Case 1

1. Case 1 In the immediate aftermath of the 1989 Loma Prieta earthquake large numbers of UCSF housestaff and medical students made their way to SFGH to offer unscheduled assistance. If a similar event occurred today where would you go?

2. Case 2At 11 AM on a weekday the SF VAMC loses all power including its backup generator and emergency lighting. Ward residents have been told not to go to their afternoon continuity clinics in anticipation that they will be needed for manual bagging as the ICU ventilators batteries will soon lose power.

3. Flirting with Disaster

4. Disaster? .

5. Sylmar (San Fernando) Quake • 1971 VA San Fernando: Collapsed four buildings; killing 47 people.

6. Five Years After Palo Alto • 1994 Northridge: VAMC Sepulveda main building destroyed. Mission changed - rebuilt as OPC.

13. Goals of this talk • Brief introduction to emergency preparedness and emergency management with a glance at structure and function • Role of the resident and fellow during an event • Personal Preparedness

14. Disclaimer • This is not the Town Hall meeting • I will not be discussing clinical issues related to disaster response

15. Emergency Management “Is the discipline and profession of applying science, technology, planning and management to deal with extreme events that can injure or kill large numbers of people, do extensive damage to property, and disrupt community life. When such events occur and do extensive damage, they are called disasters.” Operations Level

16. The American Way • The management of routine, daily emergencies in the U.S. is influenced by a national preference for local control and private enterprise. The result is a complex, decentralized structure where the various tasks are divided among a myriad of independent public and private organizations. • In larger than normal emergencies, this decentralized structure creates problems in interagency coordination. Drabek Operations Level

17. Four Structural Qualitiesof American Society • Localism (decentralization of authority) • Lack of standardization • Unit diversity (formal and informal groups respond to disasters) • Fragmentation (vertical and horizontal) Drabek Operations Level

18. Federal Role • Leadership and coordination of Federal Departments & agencies for national security emergencies • Leadership and coordination of State and local emergency management agencies • Traditional focus: Preparedness and Recovery • Current foundation: Mitigation Operations Level

19. State Role • Leadership to State agencies • “Pivot point” between local and Federal government: determines needs of the political subdivisions and channels State and Federal resources for: • Hazard mitigation • Capability development/preparedness • Emergency operations (response & recovery) Operations Level

20. Responsibility & Authority • Governors, not the President, are responsible for the health and welfare of the citizens • Emergency powers of the Governor include: • Suspend State statutes, issue declarations • Commandeer private property • Direct evacuations • Control access to disaster areas • Authorize release of emergency funds • Apply for and monitor Federal disaster assistance • Quarantine the population Operations Level

21. Other Groups • Private sector • Social service organizations • Religious groups • Volunteers Operations Level

22. Five Conclusions about Disaster Response • Multi-organizational • Emergent • Organizations are loosely-coupled • Standard management will not apply • Evaluations must be directed at the network or system Drabek Operations Level

23. Four Continuing Problems • Inadequate capability for inter-agency communications • Ambiguity of authority • Poor utilization of specialized resources • Unplanned media relationships usually negative in nature Drabek Operations Level

24. Maximum Capability Required Optimally Integrated Plans Continual Maintenance 5 MITIGATION EFFORTS CAPABILITY ASSESSMENT EMERGENCY OPERATIONS PLANS CAPABILITY MAINTENANCE 6 7 EMERGENCY OPERATIONS EVALUATION 2 3 4 HAZARDS ANALYSIS 11 STATE/ LOCAL RESOURCES 13 1 CAPABILITY SHORTFALL MULTI-YEAR DEVELOPMENT PLAN ANNUAL DEVELOPMENT INCREMENT ANNUAL WORK INCREMENT 12 FEDERAL RESOURCES 8 9 10 Operations Level

25. ComprehensiveEmergency Management:4 Phases • Mitigation • Preparedness • Response • Recovery Operations Level

26. Mitigation • A sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects. Mitigation is the ongoing effort to lessen the impact disasters may have on people and property.

27. Important Mitigation Steps • Hazards Analysis - Internal & External • What types of natural, technological or man caused events threaten the organization? • Vulnerability Analysis • For each threat ask “what will be the likely impact?” • Actions taken to reduce the impacts • What can be done to ensure operating systems remain functional and have back-ups?

28. HVA Assessment Tool

29. Preparedness • Includes planning, training, exercises • Building organizational resiliency and capacity for response and recovery

30. ImportantPreparedness Steps • Resources Listing • Pre-arranged agreements • Staff orientation and training on basic response actions • Organization-wide rehearsals - That provide the back-up for damage to the plant, supplies, equipment, communications, and people. - Simple guidelines covering how you expect each employee to behave during any emergency. - That stress organizational mobilization coordination, and communications Operations Level

31. Response • Activities immediately before (for an impending threat), during and after a hazard impact to address the immediate and short-term effects of the emergency.

32. ImportantResponse Steps • Situation assessment • Warning and notifications • Setting objectives and priorities • Organization-wide instructions • Plan for what happens next • Liaison with external systems • Take appropriate actions to protect life and conserve property • Notify persons in charge • Continue to organize and manage All Staff Mgmt. Operations Level

33. Recovery • Activities and programs implemented during and after response that are designed to return the organization to its usual state or to a “new normal”

34. ImportantRecovery Steps • Determine present level and extent of patient care capability • Adjust patient care policies • Set objectives and priorities for the re-establishment of operating systems • Make stress debriefing services available to patients and staff • Schedule and conduct an incident critique • Make improvements to the CEM program Operations Level

35. IEMS is ... • A philosophy of inclusiveness - those groups that will respond to disasters are brought into the planning process • A method of organization - around functions generic to all disasters, not around specific hazards, agencies or people Operations Level

36. Planning Functions • Transportation • Communications • Public Works • Firefighting • Information/Planning • Mass Care • Resource Support • Health & Medical • Search & Rescue • Hazardous Materials • Food • Energy • Law Enforcement • Military Support Operations Level

37. IEMS is Also... • Strategic framework for implementing Comprehensive Emergency Management - a set of program development steps tied to the four phases: • Mitigation • Preparedness • Response • Recovery Operations Level

38. Maximum Capability Required Optimally Integrated Plans Continual Maintenance 5 MITIGATION EFFORTS CAPABILITY ASSESSMENT EMERGENCY OPERATIONS PLANS CAPABILITY MAINTENANCE 6 7 EMERGENCY OPERATIONS EVALUATION 2 3 4 HAZARDS ANALYSIS 11 STATE/ LOCAL RESOURCES 13 1 CAPABILITY SHORTFALL MULTI-YEAR DEVELOPMENT PLAN ANNUAL DEVELOPMENT INCREMENT ANNUAL WORK INCREMENT 12 FEDERAL RESOURCES 8 9 10 Operations Level

39. 1 2 3 4 Form Emergency Management Committee Establish Roles, Assign Responsibilities Develop Hazard Vulnerability Analysis & Complete Operating Unit Templates Determine Threats and Impacts Develop Standard Operating Procedures Develop Strategies for Mitigation, Preparedness, Response & Recovery Implement Mitigation and Preparedness Activities Take Actions to Reduce Impacts, Build Capacity 5 Report Results of Mitigation and Preparedness to Emergency Management Committee On-going Monitoring 6 7 8 9 Develop Emergency Operations Plan Organizational Concept of Operations Conduct Staff Education & Training Understand Roles, Build Competencies and Confidence Implement Emergency Operations Plan, Conduct Critique Rehearsal or Actual Event Annual Evaluation & Corrective Actions Review and Refine the Emergency Management Program Operations Level

40. Entities & Disciplines • Government • Business & Industry • Academia • Non-profit • Religious • Emergent Groups • Public Administration • Engineering • Medicine • Social Work • Public Safety • Legal Operations Level

41. Summary • The U.S. emergency management system is inter-governmental, inter-disciplinary and inter-agency in nature • Local jurisdictions provide the initial response to emergencies and disasters, supported by the State, then Federal government Operations Level

42. What about residents and fellows • Hospital Plans- HICS • UC GME Guidelines • Personal Preparedness

43. Where do you fit in?

44. Health Care Workers Response During a Declared Emergency • Health care workers’ ability and willingness to report to duty during catastrophic disasters • JournalJournal of Urban Health PublisherSpringer New York ISSN1099-3460 (Print) 1468-2869 (Online) IssueVolume 82, Number 3 / September, 2005 DOI10.1093/jurban/jti086 Pages378-388 Subject CollectionMedicine SpringerLink Health care workers’ ability and willingness to report to duty during catastrophic disasters • K. Qureshi1 , R. R. M. Gershon1, M. F. Sherman3, T. Straub2, E. Gebbie1, M. McCollum1, M. J. Erwin1 and S. S. Morse1 • (1)  Mailman School of Public Health, Columbia University, New York, New York (2)  Greater New York Hospital Association, New York, New York (3)  Loyola College, Baltimore, Maryland (4)  School of Nursing, Adelphi University, 1 South Avenue, 11530 Garden City, NY • Abstract  Catastrophic disasters create surge capacity needs for health care systems. This is especially true in the urban setting because the high population density and reliance on complex urban infrastructures (e.g., mass transit systems and high rise buildings) could adversely affect the ability to meet surge capacity needs. To better understand responsiveness in this setting, we conducted a survey of health care workers (HCWs) (N=6,428) from 47 health care facilities in New York City and the surrounding metropolitan region to determine their ability and willingness to report to work during various catastrophic events. A range of facility types and sizes were represented in the sample. Results indicate that HCWs were most able to report to work for a mass casualty incident (MCI) (83%), environmental disaster (81%), and chemical event (71%) and least able to report during a smallpox epidemic (69%), radiological event (64%), sudden acute respiratory distress syndrome (SARS) outbreak (64%), or severe snow storm (49%). In terms of willingness, HCWs were most willing to report during a snow storm (80%), MCI (86%), and environmental disaster (84%) and least willing during a SARS outbreak (48%), radiological event (57%), smallpox epidemic (61%), and chemical event (68%). Barriers to ability included transportation problems, child care, eldercare, and pet care obligations. Barriers to willingness included fear and concern for family and self and personal health problems. The findings were consistent for all types of facilities. Importantly, many of the barriers identified are amenable to interventions.

45. UCSF GME Disaster Planning Policy • Augments Facility (SFGH, SFVA, UC Hospitals) plans • Specifically addresses residents and fellows • Emphasizes commitment to housestaff training in a safe, organized and effective environment

46. UCSF GME Disaster Planning con’t • Acknowledges importance of balancing initial and continuing deployment of residents/fellows during an emergency and the critical role they play during an emergency with the educational needs of these trainees and the health and safety of the trainees and their families.

47. GME plan Con’t • Upon the Occurrence of an event, immediately following and up to one week: • Residents and fellows able to report to work will report to the institution of their current rotation assignment. Residents and fellows will be deployed as directed by the leader of the Hospital Incident Command at each institution.

48. GME plan con’t • Ongoing decision-making regarding continued deployment of trainees will be based on the clinical needs of the institution, the ability to adequately supervise trainees and the safety of the trainees.

49. GME plan con’t • By the end of week one if the emergency is ongoing an assessment will be made of: 1. the continuing need for provision of clinical care by trainees 2. adequacy of trainee supervision 3. likelihood that training can continue on site

50. GME plan con’t • By the end of the second week … 1) Program directors will be asked to assess ability to continue to provide training 2) Investigate/suggest alternative training sites if local training deemed untenable