS was modeled after this. Our long experience with disasters have led to our influence on national planning, with SEMS acting as a template for the National Incident Management System on the federal level.

    16. WHAT IS NIMS? Standardized system for managing disasters within from the local to federal level Structured to aid local authorities with mutual aid and resource assistance Local governments (agencies), states, and federal agencies use NIMS *CORE SLIDE We are going to talk about NIMS. This is the management tool we use for emergencies/disasters in California. It has many elements that we will discuss later in individual detail because it is important to know your response. The level of NIMS response is from the field to the state to federal level. And in an emergency, you may have many branches functioning at one time. Important to stress why we are talking about this. First, it is important to have some idea how disasters are handled in this state and know how we fit into the response. Secondly, if we want to interact and respond to other states and federal agencies for services rendered in a disaster, we need to be operating within the NIMS framework. We are not going to make you a NIMS expert – there are two-week long, boring courses that address this subject. I will just provide a quick overview. *CORE SLIDE We are going to talk about NIMS. This is the management tool we use for emergencies/disasters in California. It has many elements that we will discuss later in individual detail because it is important to know your response. The level of NIMS response is from the field to the state to federal level. And in an emergency, you may have many branches functioning at one time. Important to stress why we are talking about this. First, it is important to have some idea how disasters are handled in this state and know how we fit into the response. Secondly, if we want to interact and respond to other states and federal agencies for services rendered in a disaster, we need to be operating within the NIMS framework. We are not going to make you a NIMS expert – there are two-week long, boring courses that address this subject. I will just provide a quick overview.

    17. NIMS ELEMENTS Command and Management Preparedness Resource Management Communications *CORE SLIDE NIMS is broken down into 4 elements now. This is the first look at these elements and we will give a brief overview of each of these. *CORE SLIDE NIMS is broken down into 4 elements now. This is the first look at these elements and we will give a brief overview of each of these.

    18. NIMS ELEMENTS Command and Management Incident Command Operational area (local) approach Use of Incident Command System (ICS) at all levels Multi-organization coordination Public Information Systems Under commnand and management you have 3 areas ICS to manage and coordinate the response. This will ensure equal communication form all areas of the response world Multi-organization coordination ensures that each organization is represented from local to regional to federal area so there is coordination and no duplication of resources. PIS ensures that the command gives the message and that there uniformity across all forms of response and government Under commnand and management you have 3 areas ICS to manage and coordinate the response. This will ensure equal communication form all areas of the response world Multi-organization coordination ensures that each organization is represented from local to regional to federal area so there is coordination and no duplication of resources. PIS ensures that the command gives the message and that there uniformity across all forms of response and government

    19. OPERATIONAL AREA CONCEPT Chain of Command Federal State Region County Local Gov’t Field *CORE SLIDE SEMS/NIMS establishes the chain of command within our state. As I said, “all disasters are local.” Command starts with the field responders and moves up the chain as needed. Each level may ask for assistance from the next. The chain may start in the field then progress up to the Federal level if need be. This requires that California is divided into regions, then counties, then local governments. These are the functional units that make up each level on the chain of command in California. The US is also divided into regions for response in a similar manner. For all intensive purposes, the county is the basic operational area within CA. *CORE SLIDE SEMS/NIMS establishes the chain of command within our state. As I said, “all disasters are local.” Command starts with the field responders and moves up the chain as needed. Each level may ask for assistance from the next. The chain may start in the field then progress up to the Federal level if need be. This requires that California is divided into regions, then counties, then local governments. These are the functional units that make up each level on the chain of command in California. The US is also divided into regions for response in a similar manner. For all intensive purposes, the county is the basic operational area within CA.

    20. Here is how the operational areas now form into regions, 6 of them in CA. Here is how the operational areas now form into regions, 6 of them in CA.

    21. INCIDENT COMMAND SYSTEM Purposes Using management best practices, ICS helps to ensure: The safety of responders and others The achievement of tactical objectives The efficient use of resources *CORE SLIDE The incident command system (ICS) is not unique to California, though it was developed here. This is a command system used for managing disaster/emergency events. It utilizes a command system as seen on the slide. Each functional level is divided up into different branches. Parts may be activated as they are needed. ICS is used by the military and by almost universally by fire services. In the US we use NIMS so we use ICS. Very important to stress the puropse is the following: safety, achievement of tactical objectives, and efficient use of resources. ICS crosses jurisdictional boundires. *CORE SLIDE The incident command system (ICS) is not unique to California, though it was developed here. This is a command system used for managing disaster/emergency events. It utilizes a command system as seen on the slide. Each functional level is divided up into different branches. Parts may be activated as they are needed. ICS is used by the military and by almost universally by fire services. In the US we use NIMS so we use ICS. Very important to stress the puropse is the following: safety, achievement of tactical objectives, and efficient use of resources. ICS crosses jurisdictional boundires.

    22. ICS Requirements ICS is a key feature of NIMS and thus is a requirement for all state, county, and local officials and employees May be used for events, disasters, terrorism, or other large scale responses Represents best practices across country We are required to use NIMS, and thus ICS at many levels of local, regional, and state governments. Hospital and healthcare staff that are in first response or disaster preparedness are also required to engage in basic training and response. This would include introductory ICS, called ICS 100. All State and local workers, regardless of position or staff role, are required to take ICS 100. All MRC and other response groups, regardless of role, are required to be ICS 100 trained and NIMS compliant. We are required to use NIMS, and thus ICS at many levels of local, regional, and state governments. Hospital and healthcare staff that are in first response or disaster preparedness are also required to engage in basic training and response. This would include introductory ICS, called ICS 100. All State and local workers, regardless of position or staff role, are required to take ICS 100. All MRC and other response groups, regardless of role, are required to be ICS 100 trained and NIMS compliant.

    23. Basic Features of ICS (1) Common terminology Modular organization Management by objectives Reliance on Incident action plan Chain of command & unity of command Unified command Manageable span of control Common terminology:use common terms to define organizational functions, incident facilities, resource descriptions, and position titles. No jargon or codes used Modular organization: Top down approach as seen on the first slide. Based on the size and complexity of the incident. Only functions that are necessary are going to be filled. Each element has a person in charge Management by objectives: simple objectives communicated through the entire organization. Tactical direction is based on the incident objectives created. Usually based on the following in order of importance: Life saving, stabilization, property preservation. Incident action plan: This is the plan that states the objectives and gives a written or oral direction. Give operational period, responsibility, communication, and alternate plans if structure hindered. Chain of command: orderly line of authority within the ranks. Unity of command: You report to one supervisor and receive work assignments from only one supervisor. Unified Command: Enables all responsible agencies to manage an incident together by establishing a commons set of objectives and strategies. Allows incident commanders to make joint decisions by using a single command structure for multiple agencies. Thin unifeid commnad in military where, army, navy, AF all reside and give command to each group. Manageable span of control: Each supervisor oversees an effective ratio of subordinates and activities. Acceptable ratios are 2:1 to 7:1, with ideal being 3:1 to 5:1. If a supervisor has only 1 subordinate, he or she could be doing the job; if more than 7, it becomes difficult to adequately supervise. Ratios should be smaller for more complex assignments.Common terminology:use common terms to define organizational functions, incident facilities, resource descriptions, and position titles. No jargon or codes used Modular organization: Top down approach as seen on the first slide. Based on the size and complexity of the incident. Only functions that are necessary are going to be filled. Each element has a person in charge Management by objectives: simple objectives communicated through the entire organization. Tactical direction is based on the incident objectives created. Usually based on the following in order of importance: Life saving, stabilization, property preservation. Incident action plan: This is the plan that states the objectives and gives a written or oral direction. Give operational period, responsibility, communication, and alternate plans if structure hindered. Chain of command: orderly line of authority within the ranks. Unity of command: You report to one supervisor and receive work assignments from only one supervisor. Unified Command: Enables all responsible agencies to manage an incident together by establishing a commons set of objectives and strategies. Allows incident commanders to make joint decisions by using a single command structure for multiple agencies. Thin unifeid commnad in military where, army, navy, AF all reside and give command to each group. Manageable span of control: Each supervisor oversees an effective ratio of subordinates and activities. Acceptable ratios are 2:1 to 7:1, with ideal being 3:1 to 5:1. If a supervisor has only 1 subordinate, he or she could be doing the job; if more than 7, it becomes difficult to adequately supervise. Ratios should be smaller for more complex assignments.

    24. Basic Features of ICS (2) Manageable span of control Predesignated locations and facilities Resource management Information & intelligence management Integrated communications Accountability Mobilization Span of control: Number of individuals or resources that one person can supervise. Ranges from 2-8, ideal is 1:4 Presignated incident facilities: These facilities inclde there areas where the tacitcal management will occur, such as base, camp, staging area, and IC post. Resource Management: Very important process of categorizing, ordering, and dispatching resources. Also includes recovery and reimbursement. Integrated Communications: common communications plan with interoperability Accountability: Series of principles that must be adhered to, including check in, incident action plan, unity of command, span of control, and resource tracking. Mobilization: respond only when requested by an appropriate authoritySpan of control: Number of individuals or resources that one person can supervise. Ranges from 2-8, ideal is 1:4 Presignated incident facilities: These facilities inclde there areas where the tacitcal management will occur, such as base, camp, staging area, and IC post. Resource Management: Very important process of categorizing, ordering, and dispatching resources. Also includes recovery and reimbursement. Integrated Communications: common communications plan with interoperability Accountability: Series of principles that must be adhered to, including check in, incident action plan, unity of command, span of control, and resource tracking. Mobilization: respond only when requested by an appropriate authority

    25. IC and Command Staff IC: Provides overall leadership for response and delegates authority May have a command staff to include Public Information officer Functions Liaison officer Functions Safety officer Functions IC as above. First role is safety of all staff, then response that saves lives, stabilizes incident, and property recovery in that order PIO: advise IC on information dissemination and media relations. Gets info from planning section. SO: advises IC on incident safety. Works most closely with operations LO: assists IC by serving as a point of contact from other agency representatives. IC as above. First role is safety of all staff, then response that saves lives, stabilizes incident, and property recovery in that order PIO: advise IC on information dissemination and media relations. Gets info from planning section. SO: advises IC on incident safety. Works most closely with operations LO: assists IC by serving as a point of contact from other agency representatives.

    26. INCIDENT COMMAND SYSTEM AT A GLANCE Incident Command: Leads the response, appoints team leaders; sets tone and standards for response Operation Section: Handles key tactical actions including casualty care, search and rescue, fire suppression, securing the site Planning Section: Gathers information, thinks ahead and keeps all team members informed and communicating Logistics Section: Finds, distributes, and stores all necessary resources (supplies and people) Finance/Administration Section: Tracks all expenses, claims and activities and is the record keeper for the incident. IF you believe the group needs more detail These are the primary functions of each of the main ICS teams. You can learn more detailed information by looking at the job actions sheets found on the Emergency Medical Systems Authority website, www.emsa.ca.gov. ICS is based on job actions rather than on people. It’s a good idea to have at least one backup person assigned to each leadership role within ICS. IF you believe the group needs more detail These are the primary functions of each of the main ICS teams. You can learn more detailed information by looking at the job actions sheets found on the Emergency Medical Systems Authority website, www.emsa.ca.gov. ICS is based on job actions rather than on people. It’s a good idea to have at least one backup person assigned to each leadership role within ICS.

    27. ICS Facilities Incident command post Staging area Base Camps Helibase/Helispots These are the basic facilities for ICSThese are the basic facilities for ICS

    28. Incident command post Site where commander oversees all operations May change locations Includes vehicle, trailer, tent or building Located outside of the present hazard zone but close enough to maintain command

    29. Staging area Location where personnel and equipment are kept while waiting Close enough to response for timely delivery Many locations possible

    30. Base Location of primary logistics and administrative functions Only one base per incident, may be located in the IC Post Managed by logistics section

    31. Camps Place where resources are kept for incident operations if not at Base Usually the location where housing, staff, food, and sanitary services are kept

    32. Helibase Location from which helicopters may be parked, maintained, fueled & loaded In most incidents there will be only one helibase, known by the incident name. There may, however be more than one.In most incidents there will be only one helibase, known by the incident name. There may, however be more than one.

    33. Helispots Temporary locations where helicopters can safely land, load, unload and take off May be as many helispots as necessary, identified by numbers in the symbol.May be as many helispots as necessary, identified by numbers in the symbol.

    34. Common Responsibilities Mobilization Responsibilities of the incident Accountability responsibilities Demobilization responsibilities These are the common responsibilities that are part of a ICS team. They involve the following areas: mobilization, incident, accountibility, and demobilization. These are the common responsibilities that are part of a ICS team. They involve the following areas: mobilization, incident, accountibility, and demobilization.

    35. Mobilization Responsibilities Only mobilize to an incident when requested or dispatched by an appropriate authority You must make sure you receive a complete deployment briefing This is very logical. A deployment briefing consists of the following: Descriptive location and response area Incident check in Specific assignments Reporting time Communication instructions Special support requirements Travel arrangementsThis is very logical. A deployment briefing consists of the following: Descriptive location and response area Incident check in Specific assignments Reporting time Communication instructions Special support requirements Travel arrangements

    36. Incident Responsibilities Check in as directed Obtain initial Incident Briefing Maintain accurate Incident Records Supervisor actions: Maintain a Unit Log for your team Provide briefings to subordinates, adjacent units/facilities, and replacement personnel Check in: Must do for personal accounability, track resources, and a number of other items. You only need ot check in once at an authorized location such as base, IC post, camp, etc. Incident Briefing: Get current situation and job assessment, job responsibilities, procedural instructions, and safety hazards. Accurate records is self explanatory Supervisor actions include a daily log including activites and briefings done to all. Check in: Must do for personal accounability, track resources, and a number of other items. You only need ot check in once at an authorized location such as base, IC post, camp, etc. Incident Briefing: Get current situation and job assessment, job responsibilities, procedural instructions, and safety hazards. Accurate records is self explanatory Supervisor actions include a daily log including activites and briefings done to all.

    37. Accountability Maintain chain and unity of command Communicate hazards and changing conditions Act professionally, even when on “down” time Chain of command: Orderly line of authority within an organization Unity of command: Each person reports to, and accepts work assignments from, only one supervisorChain of command: Orderly line of authority within an organization Unity of command: Each person reports to, and accepts work assignments from, only one supervisor

    38. Demobilization Complete all work assignments & documentation Brief replacements, subordinates, and supervisors Evaluate performance of subordinates Check out using prescribed process Return any issued equipment Upon arrival at home, notify your facility

    39. NIMS ELEMENTS Preparedness Planning Exercises Training Personal Certification (ICS 100/700) Equipment allocation and certification Mutual aid These are the main areas of planning. Most are self explanatory, but personal certification means everyone can get certified and trained. Equipment allocation means there is planned and appropriate allocation before and during the response. Mutual aid is the same principle under SEMS, that effected areas will receive support from unaffected areas.These are the main areas of planning. Most are self explanatory, but personal certification means everyone can get certified and trained. Equipment allocation means there is planned and appropriate allocation before and during the response. Mutual aid is the same principle under SEMS, that effected areas will receive support from unaffected areas.

    40. NIMS ELEMENTS Resource management Tracking and following of resources from federal to local level during response Tracking will allow utilization of resources in best manner

    41. NIMS ELEMENTS Communications Incident management commands communication response Information management is managed over local to federal response Equipment Personnel Technologies

    42. Why does NIMS matter to me? If I work in a clinic or hospital, why would I need this? Why does NIMS matter to me, the primary care provider? Want them to know where they fit into the big picture. Know that they are at the local level and their local agencies are in control. Resources are provided from the levels above: local <= operational area <= regions <= state <= federal gov’t. Want them to know that as long as they fit into the framework of SEMS, they won’t incur the costs of the disaster – they will be provided with resources or be reimbursed. Why does NIMS matter to me, the primary care provider? Want them to know where they fit into the big picture. Know that they are at the local level and their local agencies are in control. Resources are provided from the levels above: local <= operational area <= regions <= state <= federal gov’t. Want them to know that as long as they fit into the framework of SEMS, they won’t incur the costs of the disaster – they will be provided with resources or be reimbursed.

    43. GETTING PREPARED Now it’s time to talk about getting prepared ……. As healthcare providers, how do we usually prepare for disasters? Now it’s time to talk about getting prepared ……. As healthcare providers, how do we usually prepare for disasters?

    44. BASICS OF DISASTER PREPAREDNESS Clinics and Hospitals must have a written disaster plan (CA Code of Regulations – Title 22, Div 5, Section 78423) Joint Commission requirement of healthcare facilities Must define community, including risk and special needs populations Must have goals, objectives with planning Need plan Must have someone in charge of plan Must train, exercise, and have after action of plan *CORE SLIDE While there is no specific requirement, there is a California code that says that all clinics should have a written disaster plan. Another reason to have one! Joint commission has it as an requirement and there is just a few features listed here. We will talk about some of those next. The first step is figuring out who will be administrator or to designate a command staff. This person (or group) will be responsible for making the plan, drills, evaluating it, and updating it. Make sure that it is clear in your planning who has the authority to activate the plan. Otherwise it will not be activated when needed or activated inappropriately. Most importantly, it is a Joint Commission requirement to have a disaster plan, which includes surge capacity, alternate care sites, and integration into the larger community response network. *CORE SLIDE While there is no specific requirement, there is a California code that says that all clinics should have a written disaster plan. Another reason to have one! Joint commission has it as an requirement and there is just a few features listed here. We will talk about some of those next. The first step is figuring out who will be administrator or to designate a command staff. This person (or group) will be responsible for making the plan, drills, evaluating it, and updating it. Make sure that it is clear in your planning who has the authority to activate the plan. Otherwise it will not be activated when needed or activated inappropriately. Most importantly, it is a Joint Commission requirement to have a disaster plan, which includes surge capacity, alternate care sites, and integration into the larger community response network.

    45. BASICS OF DISASTER PREPAREDNESS Four phases of disaster response Mitigation* Preparedness* Response Recovery These are the four phases of disaster response. Just show that we are now in the first two stages of mitigation and preparedness. We will be talking about some aspects of disaster planning. I don’t expect that audience will make a disaster plan based on this talk. Just an overview. They need to get a clinic disaster template and make their plan. By the way, ‘Mitigation’ is just trying to soften or limit the effects of a disaster ahead of time. Trying to ‘mitigate’ the damage by planning and making provisions ahead of time. These are the four phases of disaster response. Just show that we are now in the first two stages of mitigation and preparedness. We will be talking about some aspects of disaster planning. I don’t expect that audience will make a disaster plan based on this talk. Just an overview. They need to get a clinic disaster template and make their plan. By the way, ‘Mitigation’ is just trying to soften or limit the effects of a disaster ahead of time. Trying to ‘mitigate’ the damage by planning and making provisions ahead of time.

    46. BASICS OF DISASTER PREPAREDNESS HAZARD MITIGATION Risk assessment Potential for natural disasters (e.g., earthquakes, fires, avalanches) Potential for man-made disasters (e.g., chemical plants, nuclear facilities) Portals of entry (e.g., airports, populations in your community) Terrorist threats difficult to assess = all communities are at risk *CORE SLIDE The first step in disaster planning is to make a risk assessment. Need to try and identify the particular risks in your community and in proximity to your clinic. May not be able to think of every possible scenario, but by making risk assessment you can identify things that may be of particularly high risk. Risk assessment Terrorist threats difficult to assess = all communities are at risk (just recognize this) & hard to predict Potential for natural disasters (i.e.: earthquakes, fires) Portals of entry (airports, populations in your community) Potential for man-made disasters (i.e.: chemicals plants, nuclear facilities)*CORE SLIDE The first step in disaster planning is to make a risk assessment. Need to try and identify the particular risks in your community and in proximity to your clinic. May not be able to think of every possible scenario, but by making risk assessment you can identify things that may be of particularly high risk. Risk assessment Terrorist threats difficult to assess = all communities are at risk (just recognize this) & hard to predict Potential for natural disasters (i.e.: earthquakes, fires) Portals of entry (airports, populations in your community) Potential for man-made disasters (i.e.: chemicals plants, nuclear facilities)

    47. BASICS OF DISASTER PREPAREDNESS HAZARD MITIGATION Capabilities / capacity evaluation Available resources (e.g., drugs, beds, ventilators, surgical equip) Staff (e.g., physicians, PAs, nurses, nonmedical) Physical limitations (e.g., size, location, isolation/decon facilities) Vulnerabilities *CORE SLIDE Next you will want to evaluate the capabilities of your facility. Look at what resources you have already available, and then look and what you might be able to acquire. Need to think about limitations you may have too. Also think about vulnerabilities that your clinic may have and how you might address these. *CORE SLIDE Next you will want to evaluate the capabilities of your facility. Look at what resources you have already available, and then look and what you might be able to acquire. Need to think about limitations you may have too. Also think about vulnerabilities that your clinic may have and how you might address these.

    48. BASICS OF DISASTER PREPAREDNESS PREPAREDNESS Develop a disaster and surge plan Personal / family disaster plans Command & Control System Limit confusion! ICS = standardized command structure Facility emergency response team Facility protection Security, patient flow, crowd control Patient decon, staff protection (PPE) Evacuation *CORE SLIDE Some aspects of disaster planning that you should be familiar with Personal disaster planning = important!! Command & Control. Plan activation = who has authority to activate? (impt, often overlooked aspect) ICS = standardized command system for any emergency – used by government agencies and hospitals (and now you) Clinic emergency response team = model tailored for use of clinics, based on their current staffing structures. Modification because clinics are not usually first responders and do not always have staffing to carry out ICS (you may see this variation of ICS in some clinic disaster plans) Facility protection (esp impt in chemical, bio, nuclear events) Security, patient flow, crowd control, evacuation plans PPE – staff protection Decontamination Overt events (chemical/hazmat) = most important Covert events = pts freq self decontaminated during incubation period = less impt *CORE SLIDE Some aspects of disaster planning that you should be familiar with Personal disaster planning = important!! Command & Control. Plan activation = who has authority to activate? (impt, often overlooked aspect) ICS = standardized command system for any emergency – used by government agencies and hospitals (and now you) Clinic emergency response team = model tailored for use of clinics, based on their current staffing structures. Modification because clinics are not usually first responders and do not always have staffing to carry out ICS (you may see this variation of ICS in some clinic disaster plans) Facility protection (esp impt in chemical, bio, nuclear events) Security, patient flow, crowd control, evacuation plans PPE – staff protection Decontamination Overt events (chemical/hazmat) = most important Covert events = pts freq self decontaminated during incubation period = less impt

    49. BASICS OF DISASTER PREPAREDNESS PREPAREDNESS Develop a disaster plan (cont) Supplies Impossible to stock all possible supplies Plan for loss of power, light, phones, etc. Notification plans Recovery Facility decontamination, resupply Psych support Financial reimbursement *CORE SLIDE Supplies (your clinic, local hospitals, Nat’l Pharmaceutical Stockpile) Impossible to stock all possible resources – need plans to acquire resources Plan for loss of power, light, phones, etc. Notification (EMS, local health dept, Red Cross, CDC, FBI, local media?) Recovery (facility decon, resupply, psych support, financial reimbursement*CORE SLIDE Supplies (your clinic, local hospitals, Nat’l Pharmaceutical Stockpile) Impossible to stock all possible resources – need plans to acquire resources Plan for loss of power, light, phones, etc. Notification (EMS, local health dept, Red Cross, CDC, FBI, local media?) Recovery (facility decon, resupply, psych support, financial reimbursement

    50. Disaster preparedness kit from the Red Cross. There are many types of commercially available disaster kits. Wide range of available kits. You may want to look at something like this for your home or for clinic use. Disaster preparedness kit from the Red Cross. There are many types of commercially available disaster kits. Wide range of available kits. You may want to look at something like this for your home or for clinic use.

    51. BASICS OF DISASTER PREPAREDNESS PREPAREDNESS Communications Review available communications Plan redundant sources Must be able to work within ICS structure with common terminology *CORE SLIDE Review main form of communications in your clinic, both for patient care and health alerts Plan redundant source in case primary communications disrupted One of the most difficult to plan - Internet & phone sole source in most clinics - Cell phone circuits may become overloaded (clear from past disaster experience) - Satellite/aux communications costly This a difficult problem that we don’t have a universal solution for. Clinics have to make an assessment and decide what forms of communication they can or should have. Consider location, how rural, and what forms of communications already available.*CORE SLIDE Review main form of communications in your clinic, both for patient care and health alerts Plan redundant source in case primary communications disrupted One of the most difficult to plan - Internet & phone sole source in most clinics - Cell phone circuits may become overloaded (clear from past disaster experience) - Satellite/aux communications costly This a difficult problem that we don’t have a universal solution for. Clinics have to make an assessment and decide what forms of communication they can or should have. Consider location, how rural, and what forms of communications already available.

    52. BASICS OF DISASTER PLANNING PRACTICE Plan is no good without practice! Knowledge based training Cal-Pen Modules Skills based Training & Exercises Table top – low cost, convenient Functional – tests staff capabilities Full-scale – simulate an actual emergency *CORE SLIDE One of the most important of all elements! - once your plan is in place, you must educate and train individuals There is no use having a disaster plan if clinic staff can’t carry it out. For example, if an individual is assigned to work the auxiliary communications, you need to train them so they know how. Also you need to find out in an exercise if that person is unable to do that job. Ideally, exercise should feel no different than the real event. Table-top = least realistic, but easy. Functional = is a casual walk through that helps staff get acquainted with the plan, but not realistic. The best is the full-scale = this is like a dress rehearsal, tries to simulate some of the stress of a real disaster. *CORE SLIDE One of the most important of all elements! - once your plan is in place, you must educate and train individuals There is no use having a disaster plan if clinic staff can’t carry it out. For example, if an individual is assigned to work the auxiliary communications, you need to train them so they know how. Also you need to find out in an exercise if that person is unable to do that job. Ideally, exercise should feel no different than the real event. Table-top = least realistic, but easy. Functional = is a casual walk through that helps staff get acquainted with the plan, but not realistic. The best is the full-scale = this is like a dress rehearsal, tries to simulate some of the stress of a real disaster.

    53. FAMILY DISASTER PLAN Important for provider to know that family members are OK – allows them to perform Create a specific plan for your family Common contact or meeting place Supplies and evacuation plan Plan childcare if unable to get home *CORE SLIDE Even before you make a clinic disaster plan, you should have a family/personal plan! Knowing that family members are taken care of is very important - reduces health provider’s fears and allows them to perform. Create a specific plan for your family If separated, have a common contact or place in case local communications inoperable Have supplies available and evacuation plan Plan childcare in case unable to get home*CORE SLIDE Even before you make a clinic disaster plan, you should have a family/personal plan! Knowing that family members are taken care of is very important - reduces health provider’s fears and allows them to perform. Create a specific plan for your family If separated, have a common contact or place in case local communications inoperable Have supplies available and evacuation plan Plan childcare in case unable to get home

    54. Triage We will quickly hit on a few points regarding basic disaster medicine. This is some more clinical information. Just some stuff that healthcare providers who may be dealing with patients in a disaster situation should be familiar. We will quickly hit on a few points regarding basic disaster medicine. This is some more clinical information. Just some stuff that healthcare providers who may be dealing with patients in a disaster situation should be familiar.

    55. TRIAGE Important concept in disaster medicine Initial triage for patients in disaster situation may be the most important role for a primary healthcare provider Sites may vary and method will thus vary Sites include field, E.D. alternate care site, within hospital Priority change from providing best care to every patient to maximizing number of survivors *CORE SLIDE Very important concept in disaster medicine – really the basis for practicing disaster medicine Providing initial triage for patients in disaster situation may be the most important role for primary healthcare providers. I present this not because I want to make you into an emergency first responder, but you may provide invaluable service by prioritizing patients that clearly don’t need immediate care from those who do. Changes priority from providing best care for every patient to maximizing number of survivors Add discussion here about the importance of triage at many sites, including in the hospital or alternate care site when allocation of scarce resources may occur. *CORE SLIDE Very important concept in disaster medicine – really the basis for practicing disaster medicine Providing initial triage for patients in disaster situation may be the most important role for primary healthcare providers. I present this not because I want to make you into an emergency first responder, but you may provide invaluable service by prioritizing patients that clearly don’t need immediate care from those who do. Changes priority from providing best care for every patient to maximizing number of survivors Add discussion here about the importance of triage at many sites, including in the hospital or alternate care site when allocation of scarce resources may occur.

    56. START TRIAGE Simple Triage and Rapid Treatment Triage must be continually repeated as patient conditions will change Triage categories Green Yellow Red Black This is a concept that most physicians will have some familiarity with even if they aren’t experienced in emergency medicine or disaster medicine. START = Simple Triage and Rapid Treatment. Most common and basic triage system that is taught for disaster medicine. Uses four color codes that depend on the patient’s clinical severity. Remember that available resources must be taken into account when assigning categories. Can’t think who could be saved in an ideal circumstance – think who can be saved given the resources we have. For example if a patient could be saved with immediate surgery, but we have no OR, then they aren’t going to survive. Expending resources on that patient may cost other patients’ lives. TRIAGE CATEGORIES Red = first priority. Life threatening airway problem, hypoxia, or shock present but patient can be stabilized with immediate care. Most urgent care. Yellow = second priority. Injuries have systemic implications. Patient not yet have airway issue, hypoxia, or shock, but may develop over time. These patients generally able to sit 45 to 60 minutes without immediate risk, but will need care. Urgent. Green = third priority. Injuries without immediate systemic implications. Can sit for several hours without care. Nonurgent. AKA: “walking wounded”. Black = Dead/doomed. These are patients who are dead or cannot be saved with the available resources. No distinction can be made between biological and clinical death in triage situation – all patients without spontaneous ventilation and circulation are considered dead.This is a concept that most physicians will have some familiarity with even if they aren’t experienced in emergency medicine or disaster medicine. START = Simple Triage and Rapid Treatment. Most common and basic triage system that is taught for disaster medicine. Uses four color codes that depend on the patient’s clinical severity. Remember that available resources must be taken into account when assigning categories. Can’t think who could be saved in an ideal circumstance – think who can be saved given the resources we have. For example if a patient could be saved with immediate surgery, but we have no OR, then they aren’t going to survive. Expending resources on that patient may cost other patients’ lives. TRIAGE CATEGORIES Red = first priority. Life threatening airway problem, hypoxia, or shock present but patient can be stabilized with immediate care. Most urgent care. Yellow = second priority. Injuries have systemic implications. Patient not yet have airway issue, hypoxia, or shock, but may develop over time. These patients generally able to sit 45 to 60 minutes without immediate risk, but will need care. Urgent. Green = third priority. Injuries without immediate systemic implications. Can sit for several hours without care. Nonurgent. AKA: “walking wounded”. Black = Dead/doomed. These are patients who are dead or cannot be saved with the available resources. No distinction can be made between biological and clinical death in triage situation – all patients without spontaneous ventilation and circulation are considered dead.

    57. START Step 1: Delayed Patients- GREEN If they can walk, they are delayed Step 2: Respiration Check (non-walkers) No RR- dead RR >30- red, highest priority RR<30- green Step 3: Perfusion Check Radial pulse poor- red Good pulse- yellow Step 4: CNS eval Follows directions- yellow or green No directions- red

    58. Sustained Care Emergency mass care, in a sustained event like an influenza pandemic, will lead to sustained disaster response Principles will be different More likely to deplete resources and staff More likely to lead to austere care and allocation of resources Requires community planning Many providers will practice out of scope Here we are mentioning the difference between a single, likely overt attack like an IED or accident. However, many disasters will lead to a sustained response, which has a much greater likelihood to be difficult. For a single event, response teams can often get adequate support, but over days to weeks to months, this differs and will have problems as listed above. Here we are mentioning the difference between a single, likely overt attack like an IED or accident. However, many disasters will lead to a sustained response, which has a much greater likelihood to be difficult. For a single event, response teams can often get adequate support, but over days to weeks to months, this differs and will have problems as listed above.

    59. Here is how emergency mass care would look, with the most critically ill patients in the hospitals, and other less ill filtering down outside those sites. This will lead to the maximal care as single sites and the less urgent out at alternate care sites and other facilities. This is the community approach, as a national model, that will be in action in sustained emergency care. Here is how emergency mass care would look, with the most critically ill patients in the hospitals, and other less ill filtering down outside those sites. This will lead to the maximal care as single sites and the less urgent out at alternate care sites and other facilities. This is the community approach, as a national model, that will be in action in sustained emergency care.

    60. Triage in Healthcare Facility May have to employ triage within hospital or healthcare based facilities due to scarce resources No consensus on triage mechanism, but SOFA may be best Sequential Organ Failure Assessment Score PaO2/FiO2 ratio (respiratory) Glasgow Coma Score (CNS) Mean Arterial Pressure/vasopressor (CV system) Bilirubin (Liver) Platelets (coagulation) Creatinine (renal system) This slide is to mainly introducte the idea of triage in the setting of a hospital or alternate care site. We are unsure as the the triage method to be used, but the following should be kept in mind Triage in these settings will be implemented and more uniform when there is scarce resources that occur. There will be a standardized triage method for ethical reasons that will be applied uniformly across the board. This SOFA score is endored by CC and trauma societies, but may not be the local one used. Mainly we want to introduce the concept that triage can be simple, as in START, or complex and ongoing, as in the SOFA score. This slide is to mainly introducte the idea of triage in the setting of a hospital or alternate care site. We are unsure as the the triage method to be used, but the following should be kept in mind Triage in these settings will be implemented and more uniform when there is scarce resources that occur. There will be a standardized triage method for ethical reasons that will be applied uniformly across the board. This SOFA score is endored by CC and trauma societies, but may not be the local one used. Mainly we want to introduce the concept that triage can be simple, as in START, or complex and ongoing, as in the SOFA score.

    61. Next Steps (1) Disaster Preparedness is important for primary care providers, regardless of location and size of clinic A well developed plan will augment the state’s disaster response under NIMS A well organized plan will provide care to the staff, patients and community in a time of crisis

    62. Next Steps (2) Your plan will provide safety to your staff and unaffected patients Assess your risk and community needs Develop your plan based on these risks and needs with job action sheets describing each position’s role Teach your plan EXERCISE YOUR PLAN

    63. Final Note “With commitment, all things are possible. Without commitment, nothing else matters.”

    64. CONTACT NUMBERS

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