RISK MANAGEMENT AND Weapons of Mass Effect

The actual risks from the use of such horrific weapons by terrorists against the American population are difficult to determine. Most communities face a much greater threat from unintentional anthrogenic or natural disasters. Traditional events—those due to accident, nature, or human error—can be predicted or at least anticipated based on historical records, and the magnitude of the consequences can be estimated. For instance, the existence and location of floodplains are known, as are areas prone to tornadoes or hurricanes, and local emergency planning committees are aware of the locations and quantities of highly toxic materials. Armed with such information, engineering and administrative controls instituted as an outcome of previous disasters have greatly lessened the consequences of these events.

The key elements of effective risk management are threat and vulnerability assessments. These processes, discussed in greater detail in Chapter 3, form the backbone for risk assessment. Risk assessment drives mitigation initiatives to prioritize actions to reduce either the probability that an event will occur or lessen the consequences should it happen. Modeling and simulation are powerful tools to identify community or facility vulnerabilities to a wide range of potential threats but do little to determine the actual threat.

The WME threat is based on terrorist motive, opportunity, and availability of the weapons or agents. Little need be said concerning terrorist motivation to do harm against the United States and its citizens. Although the United States is the most open society in the world, difficulties in gaining entrance to the nation while harboring significant caches of these weapons lessen, but do not eliminate, the opportunity. It is only the lack of the availability of such weapons, or the skills and resources by which to produce them, that keeps the overall threat low. Advances in science may work against these odds in the future, however. It is generally presumed that terrorists will have the greatest difficulty in obtaining or fielding those weapons that produce the greatest threat: nuclear or biological weapons. Chemical-warfare attacks and the use of radiological dispersal devices are considered to pose an intermediate threat, and the use of conventional explosives or the intentional release of toxic industrial materials poses the greatest threat.

It is equally difficult to measure the threat against a specific community or organization. Most terrorist attacks historically were targeted against governments, the military, or industry. Although these organizations and entities remain high on terrorist lists, a trend has developed over the last decade toward attacks against the civilian population. This shift is in keeping with the prime motivation of terrorists to create terror. Although the random sniper attacks near Washington, DC, in fall 2002 did not use WME, the effect was the same: a population significantly affected by fear. Finally, extremist organizations within our borders, such as religious cults or single-issue terrorists, may target organizations traditionally not prone to such attacks. One can only imagine the overall effect on its citizens if hospitals in small towns across the United States were targeted for explosions in a random fashion over several weeks or months.

Preparing Your Healthcare Facility for Disaster


Checklist 1.1. A successful Emergency Planning Process

  • Image from book Commitment and leadership from the top of the organization: The CEO, or equivalent, must be the champion for preparedness, setting an example for all employees and being the purveyor of the growth of a “disaster culture” in the organization.

  • Image from book An organizational need and desire to “do the right things”: A mandated plan, for the sake of meeting mandated requirements, is a useless tool. It will not be followed, is rarely developed as a facilityspecific entity, and will fail to meet the needs of the facility. The desire for preparedness must be inherent within the organization.

  • Image from book A facility-specific disaster plan: Plans that address appropriate responses to the needs of your facility are not transferable to your neighbor’s facility, nor to other types of healthcare facilities.

  • Image from book Input from the organization as a whole: Management and staff must participate to create staff ownership and pride in the plan and to ensure that all areas of concern and need are appropriately addressed.

  • Image from book Integration with the community: Coordination with and understanding of community resources and assistance are critical.

  • Image from book Delineated support functions: Authority and coordination, roles and responsibilities, and the ability to find and access needed resources must be addressed in detail.

Source: Adapted from Anderson, B., J.Dilling, P.Mann, A.Moore. 1996. Emergency Planning for Assisted Living Facilities. Silverdale, WA: Emergency Training & Consulting, International. Used with permission.

Checklist 1.2. Facility Preparedness for Terrorism

I. Emergency Management Team and Planning

  1. Designate an emergency management or disaster planning team in each facility and the community that

    • Image from book Consists of all disciplines that will respond to the disaster

    • Image from book Is represented by all standard and support departments (create an internal call list of team members, with all contact numbers)

    • Image from book Designates and understands the healthcare facility’s role in the community emergency management team and response

    • Image from book Understands the medical functions and their interconnectivity in a federalized response

  1. Define the work of the emergency management team and the work to be accomplished.

    • Image from book Conduct an internal hazards vulnerability analysis (HVA)

    • Image from book Prioritize threats and risks, and establish a plan to address each

    • Image from book Conduct a community and area HVA

    • Image from book Develop production time lines for each HVA issue addressed

    • Image from book Assess community programs and processes for current disaster response, and identify weaknesses and gaps in service

    • Image from book Plan for alternative delivery methods and routes for delivery of supplies, personnel, or other needs

    • Image from book Review all relevant disaster-response plans, and ensure that appropriately designated staff are familiar with their content and strategies

    • Image from book Know the community’s local or regional emergency management plans, command structures, and contacts in each organization

    • Image from book Determine secondary and backup processes and programs, and identify need for redundant systems

  1. Assess and test power and backup systems.

    • Image from book Identify all patient care needs in a power failure; prepare to use manual systems for a prolonged time

    • Image from book Develop a staffing support system for critical tasks during power or infrastructure failures

    • Image from book Understand the capabilities of the area emergency operations center (EOC) for communication and service should the area be without power for extended lengths of time

    • Image from book Preidentify special needs and services that the healthcare facility will require from the community or area services in a power failure; have a clear understanding of capabilities and limitations available in the local area

    • Image from book Assess strengths and vulnerabilities of internal technology, communications, information, and data systems

    • Image from book Ensure manual access to automated systems (e.g., medication dispensing) in power failures

  1. Establish an internal command center in each healthcare facility.

    • Image from book Prepare staff and volunteers via incident command system standards and protocols for seamless response

    • Image from book Practice setting up and operating the center frequently

    • Image from book Involve ham or volunteer radio operators in EOC operations; you may elect to have an on-site HAM operator to ensure continual communications

II. Communications Systems

  • Image from book Establish internal and external lines of communications (to medical staff, personnel, responding agencies, and public health authorities) with appropriate and redundant technology; develop a call list of external team members and contact numbers.

  • Image from book Establish collaborative strategies for communicating with neighboring hospitals, civic leaders, law enforcement, public health authorities, and emergency response agencies.

  • Image from book Assess routine staffing and emergency call-up plans, and ensure they are supported with communication and transportation strategies.

  • Image from book Maintain ongoing primary and redundant communication systems.

  • Image from book Inform staff of how you will communicate with them when off duty and what is expected of them in disasters; if a call chain is to be used for staff activation from home, make certain that alternate means of reaching each person are available.

  • Image from book Communications systems for influx of large volumes of calls must be predetermined, tested often, and designed to meet the needs of all Emergency Support Functions of the National Response Plan.

  • Image from book Ensure adequate internal communication systems and prepare for failures of vital equipment (e.g., cell phones and pagers); develop alternative delivery systems, including runners.

III. Communications, Alerts, and Warnings

  • Image from book Coordinate all activities through the area command center, emergency management agency, or EOC.

  • Image from book Know the alert systems and sources for alert information in your area.

  • Image from book Incorporate the community warning system into your facility disaster planning.

  • Image from book Link the community command center or EOC to each healthcare provider in your area.

IV. Community Integration

  • Image from book Develop strong relationships with other healthcare organizations and providers.

  • Image from book Develop personal and professional relationships with providers through a continual planning process.

  • Image from book Plan and conduct communitywide drills often, taking into account input from all sectors of the community.

  • Image from book Establish formal memoranda of understanding and agreements with critical providers of services.

  • Image from book Establish ties with counterparts at other healthcare organizations (e.g., incident commanders, pharmacists, laboratory directors, administrators) to better know each other and understand the plans of respective facilities.

  • Image from book Quantify pharmaceutical and antibiotic supplies, both at central and satellite facilities; routinely update this list.

  • Image from book Participate in the development of a coalition of hospitals that are geographically close to share supplies, pharmaceuticals, and staff under a clear chain of command.

  • Image from book Assess strengths and vulnerabilities of the community’s internal technology, communications, and information and data systems, and know how these interact with healthcare facility systems or providers.

  • Image from book Ensure that appropriate healthcare professionals from all agencies are aware of the importance of reporting unusual disease presentations, clusters, and atypical patterns of hospital use, and know the mechanisms for reporting.

V. Disaster Preparedness

  • Image from book Ensure preparedness to operate independently and be self-sufficient for up to 72 hours minimum.

  • Image from book Assess routine staffing and emergency call-up plans, and ensure that these are supported with communication and transportation strategies; update the roster of essential personnel.

  • Image from book Develop work-arounds or substitutions for any services and supplies you anticipate may not be available or may be inaccessible for delivery.

  • Image from book Consider developing a volunteer safety service team to assist with safety, security, and crowd control if professional help is not available.

  • Image from book Coordinate the preestablishment of an areawide licensure or certification approval system for local physicians, nurses, and other professional staff; establish a system to quickly evaluate essential credentials for temporary or volunteer professional staff; establish a community or area database to track and verify certification of medical personnel.

  • Image from book Develop a community or area volunteer service (e.g., Citizens Corp), and provide training and education and determine tasks for these teams in disasters to strengthen the overall response.

  • Image from book Ensure that the community is prepared to receive the Strategic National Stockpile in the event of a massive medical emergency; personnel needed for unloading, warehousing, security, and medication distribution should be preidentified; personnel should be trained and prepared in their roles and the processes tested in every drill event.

  • Image from book Prepare for mass-fatality management of deaths occurring inside the facility and in the community; bodies or body parts must be identified, cataloged, and refrigerated, and contaminated remains must be identified and secured for proper disposal.

VI. Drills and Exercises

  • Image from book Conduct both internal and external drills and exercises.

  • Image from book Participate in all communitywide disaster drills and exercises when requested.

  • Image from book Focus external drills on the role of the facility to respond to community needs in concert with emergency medical services and other emergency responders.

  • Image from book Clearly define the roles of first-responder agencies in various types of disaster events (e.g., Which department takes the lead in decontamination of victims? Will this be done in the field or at the hospital only? Will there be assistance from outside agencies if decontamination capability is established outside the emergency department?).

  • Image from book Conduct a communitywide tabletop exercise to include the most difficult tasks such as lockdown or quarantine of the town, a facility, or an area.

  • Image from book Drill multiple aspects of the plan at a time to provide an opportunity for the healthcare facility to realistically test interoperability with other community responders.

  • Image from book Include the establishment and operation of various shelters to provide care in a community; test medical overflow shelters or temporary structures.

  • Image from book Plan with community providers to treat a large number of patients (hundreds to thousands).

  • Image from book Test evacuation plans for the area, including the evacuation of the healthcare facilities.

  • Image from book Test shelter-in-place provisions throughout the healthcare delivery system.

  • Image from book Assess mutual-aid pacts and cooperative agreements for mass-casualty treatment capability.

Sources: This checklist was developed by K.J.McGlown, with additional information from the following: JCAHO. 2001. “The Power of Preparation.” Special issue, entitled “Emergency Management in the New Millennium.” Joint Commission Perspectives 21 (12):13–15; JCAHO. 2001. “Responding Effectively in the Midst of a Natural Emergency.” Special issue, entitled “Emergency Management in the New Millennium.” Joint Commission Perspectives 21 (12):22–23.

Checklist 1.3. Successful Drills and Exercises

  • Image from book Involve employees from all departments in planning an exercise; incorporate their suggestions and ideas for specific actions to be tested and examined.

  • Image from book Exercise emergency plans a minimum of twice a year, with a variety of internal and external events; various types of exercises can keep preparedness issues before staff year-round.

  • Image from book Fully integrate exercises to involve all area healthcare facilities and providers.

  • Image from book Test the communication and notification links within the organization and those from the organization to the external community at large.

  • Image from book Test internal systems.

    1. Notifying key personnel

    2. Setting up the command post

    3. Assessing internal damage to the physical plant and the impact on patient care delivery

    4. Preparing the emergency department (ED) to identify, process, and care for large groups of patients (establish alternate emergenct care locations in case the ED is destroyed or contaminated)

    5. Testing capacity and ability to clear beds as needed

    6. Implementing victim tracking and documentation

    7. Determining equipment and supplies available for activation (test delivery of items to ED or central care points)

    8. Establishing a triage center outside the ED

    9. Securing all ED operations and access points into the department

    10. Securing all entrances to the facility

    11. Establishing media control and public relations procedures

    12. Activating secondary call and standby for patient care services (e.g., surgery, burn unit, pediatrics, etc.)

    13. Testing communications with the area emergency operations center and other external responding agencies; testing backup systems of various types

  • Image from book Practice the stand-down of the exercise, testing the return to normalcy. These actions include adjustment of staff schedules and call coverage, communications required, and reporting processes.

  • Image from book Critique the exercise. Have outside experts evaluate your effectiveness; request comments from all participating organizations.

  • Image from book Conduct a “results oriented” evaluation process, and address (among others) the following major aspects of disaster preparedness:

    1. Alert systems

    2. Mobilization

    3. Direction and control

    4. Facilities

    5. Communications

    6. Exposure of responders

    7. Monitoring of environment

    8. Public information

    9. Media information and rumor control

    10. Special populations/schools

    11. Reception or mass-casualty receiving centers

    12. Traffic and access

    13. Medical services, transportation, facilities, and equipment

  • Image from book Develop corrective action plans from the gaps between performance and expectations.

  • Image from book Provide timely feedback to staff to reinforce lessons learned.

  • Image from book Take corrective actions on gaps identified from the exercise; document all actions taken.

  • Image from book Write the final “after action” report of the exercise, including findings and corrective action taken; share results with decision makers and those with a need to know.

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