Preparing for Emergencies What’s a Physician to Do?

When it comes to emergencies and disasters, whether

natural or man-made, the focus tends to be on coordi-

nating governmental and community resources—the

emergency management team comprising police, fire, rescue squad,

hazmat team, and other responders. Hospitals are often part of these

teams and participate in community-wide emergency simulations.

However, physicians’ practices and other health care providers are often

overlooked in these efforts.

One reason may be this: the Joint Commission’s accreditation standards require hospitals to identify and prepare plans to address potential emergencies and hazards, and the larger facilities are also expected to conduct periodic drills and training to test their preparedness. A study by the National Hospital Preparedness Program (HPP) shows that a majority of hospitals (more than 76 percent) participate in HPP and meet 90 percent (or more) of all program measures for “all hazards” preparedness.1 (See “How Does HPP Work?” on page 3 for more information on this program.)

Meanwhile, emergency preparedness among physician and ambulatory practices is far less reassuring, with only 34 percent reporting they are prepared and 66 percent saying they are somewhat, not very, or not at all prepared.2 This is particularly troubling given that for certain types of emergencies, such as bioterrorism events, primary care and family physicians are seen as playing an integral role in protecting patients from threats. A recent editorial in American Family Physician emphasizes how family physicians act as an “early warning system,” being among the first to identify natural disease outbreaks, such as viral pandemics, as well as bioterrorism events, such as the anthrax attacks of 2001. Because family physicians are often on the front lines for diagnosis, their emergency preparedness has never been more important.3

The tenth anniversary of the 9/11 attacks in New York has refocused attention on the need for disaster and emergency preparedness, inspiring numerous events and initiatives. To be sure, catastrophes of this magnitude are rare. Even so, medical practices in the New York metropolitan area are not immune to various natural disasters, with frequent threats from floods, hail, blizzards, tornadoes, and other severe weather conditions. Add to these the possibility of business disruptions due to power and equipment failures, fire, computer viruses, or disease outbreaks or pandemics, and there is plenty to be concerned about on the part of medical practices. For instance, one study found that human-made events—rather than large-scale natural disasters—were far more likely to blame for significant interruptions to US businesses. These man-made problems include serious disruptions related to power outages (72 percent), computer/hardware problems (52 percent), and telecommunications failures (46 percent)—versus 14 to 17 percent for floods, fires, or explosions.4 The Occupational Health and Safety Administration (OSHA) requires all businesses, including medical offices, to establish disaster recovery plans—but this regulation may not be enforced. As the American Red Cross notes, “Disaster recovery begins before the disaster. … As many as 40 percent of small businesses do not reopen after a major disaster like a flood, tornado, or earthquake.”5 All this highlights the need for physician practices to better prepare for disasters and emergencies.

The Quarterly Journal for Health Care Practice and Risk Management

FOJP SERVICECORPORATION

VOLUME 17 | WINTER 2011-12

FEATURE STORIES1 What’s a Physician to Do?

10 Ways to Protect Yourself, Your Patients, and Your Family

15 Lessons Learned from Hurricane Katrina and Other Disasters

22 Insights on Emergency Prepared- ness and Response in New York

ALSO IN THIS ISSUE 3 How Does HPP Work?

4 Volunteer Opportunities in New York and Beyond

5 Resource Listing

7 Emergency Training Is Their Mission

8 Volunteer Resources and Rights

9 Are Future Physicians Disaster Ready?

14 There’s an App for That

17 What Is HICS?

18 Cyberthreats and Bioterrorism

19 Are We Ready for Radiation and Nuclear Hazards?

27 From the Chief Medical Officer

Inside

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What’s a Physician to Do?Ten Practical Steps for Preparing Your PracticeYou might wonder whether disaster planning can really make a difference for medical practices. You might think, for instance, that your practice is already suitably prepared. In their book, Disaster Planning for the Clinical Practice, authors Neil Baum and John W. McDaniel outline a series of “what if” disaster scenarios designed to encourage private practices to consider their readiness and planning needs more closely. Their hypotheticals represent common events (not widespread catastrophes) that could easily occur and seriously disrupt any practice environment. Here are a few examples:6

●● “If all of your office computers were stolen, [do] you have their serial numbers, original costs, and values, as well as the ability to recreate all patient and practice management data?”

●● “If you were unable to come into the office for a few days or weeks, could anyone locate anything on your desk or in your patients’ charts? Is the answer the same if your office manager was sick or away at the same time?”

●● “If you or a partner in your practice [were] disabled for an extended period of time, [would] you or he or she be able to draw a salary? If so, how much, and for how long? If you are a solo practitioner, how will expenses of the practice be paid while you are unable to generate income?”

The authors assert that if your practice could not effectively respond to these or similarly challenging situations, it is time to start developing your practice’s disaster preparedness and recovery plans, or risk possible disruptions in patient care and business operations.

Accidents happen; a practice that is quickly destroyed by fire can take months to rebuild. If paper charts or computer records go up in smoke, how would you recreate them? Do you have an updated list of office inventory/equipment and other business assets? What about your accounts/billing and insurance? Problems in these areas can add considerable time and cost to the recovery process, reducing your ability to care for patients. For example, a two-person family practice in Oregon was ruined by a fire that started in a trash can. Because the practice had no disaster plan, it lacked an inventory list or designated alternate site for reopening. Even though a temporary location was found, the resulting space constraints stressed staff and patients and hurt the practice’s bottom line. Smoke-damaged paper medical records also had to be tediously re-created, at a high cost. The practice discovered it was underinsured, resulting in large unrecovered losses. Some of the losses were attributed to the practice’s accounting procedures, which were more than a year behind in billing and collections for some services—insurance covered only what was documented for the current year. Clearly, a disaster response plan could have prevented much of this practice’s costly, time-consuming, and patient-impacting disruption.7

Disaster response and emergency preparedness in physicians’ practices can be challenging in terms of finding the impetus to get started, making time to plan, and getting commitment from everyone involved. It can be tempting to put these matters aside, especially if your practice has not been hit by disasters or other emergency situations. However, as with

insurance and other risk management measures, disaster preparedness and recovery planning are essential to any business—including medical office practices. Luckily, those interested can find a wealth of how-to resources to help practices assess potential emergency conditions/hazards, determine risks/vulnerabilities, create comprehensive plans of action, prepare responses to emergency situations, and deal with recovery issues. Following are 10 practical steps to consider in disaster preparedness for physicians’ practices. These measures have been compiled from numerous resources, ranging from the American Medical Association (AMA) booklet, “Preparedness Toolkit for Office-based Health Care Practices,”8 to an overview on the Physicians Practice Web site,9 to the comprehensive continuing medical education course on “Disaster Preparedness for the Medical Office Practice,”10 to general business guidelines from the American Red Cross. For a more detailed list of practice-planning tools with Web links, see the “Resource Listing” on page 5.

1) Commit to a Disaster Planning Effort Effective disaster planning requires commitment and a “champion” in the practice to designate a disaster or emergency management team and spearhead the effort. Planning is a collaborative process—not a product—to be embraced practice-wide with engagement by all staff. It should include patient accommodations to meet special language, physical, auditory, or visual limitations and needs.11

2) Perform a Hazard Vulnerability Analysis According to the AMA Toolkit,12 practices should identify all local hazards with the potential to “do harm to property, the environment, and/or people.” Hazards are often categorized as natural disasters, such as severe storms, blizzards, earthquakes, or flooding; external hazards, including human-made or technology-related events involving bomb threats, criminal violence or theft, hazardous materials, or cyber-attacks; or internal hazards, such as facility damage (fire, plumbing, electrical), medical records breaches, or staffing losses. The key to conducting this hazard vulnerability analysis (HVA) is to identify and prioritize the threats to your practice, based on the probability and risk of each hazard’s occurring.

For example, the AMA Toolkit includes a form that practices can use to rate each hazard on a scale from 1 to 5—with 5 being the most dangerous—for its probability, impact on the practice, and effect on the community. A practice’s disaster plan should include contingencies for any hazard that totals 10 or more on the assessment scale when the scores are totaled.13

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Other resources emphasize the need to include planning for “low-probability, high-consequence hazards,” such as bioterrorism, radioactive and chemical events, large explosions, pandemics, or food contamination—which, though rare, would have devastating consequences if they should occur.14 As part of your HVA, it is important to know your environment, which can be done by conducting a thorough walk-through of your offices and physical surroundings. At the same time, you can identify other vulnerabilities related to equipment, office obstacles, escape routes, property risks, and the like. Finally, in prioritizing hazards and determining vulnerabilities, you may find it helpful to contact local hospitals and emergency management personnel to determine what they have included on their own HVAs.

3) Assess Your Practice’s Current Preparedness and Conduct a Gap Analysis The process of conducting an HVA leads naturally to an assessment of how prepared your practice is to address various disaster conditions. This builds on the walk-through concept, in which your disaster management team reviews your practice’s existing emergency preparedness in the following areas: facilities and equipment; patient care; key medical process areas, such as patients’ records; staff pre-paration, processes, and protection; communications resources; business asset inventory and protection; business continuity plans and procedures; and knowledge of applicable regulatory requirements.

For example, a comprehensive preparedness assessment should encompass everything from physical site conditions—such as the location of fire extinguishers and floor plans—to procedures for safely evacuating disabled patients. This includes evaluating your office building to determine its sustainability and suitability for emergency operations. It is advisable to learn about your office procedures, staff training, and current methods for protecting staff—such as requiring immunizations and exposure-containment measures. An assessment also should examine your business backbone—how you safeguard patient records, insurance policies, continuity and data recovery plans, financial resources, office inventory, and supply stockpiles. It is not enough simply to identify your practice’s state of disaster preparedness. A critical additional step is to compare your HVA results with your current preparedness assessment and identify any gaps that need addressing. In some cases, this may entail making only minor tweaks to supplies or processes/procedures. For example, your building may be equipped with fire extinguishers and well-marked exit routes, but you may uncover gaps in staff training on evacuation procedures and use of equipment. Other gaps may require more significant steps. Thus, a practice located in a f lood-prone area might need to consider backing up and moving important records from ground-floor offices to more secure storage facilities. Once identified, these gaps in preparedness can be addressed as part of implementing your practice’s full disaster response plan. 4) Develop a Comprehensive Emergency/Disaster Response Plan The AMA Toolkit suggests that your practice’s emergency/disaster response plan address the following areas:

●● Emergency/Disaster Management Team: Establish a team to oversee the development of your practice’s emergency/disaster response plan. Because there are many steps to this process, one tip is to assign staff based on their interest area. For instance, an office manager might be more attuned to addressing business and financial issues, whereas other personnel might be interested in handling clinical inventories or patient communications.

●● Plan Activation: Identify what triggers activation of your practice’s disaster plan—such as an emergency notification by your local health department or hospital—and designate who is responsible for initiating activation.

●● Communications: Define how your practice will communicate with emergency responders, area hospitals and pharmacies, your staff and patients (particularly those who are critically or chronically ill), your bank/insurance agency, and others in the community. Knowing that traditional communications can fail, include backup methods and maintain up-to-date emergency contact lists. In some cases, this might entail unconventional approaches, such as text messaging, social media forums, or Twitter. For example, your practice could set up a

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How Does HPP Work? The Hospital Preparedness Program (HPP) is managed by the Office of the Assistant Secretary for Preparedness and Response (ASPR), which is part of the US Department of Health and Human Services. The program was established in 2002 to address hospital preparedness and response to bioterrorism events. This purpose was later expanded to include medical response to pandemics and all-hazards preparedness, with an emphasis on helping health care facilities build medical surge capacity and capabilities to manage care for real or simulated events.

In 2009, an ASPR study assessing hospital preparedness found that although US hospitals had improved their capacity for handling “common medical disasters,” more work was needed in the areas of responding to “catastrophic health events.” The study recommended that the HPP focus on “healthcare coalitions”—essentially, the hospitals, long-term care facilities, clinics, physicians’ offices, and other medical facilities that should be coordinated to respond effectively during major health emergencies. The idea: Strengthen and integrate health care coalitions to “lay the foundation for a national disaster health and medical response system.”

To promote these efforts, in 2011 the HPP awarded more than $360 million in grants to state, territorial, and municipal governments. These grants target planning, integration, and infrastructure improvements to enable communities, hospitals, and other health care organizations build “medical surge capability” and better prepare for public health emergencies. Today, the HPP continues to provide leadership through “cooperative planning, information sharing, and management coordination” among health care coalitions.1

1 Public Health Emergency: Hospital Prepared-ness Program Web site, US Department of Health and Human Services, http://www.phe.gov/preparedness/planning/hpp/Pages/default.aspx (accessed November 1, 2011).

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Preparing for Emergencies–What’s a Physician to Do? continued from page 3

private group via a social networking site such as Yahoo, Google, or Facebook to enable instant messaging with staff personnel during emergencies.

●● Life Safety/Contingency Planning Procedures: These represent the bulk of your efforts in preplanning and plan execution. These procedures address how you will protect people (staff, patients, and others), premises (structure and contents), resources (medical supplies/equipment, patient records, business assets/documents, and computer backup/cyber-security), and practice continuity (security, evacuation/shelter in place, alternate sites/processes, and emergency inventory). See details under “Ensure a Business Continuity of Operations Plan” later in this article.

●● Key Roles and Job Activities/Operations: These designate “point people”—key roles and job functions for your practice—based on the standard emergency management terminology and command structure of the Incident Command System (ICS) and National Incident Management System (NIMS). These help in coordinating your practice’s emergency response efforts with other responders in your local community. In addition to an incident commander, your practice might include individuals to oversee safety, community liaisons, and public information, as well as section chiefs for activities such as operations, planning, logistics, finance/administration, and medical/technical issues.

●● Demobilization/Disaster Recovery Efforts: These outline how and when your practice resumes normal operations after the “all clear” in your community. This process may involve physical cleanup, rebuilding, or even a permanent relocation of your practice; restoration of utility, computer, and other services; restocking and replacement of supplies/equipment; and insurance/federal relief claims. They can also result in financial changes with additional disaster-related expenses and patient population shifts. See more in “Promote Disaster Recovery.”

●● Disaster Response Education, Exercise, and Evaluation: To be effective, your practice’s disaster response plan must be embraced and understood by staff. This requires the “three E’s”: education, exercise, and evaluation.15 Many guidelines and planning resources stress the importance of making sure that all physicians and staff are fully informed and trained on the components of the disaster response plan and their roles should disaster strike. Periodic practice exercises or drills may be conducted to test emergency procedures and staff readiness. After this testing, a practice should evaluate the results and make adjustments to disaster plans as needed. These evaluations should be performed on at least an annual basis.

5) Ensure Personal/Family Emergency Plans When wide-scale disasters occur, health care professionals’ concerns may well extend beyond the practice and its patients to the safety of family and friends. At the same time, medically trained personnel may be called to serve their patients and the community at large—beyond their practices—making it more difficult to communicate with loved ones. To alleviate some of this potential angst, a practice’s disaster preparedness plan should include provisions for physicians and staff to develop personal and family emergency plans so everyone is better prepared should trouble occur. For more on this vital planning step, refer to “Ways

In preparing for disaster response, physicians must ensure that they are disaster-credentialed at hospitals in communities where they work or live. In New York, health care professionals can also “register, prepare, and care” as volunteers with the ServNY program to assist health care providers within the community when emergencies are declared across the state. This program is sponsored by the New York State Department of Health. For more information and to register, see the ServNY Web page at www.health.ny.gov/ServNY.

Additional opportunities exist for health care professionals to register and volunteer to help with disasters and emergencies at the state and national levels. These registries for emergency health care volunteers include the following:

Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP): This program is run by the Public Health Emergency arm of the US Department of Health and Human Services to allow health professionals who wish to volunteer during disasters or other emergencies to pre-register based on their state. ESAR-VHP streamlines verification of credentials and qualifications and enables faster mobilization of critical health care volunteers during state and national disasters. For more information, visit the ESAR-VHP Web site at http://www.phe.gov/esarvhp/pages/health-professionals.aspx.

Medical Reserve Corps (MRC): The Office of the Civilian Volunteer MRC is predicated on community-based units of health care volunteers who are willing to lend assistance during various emergencies. In addition, MRC volunteers often share “their time and expertise” by promoting public health campaigns throughout the year. There are nearly 30 MRC units in New York State, including two in New York City. For more information on joining a local MRC unit, see the MRC Web site at http://www.medicalreservecorps.gov/HomePage.

For health care professionals in New York City looking to sign up and serve the global community, the NYCMedics organization offers opportunities to volunteer and support disaster relief efforts worldwide. This group provides rapid response and deployment of mobile medical expertise to meet the needs of people located in challenging disaster zones and/or facing complex humanitarian emergencies. For more information, visit the NYCMedics Web site at www.nycmedics.org.

Responding to the Call—Volunteer Opportunities in New York and Beyond

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Preparing for Emergencies–What’s a Physician to Do? continued from page 3 to to Protect Yourself, Your Patients, and Your Family” for information

on developing emergency plans from a more personal perspective.

6) Coordinate with Community/Hospital Emergency Plans Beyond using ICS and NIMS terminology and job roles in a practice’s disaster plan, medical practices need to coordinate plans and activities with larger emergency management efforts with the community, hos-pitals, and local health departments. This helps clarify the community’s roles and expectations for health care professionals during emergency events. To accomplish this, some planning guidelines suggest inviting local emergency management personnel to your office to assess your practice’s disaster response plan and help coordinate overall preparedness.

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Resource ListingGENERAL• Centers for Disease Control and Prevention (CDC)

Training and Education for public health professionals: http://www.bt.cdc.gov/training/

• NewYorkStateDepartmentofHealthResourceslist: http://www.health.state.ny.us/environmental/

emergency/resources.htm#providers

• NewYorkCityAWARE-PublicandHEPP-healthcarecommunity resources:

http://www.nyc.gov/html/doh/html/browse/ browse-emergency.shtml

• NYConsortiumEmergencyPreparednessContinuingEducation classes and resources:

http://www.nycepce.org/resources.htm

• GreaterNewYorkHospitalAssociation(GNYHA)GeneralEmergencyPreparednessforProviders:

http://www.gnyha.org/31/Default.aspx

PHYSICIAN PRACTICES

• AMA Preparedness Toolkit for Office-based Health Care Practices (fee applies):

https://catalog.ama-assn.org/Catalog/product/ product_detail.jsp?productId=prod1440022

• AmericanAcademyofFamilyPhysicians(AAFP) Prepare Now Physician Resources:

http://www.aafp.org/online/en/home/clinical/ disasterprep/prepare/mdresources.html

• KentuckyMedicalAssociationModelDisasterPlanforPhysician Practice:

http://www.kyma.org/uploads/file/Public_ Resources/Disaster_Preparedness/Disaster_Plan.pdf

• AmericanRedCross:PreparingYourBusinessfortheUnthinkable:

http://www.redcross.org/www-files/Documents/pdf/Preparedness/PrepYourBusfortheUnthinkable.pdf

• American Academy of Pediatrics: A Disaster Preparedness Plan for Pediatricians:

http://www.aap.org/disasters/pdf/ disasterprepplanforpeds.pdf

• HICSAllHazardsIncidentPlanningGuide: http://www.hicscenter.org/docs/190.swf

PATIENTS/FAMILIES• CDC’sEmergencyPreparednessandYou: http://www.bt.cdc.gov/preparedness/

• FederalEmergencyManagementAgency(FEMA):Ready to Prepare.Plan.Stay Informed:

http://www.ready.gov/

• StateofLouisianaEmergencyPreparednessKit Checklist:

http://www.GetAGamePlan.org

• AmericanRedCross–BeRedCrossReady:Flashvideo and link to related resources:

http://72.3.171.147/#SITE

• AmericanPublicHealthAssociation–SetYourClocks,Check Your Stocks–home emergency kit:

http://www.getreadyforflu.org/clocksstocks/index.htm

• AmericanAcademyofFamilyPhysicians(AAFP) Prepare Now:

http://www.aafp.org/online/en/home/clinical/ disasterprep/prepare.html

• AmericanAcademyofPediatricsFamilyReadinessKit: http://www.aap.org/family/frk/frkit.htm

• AmericanMedicalAssociation(AMA)Centerfor Public Health Preparedness and Disaster Response:

http://www.ama-assn.org/ama/pub/physician- resources/public-health/center-public-health- preparedness-disaster-response.shtml

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7) Ensure a Business Continuity of Operations Plan Business continuity in disaster situations can be challenging. Even though it may not be possible to “disaster-proof” your practice, taking a close look at business operations and creating a business continuity of operations plan (COOP) is important to disaster response planning. This COOP serves as your “Plan B” for emergency situations and involves the following:

●● Identifying all critical business functions required for the practice to operate in an emergency, as well as the measures needed to ensure continued operations. For instance, if the building is f looded or the electronic medical records system goes down, you would need to make provisions for an alternate

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temporary office site with the ability to access hard-copy patient records or alternate/backup electronic versions.

●● Prioritizing your practice’s critical job functions, along with identifying who is responsible for performing the jobs, naming backup personnel, and creating contact lists.

●● Developing key communications for continuity, such as how to notify patients of your new practice circumstances.

●● Mapping a supply chain for obtaining critical business and medical supplies. (Current guidelines recommend maintaining a five- to seven-day emergency supply of vital medical/office supplies.)

●● Sustaining financial continuity, as by dealing with office charges/billing, payroll, and other financial needs. Some guidelines suggest establishing a line of credit to keep the practice af loat for several days or more until revenues return to normal. (A salary-insurance policy is an alternative but more costly approach.) Also be sure that the practice’s insurance policies are kept up to date.16

8) Promote Disaster Recovery The concept of disaster recovery (DR) is common in the corporate world, particularly in information technology environments. Like other businesses, medical practices should be aware of DR issues when instituting preparedness plans. Some guidelines even recommend starting with disaster recovery and working backward—that is, determining what you would have to recover often highlights everything that needs to be protected proactively through effective disaster preparedness and response planning. Regardless of approach, the practice landscape can change dramatically in the aftermath of a disaster or emergency. You may experience personal and professional loss—family, staff, patients, their loved ones. The building and much of what defines your physical practice may be damaged or destroyed. The local community may be similarly affected. Here are some issues to keep in mind with your disaster recovery efforts:17

●● Patient populations: Shifts in patient populations are common after disasters. People may move away or you may experience an influx of new patients, including under- and uninsured patients. Volunteer and other temporary aid organizations may inadvertently divert patients from local practices. Quickly establishing good communications and reliable medical recordkeeping (even if improvised) can help your practice manage patient ebb and f low.

●● Behavioral health: Disasters may increase behavioral health needs and tax available resources. This can affect anyone, from patients and staff to physicians and family members, including children. Practices may consider establishing contacts, or even contracting, with behavioral health specialists to assist staff and others with vital psychological services.

●● Staffing changes: As with patients, your staff may move on, face behavioral health issues, be eligible for workers’ compensation continued on page 8

Preparing for Emergencies—What’s a Physician to Do? continued from page 5 or family and medical leave, or require other changes to work

arrangements. It is important to be familiar with these options. You may also need to think about telecommuting options or sick leave policy changes to retain valued members of your practice.

●● Financial issues: Post-disaster, you may face various financial challenges related to gaps in insurance reimbursement, renegotiated contracts with suppliers, loan restrictions, and lack of available relief aid. For instance, most private practices are considered for-profit and are not eligible for federal funds. This is one reason that practices are advised to secure a bank line of credit as part of disaster planning.

●● Community environment: Disasters alter communities and often usher in changes to state, local, and sometimes federal regulations. You need to stay abreast of these changes, update your contacts, and keep connected with your local network of health care providers and emergency organizations.

9) Know Your Responsibilities—Beyond the Medical Practice You have readied your practice’s plans for disaster preparedness, response, and recovery. You have connected with community emergency management teams to ascertain where your practice fits into the overall disaster response. As a physician, you are a key part of the planning picture as well. The American College of Emergency Physicians (ACEP) advises hospitals to include provisions for hospital disaster physician privileging or credentialing to supplement existing medical staff as part of their emergency management plan. In addition to this localized participation, physicians can register with various organizations that mobilize emergency health care volunteers locally, nationally, and globally. For more information, see “Responding to the Call—Volunteer Opportunities in New York and Beyond” on page 4.

In the event of a large-scale disaster, physicians have an ethical obligation to be ready and to respond. A report that examines the AMA’s “Principles of Medical Ethics” respecting disaster preparedness and response concludes, “Indeed, when the health of large populations is threatened, society should expect that the medical profession will be prepared to provide medical care in a cohesive and comprehensive manner. … Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical care during disasters … even in the face of greater than usual risks to their own safety, health or life.”18

Although it may seem to be a “call to action,” this AMA report includes several commentaries that attempt to clarify the exact nature of a physician’s obligations in disaster situations. One commentary argues that during disasters, physicians should respond in a public service role, rather than as “virtuous professionals confronting personal risk,” balancing what is best for public interest and the greater good of victims instead of taking inordinate risks for individual patients. Another commentator finds the AMA’s “Principles” contradictory in terms of emergency response, noting that although Principle VI allows doctors to choose whom to serve (except in emergencies), they also have the leeway to “decide when a situation counts as an ‘emergency.’” All three commentaries conclude that “sound preparedness strategies” and better training for medical professionals would help to clarify these issues around disaster response expectations and actions.19

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Emergency training is available for health care professionals looking to learn how to respond appropriately and treat patients more effectively. Several levels of emergency/disaster training are available, from basic volunteer training to comprehensive medical certification programs. For example, theNationalDisaster Life Support (NDLS™) educationtraining program, supported by the American Medical Association (AMA), aims to develop national standards for emergency response training to improve the preparation of health care professionals and emergency response personnel for mass casualty events. Since 2003, more than 100,000 health professionals (30 percent of them physicians) havetakenNDLStraining.1

The American Red Cross is a valuable resource providing local/international emergency training to health care volunteers. To become an American Red Cross disaster relief volunteer, licensed health care professionals should con-tact their local Red Cross chapter (www.redcross.org). The Federal Emergency Management Agency (FEMA) also provides resources for training health care workers and other volunteers (see www.fema.gov). Bothorganizations offer intro-ductory and advanced courses for health care volunteers.

Additional numerous pro-grams are available to train health care professionals in specific disaster medicine techniques, including an “alphabet soup” of acronym-named courses in life support and disaster response, from advanced cardiac life support (ACLS)and advanced disaster medical response (ADMR) to acute psychological first aid (PSA). Training also includes a JumpSTART Pediatric Triage Tool (www.jumpstarttriage.com); comprehensive resources for chemical, biological, radiological, and nuclear (CBRN) incident response; and community disasterpreparation, among others.2

The American Academy of Disaster Medicine (AADM) encourages physicians everywhere to consider making disaster medicine their

“second specialty.”3 The AADM provides a comprehensive disaster medicine accreditation and licensing program for health care professionals. For more information, see the AADM Web site: http://www.abpsus.org/disaster-medicine. The AADM also publishes the American Journal of Disaster Medicine (http://www.disastermedicinejournal.com/), which presents studies, articles, and a wealth of topical information on disaster medicine in action.

For New Yorkers, two key groups/programs provide resources for emergency preparedness:

Emergency Training Is Their Mission The New York Consortium for Emergency Preparedness Continuing

Education (NYCEPCE) aims to “extend and strengthen the competency of health professionals in New York State and New York City to respond effectively to emergency events of all kinds.” NYCEPCE sponsors events and offers various online courses designed to help medical professionals identify and rapidly respond to potential emergency and disaster situations. These include training for working within institutional and community incident management systems, as well as with clinical and public health organizations to provide effective care for those affected.4

The New York City Department of Health and Mental Hygiene (NYC DOHMH) Healthcare Emergency Preparedness Program (HEPP) supports New York City’s emergency preparedness by providing the health care community with guidance, training, and resources for enhanced readiness and response. Information is available through the

NYC DOHMH-sponsored NYC Healthcare PREPARES Web site, which focuses on resources for hospital, primary care, pediatric, and emergency preparedness coordinators. Resources abound for health care emergency preparedness, from assessment tools and recommended protocols to training drills and exercises to put those tools into action and test preparedness.5 For example, the “New York City Primary Care Center Emergency Preparedness Assessment 2004” is a survey tool that primary care practices can use to assess emergency preparedness based on five categories: prior experiences general pre-paredness, education/

training, coordination/response, and logistics/operations.6

1 O’Reilly,K.B.“Katrina’sLegacy:RethinkingMedicalDisasterPlanning.”Ameri-can Medical News, September 6, 2011, p. 3, http://www.ama-assn.org/amed-news/2010/09/06/prsa0906.htm.

2 Huntington,M.K.,andT.F.Gavagan.“DisasterMedicineTraininginFamily Medicine: A Review of the Evidence.” Family Medicine 2011;43(1):16-17, http://www.stfm.org/fmhub/fm2011/January/Mark13.pdf.

3 PRWeb Press Release, “American Academy of Disaster Medicine Advocates Making Disaster Medicine Every Physician’s Second Specialty,” May 23, 2011, http://www.prweb.com/releases/AADM/disaster_medicine/prweb8465728.htm.

4 New York Consortium for Emergency Preparedness Continuing Education Web site, http://www.nycepce.org/default.htm (accessed August 12, 2011).

5 NYC Healthcare PREPARES Web site, “Preparedness Tools, Protocols, and Templates,” http://www.nyc.gov/html/doh/html/bhpp/bhpp-tools.shtml (accessed August 15, 2011).

6 New York City Department of Health and Mental Hygiene, “New York City Primary Care Center Emergency Preparedness Assessment 2004,” May 19, 2004, pp. 1-22, http://www.nyc.gov/html/doh/downloads/pdf/bhpp/bhpp-pcc-tool.pdf.

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Preparing for Emergencies—What’s a Physician to Do? continued from page 7

TheGoodSamaritandoctrine is “partofcommon lawonwhich theentire American legal system rests”; it “allows a medical professional who is sued for medical malpractice to claim that he or she was acting as aGood Samaritan and thus should be shielded from liability.” Aproblem here is that this legal shield seems limited to immediate medical assistance provided at the scene of an emergency and can therefore be difficult to apply to disasters and other emergencies, when medical volunteerism can extend into weeks or even months. Moreover, in defending their actions under theGood Samaritan law,health care professionals must show “the absence of any expectation of compensation; the absence of objection to the treatment; and the absence of gross negligence, willful and wanton conduct, or intentional injury.”Because this law is retrospective, notprospective, amedicalvolunteer who acts in an emergency situation has no guarantee that it will protect his or her actions in a subsequent suit.1

Recognizing the shortcomings of the Good Samaritan law,approximately one-third of all states (including New York) have enacted additional liability shield laws to protect health care volunteers who respond in emergencies. These laws address the issues of both immunity protection for the duration of declared public emergencies and a “prospective and authorized process” for designating health care professionals as emergency volunteers. This process is one reason that health care professionals are urged to pre-register with the state through the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP). As to the other two-thirds of the states, about a dozen have some “prospective” protections, and the remaining states have no clear statutes regarding health care volunteers.2

This lack of national uniformity in laws regarding medical volunteerism came to a head during the 2005 hurricane season, when countless healthcareprofessionalsdescendedontheGulfCoaststatestovolunteerandprovideassistanceinHurricaneKatrinareliefefforts—only tobe

“seriously delayed, and in some cases prevented, from providing services because they were unable to quickly and clearly obtain authorization to practice within the affected states.” These events prompted the Uniform Law Commission to draft the Uniform Emergency Volunteer HealthPractitioners Act (UEVHPA) in 2006. This act, amended in 2007, was developed as a legislative model for states to enact in order to provide uniform protection for health care volunteers against emergency-related

Volunteer Health Professionals—Resources and Rightsliability and to develop a framework to help streamline deployment of these volunteers during emergencies and disasters.3

The Centers for Law and the Public’s Health (a collaborative atJohns Hopkins and Georgetown Universities) have developed acomprehensive guideline to the legal and regulatory issues that may affect health professionals who volunteer during emergency response situations. This “Advanced Tool Kit” is designed to help states(and territories) address the legal issues related to registration and deployment of volunteer health care professionals. The tool kit includes an overview presentation, checklist, sample documents, case studies, and references.4

Beyond US national concerns, medical professionals who volunteeraround the world, particularly in developing countries, often encounter ethical issues in clinical care that are different from those they would see in this country. Some of these relate to general conditions of poor health and advanced disease risks, which can necessitate alternate (and unfamiliar) approaches to medical intervention, treatment, and medication.Beingawareof,andattunedto,uniqueenvironmentalandcultural needs can help medical volunteers provide more effective and appropriate care to these global communities. A recent HEC Forum titled“SpecialThematic Issue:GlobalHealthNeedsandShort-TermMedical Volunteers: Ethical Considerations” addressed these ethical issues and provided contextual guidelines for medical volunteerism.5

1 Rosenbaum,S.,M.Harty,andJ.Sheer.“LawandthePublic’sHealth:StateLawsEx-tendingComprehensiveLegalLiabilityProtectionsforProfessionalhealth-CareVol-unteers During Public Health Emergencies.” Public Health Reports, 2008;123(March–April):238, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2239336/pdf/phr123000238.pdf.

2 Ibid., pp. 239-40.

3 UniformLawCommissionWebsite,“EmergencyVolunteerHealthPractitionersSummary,” http://uniformlaws.org/ActSummary.aspx?title=Emergency%20Volun-teer%20Health%20Practitioners (accessed August 17, 2011).

4 TheCentersforLawandthePublic’sHealth:ACollaborativeatJohnsHopkinsandGeorgetownUniversities,“Legal&RegulatoryIssuesConcerningVolunteerHealthProfessionalsinEmergencies:AdvancedToolKit,”April2007,pp.1-48,http://www.publichealthlaw.net/Research/PDF/ESAR%20VHP%20Toolkit.pdf.

5 DeCamp,M.“EthicalReviewofGlobalShort-TermMedicalVolunteerism.”HEC Fo-rum 2011;23(2):91-103, http://www.springerlink.com/content/270t210679160115/.

A “perspective” appearing in the New England Journal of Medicine holds, “Health care volunteers can enhance their effectiveness by preparing for a disaster before it occurs and thinking critically about their ability to respond.”20 To this end, the piece offers a series of steps to guide health care providers in better preparing for emergency volunteerism—from registering with volunteer agencies to seeking appropriate training. (For more on training opportunities in disaster medicine, see “Emergency Training Is Their Mission” on page 7.) Health care professionals who answer the call to volunteer should also be aware of some of the specific guidelines and standards, as well as legal and regulatory requirements, that may apply during disasters and other emergency situations. For more information, see “Volunteer Health Professionals—Resources and Rights” below. Additionally, “Are Future Physicians Disaster Ready?” on page 9 offers a glimpse into medical school training and student preparedness for disaster response.

10) Training Doesn’t Hurt—But Does It Help? Despite the emphasis on disaster training efforts, a recent study found guidelines and requirements for disaster medicine competency to be “consensus based rather than evidence based.” In reviewing available literature, the study concluded that “reports of actual benefits in patient-oriented outcomes attributable to improved training in disaster medicine competencies are virtually nonexistent.” This review examined literature covering disaster response training related to disaster medicine, safety, specialized triage, clinical competencies, psychological issues, and knowledge of ICS and NIMS operations. Within each training type, the study also looked at available information on the effectiveness of different formats—from classroom and virtual classes to tabletop exercises, computer-based simulations, or simulated “live” disaster drills. Although some training, such as triage-specific exercises, did improve physician performance during emergency situations, the review urgently called for “further research in outcome-

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based disaster preparedness training.”21 The passing of time will bring increased research into this area, to test assumptions, assess efficacy of current training strategies, and provide an informed basis for future improvements to disaster medicine.

In theory, creating a plan for disaster preparedness should help medical practices cope with and recover from disasters. And common sense suggests that training in disaster medicine should help physicians respond more effectively to emergency situations, producing better patient outcomes. Perhaps most telling, we have the catastrophic events of the past decade—the 9/11 attacks, Hurricanes Katrina and Rita, and tornadoes in Tennessee and Joplin, Missouri—where valuable lessons continue to spring from the devastation, replacing horror with hope for better outcomes in future events. (To find out more, see “Lessons Learned from Hurricane Katrina and Other Disasters” on page 15.) It is clear that you can never totally “disaster-proof” your practice. However, putting the recommendations given here into effect, as well as conducting regular drills and making sure you and your staff are familiar with all disaster preparedness procedures, will help you be as prepared as possible when disaster strikes.

RESOURCES: 1 U.S.DepartmentofHealth&HumanServices,“MajorityofU.S.hospitalsmeetall-

hazards preparedness measures,” Press Release, May 5, 2011, http://www.hhs.gov/news/press/2011pres/05/20110505a.html.

2 FirstLook,HealthcareInformaticsResearchSeries,“TrendsinDisasterPreparednessandRecovery Technologies,” pp. 1-3, http://www.healthcare-informatics.com/Media/Docu-mentLibrary/Trends%20in%20disaster%20preparedness1.pdf(accessedAugust9,2011).

3 Harris,M.D.,andK.Yeskey.“BioterrorismandtheVitalRoleofFamilyPhysicians.”American Family Physician 2011;84(1):1-2, http://www.aafp.org/afp/2011/0701/p18.pdf.

4 Baum,N.,andJ.W.McDaniel.Disaster Planning for the Clinical Practice 5(Jones&Bartlett,LLC,2009).

5 “PreparingYourBusinessfortheUnthinkable,”AmericanRedCross,http://www.red-cross.org/www-files/Documents/pdf/Preparedness/PrepYourBusfortheUnthinkable.pdf.

6 BaumandMcDaniel,op. cit., pp. 2-3.

7 Defino, T. “Emergency Preparedness: Planning for the Worst: How to Establish a Plan thatWillKeepYourPracticeRunningShouldTragedyStrike.”Physicians Practice, 2006;16(13):1-5, http://www.physicianspractice.com/display/article/1462168/1589690..

8 Gebbie,K.M.,J.James,andI.Subbarao.“WhattoDoBefore,During,andAfteranEmergencyorDisaster:APreparednessToolkitforOffice-BasedHealthCarePractices,”American Medical Association, 2009, p. 9, https://catalog.ama-assn.org/MEDIA/Product-Catalog/m2310764/What%20to%20Do%20-%20Front%20Matter.pdf.

9 Defino, op. cit., pp.1-6.

10 Salyers, M. “Disaster Preparedness for the Medical Office Practice,” Mountain Area Health EducationCenter,CarolinaGeriatricEducationCenter,andPublicHealthRegionalSur-veillance Team 6, pp. 1-43, http://www.med.unc.edu/aging/cgec/professional/documents/PREPAREDNESS_FOR_MED_PRACTICE_OFC_final-1.ppt.

11 Ibid., p. 8.

12 Gebbie,etal.,op.cit.,p.9.

13 Ibid., p.11.

14 Salyers, op. cit., p. 14.

15 Salyers, op. cit., pp. 32-33.

16 Defino, op. cit., p. 3.

17 Salyers, op. cit., pp. 37-38.

18 K.Morin,D.Higginson,andM.Goldrich,“PhysicianObligationinDisasterPreparednessand Response,” Cambridge Quarterly of Healthcare Ethics 2006;15(4):417-21 http://a2p2.com/mep-p/ethics/physician_obligation.pdf.

19 Ibid., p. 426.

20 Merchant,R.M.,J.E.Leigh,andN.Lurie.“Perspective:HealthCareVolunteersandDisas-terResponse—First,BePrepared.”New England Journal of Medicine 2010;362:872-73, http://www.nejm.org/doi/full/10.1056/NEJMp1001737.

21 Huntington,M.K.,andT.F.Gavagan.“DisasterMedicineTraininginFamilyMedicine:A Review of the Evidence.” Family Medicine 2011;43(1), http://www.stfm.org/fmhub/fm2011/January/Mark13.pdf.

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In 2003, the American Academy of Family Physicians (AAFP) issued a Curriculum Guideline for Disaster Medicine outlining a

“recommended training strategy for family medicine residents.” This guideline (revised in October 2009) covers “planning, coordination, execution, and debriefing” for disaster response; defines the competencies, attitudes, knowledge, and skill sets to be achieved; and provides goals and resources to assist with implementing a disaster medicine program.1

In spite of these academic goals, a Web-based survey reports that many medical school students in the United States feel they are not receiving the education and training to know how to respond, or even participate, in the event of a disaster. According to the report, “Of the 523 medical students who completed the survey, 17.2% believed that they were receiving adequate education and training for natural disasters, 26.2% for pandemic influenza, and 13.4% for radiological events, respectively; 51.6% felt they were sufficiently skilled to respond to a natural disaster, 53.2% for pandemic influenza, and 30.8% for radiological events. Although 96.0% reported willingness to respond to a natural disaster, 93.7% to a pandemic influenza, and 83.8% to a radiological event, the majority of respondents did not know to whom they would report in such an event.”2

The American Red Cross and other organizations offer opportunities for interested parties to get involved and volunteer to gain valuable experience in emergency situations. For a perspective on this issue, see “Jumpstart Your Healthcare Career by Volunteering,” at http://allhealthcare.monster.com/careers/articles/3605-jump-start-your-healthcare-career-by-volunteering. Additional information on volunteer opportunities for licensed health care professionals is provided in “Emergency Training Is Their Mission” and “Responding to the Call—Volunteer Opportunities in New York and Beyond,”both in this issue of infocus.

1 American Academy of Family Physicians, “Disaster Medicine: Recommended Cur-riculumGuidelinesforFamilyMedicineResidents,”AAFPReprintNo.290,Revised10/2009, http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/rap/curriculum/disastermed.Par.0001.File.tmp/Reprint290.pdf.

2 Kaiser,H.E.,D.J.Barnett,E.B.Hsu,etal.“PerspectivesofFuturePhysiciansonDisasterMedicineandPublicHealthPreparedness:ChallengesofBuildingaCapable and Sustainable Auxiliary Medical Workforce.” Disaster Medicine and Public Health Preparedness, 2009;3(4):210-16, http://www.dmphp.org/cgi/content/short/3/4/210.

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Ways to Protect Yourself, Your Patients, and Your Family

E mergency preparedness and proactive planning for disasters may be vitally important for most of us, but it ranks near the bottom on our list of priorities. That is

because 95 percent of Americans take the “sunny day” approach, thinking, “It will never happen to me” or

“That never happens here” when, in fact, 60 percent of the population has been affected by some type of emergency event over the years.1

Perhaps that is why the Centers for Disease Control and Prevention (CDC) decided to attract some interest by capitalizing on the current fascination with zombies. The CDC’s recent blog campaign introduced a “zombie apocalypse” as the impetus for developing a personal preparedness plan. For details on this approach, see “Zombie Apocalypse—CDC Goes Viral with Disaster Prep” on page 11.

Resources for All In the same way that health care facilities, physicians’ practices, and local communities prepare for emergency response, you and your family also need a personal plan and supplies in place for protection during a disaster. In fact, ensuring that health care professionals have their personal/family preparedness plans in place is often a required part of facility and practice planning. Your patients and their families can also benefit from this valuable planning information. Emergency preparedness materials range from guides, checklists, and kits to Web and mobile applications, podcasts, videos, and even a soon-to-be-released video game. There is no shortage of resources available from federal, state, and local institutions, public health departments, medical organizations, and consumer advocacy groups. Specialized resources are also at hand to address the needs of specific audiences, including children and young families, those with disabilities and chronic illnesses, and multicultural and multilingual groups. Refer to the Resource Listing on page 5 for helpful tools and information.

Here are some plans and approaches to equip yourself, your family, and your household for emergency situations. This information can also be shared with patients as part of a wider outreach, to emphasize the importance of personal preparedness for disasters.

A Common Theme for Preparedness The CDC, the American Red Cross, and the Federal Emergency Management Agency (FEMA) support comprehensive programs for personal emergency preparedness built around the common theme, “Get a Kit. Make a Plan. Be Informed.” Here are some details:

●● The CDC’s version, Emergency Preparedness and You (http://www.bt.cdc.gov/preparedness/), provides highly detailed Web-based instructions.

●● The American Red Cross’s campaign, Be Red Cross Ready (http://www.redcross.org/portal/site/en/menuitem.86f46a12f382290517a8f210b80f78a0/?vgnextoid=fc56d7aada352210VgnVCM10000089f0

870aRCRD&vgnextfmt=default), features a series of checklists and links to one-page fact sheets, plus an online module with a video

“Do More Than Cross Your Fingers,” and a Prepare 4 Game (see http://www.redcross.org/domore).

●● The Ready.gov Web site (www.ready.gov), sponsored by FEMA and several other government groups, offers consumer-based tools and separate sections with specific guidance for businesses, children, and others.

Prepare a KitTo ensure that they are properly equipped and supplied for emergencies, everyone should prepare a survival kit for personal/family use. In deciding what to include, consider that during disasters, rescue workers are not likely to reach everyone right away. Basic services—such as electricity, water, sewers, and telephones—may also be disrupted for days or weeks, so plan accordingly. All the Web sites mentioned in this article provide comprehensive lists of the essentials, plus additional items to include in your kit. They also stress the importance of stocking sufficient emergency supplies for at least three days—some recommend five to seven days. Here are some of the basic categories and items that each kit should include:

●● Sustenance: Water (1 gallon per person per day), nonperishable ready-to-eat food, can opener, and utensils for eating and drinking.

●● Communications: Battery-, solar-, or hand-crank-powered radio; cell phones and chargers; two-way radios; flashlights and batteries; and a whistle to signal for help.

●● Personal care: First-aid supplies, seven-day supply of medications, personal hygiene items, regular bleach, masks, gloves, and extra clothing.

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●● Shelter: Plastic sheeting and duct tape for sheltering in place, tools (for utility shutoff), sleeping bags, wipes and plastic bags for sanitation purposes, fire extinguisher, matches, and related materials.

●● Personal/financial: Copies of medical records; proof of identification/address; other important family and financial documents, such as birth certificates, passports, deeds/titles, bank account records; and extra cash. See “Templates to Take Along” on page 12 for guidelines on formatting emergency medical information and contact cards.

●● Other: Consider extra needs and supplies for infants, children, elderly family members, and pets.

Refer to the respective Web sites (CDC, American Red Cross, and Ready.gov) for a more complete checklist of supplies. Ideally, the items in your disaster kit should be stored in waterproof containers in case of storm damage or f looding. The CDC even advises creating multiple kits to store at home, in the office, at school, and/or in a vehicle in case you are en route or must evacuate when disaster occurs. The number of kits and the specific supplies you stockpile will depend on your disaster plan and the particular hazards in your area.

For those with no time to pull it all together, a number of online sites, from Amazon.com to the Red Cross Store, have jumped into the disaster preparedness gap with a wide range of purchasable, prepackaged disaster kits, ranging from basic 72-hour personal “grab-’n’-go” emergency bags to deluxe multiperson survival kits.

Make a PlanBeyond assembling supplies, it is vital for families to develop a comprehensive disaster plan, complete necessary steps to implement the plan, ensure that family members understand and can follow the plan, and update the plan on a regular basis. The Web sites referenced in this article suggest these planning activities:

●● Assess family members’ responsibilities: Responsibilities will vary based on family composition and capability. One point stressed in emergency planning is to ensure that young children know the basics: their name, parents’ names, and key contact information such as their home address and emergency phone numbers. It is also important that they be aware of the disaster plans in place for their family’s workplace, day care, and/or school locations.

●● Identify two meeting places: Decide where to meet in case family members get separated, both outside your home and outside your neighborhood, if you are not able to return to your local area.

●● Select an out-of-town emergency contact: This is often a friend or relative with whom all family members can make contact as a central contact point to help locate one another in an emergency. One suggestion is to program this contact information into everyone’s cell phones as part of your ICE (In Case of Emergency) connections. To help families locate one another during disaster situations, the Red Cross has developed a special “Safe and Well” Web site and message board.

●● Determine an evacuation strategy: If you had to evacuate, would you stay with a friend or relative, at a hotel, or in an area shelter? Familiarize yourself with the options and determine several evacuation routes. Also, do not forget your pets in the planning process.

●● Practice, practice, practice: Most guidelines suggest practicing your emergency plan with all family members so there is no confusion about how to respond to a disaster. Recommendations are to practice every six months, including questioning children on what to do, conducting emergency drills, and following evacuation plans.

The CDC site lists additional planning recommendations, including preventive measures such as regularly testing smoke detectors, carbon monoxide detectors, and fire extinguishers; reviewing and refreshing supplies in your emergency kit; and ensuring that contact information is up to date.

Zombie Apocalypse— CDC Goes Viral with Disaster PrepLast spring, the Centers for DiseaseControl and Prevention (CDC) released a tongue-in-cheek Public Health Matters blog post, “Preparedness 101: Zombie Apocalypse,” with the premise, “If you’re ready for a zombie apocalypse, then you’re ready for any emergency.” Capitalizing on recent media fascination with this particular type of monster took off, and paid off.

The “zombie blog” quickly went viral, initially crashing the CDC site with volume, and ultimately generating unprecedented public interest in the CDC’s emergency preparedness materials. In five days, the blog page logged 2 million views (compared to their average 3,000 views per month). Visitors did not stop there but proceeded to access the CDC’s emergency preparedness pages (views jumped 3,147 percent) and half the viewers indicated their intentions to implement emergency preparedness plans.1 The CDC’s creative approach brought tremendous interest and awareness to the usually staid topic of disaster/emergency management. For more information, read the blog: http://blogs.cdc.gov/publichealthmatters/2011/05/preparedness-101-zombie-apocalypse/.

As a side note, taking its cue from the CDC’s tongue-in-cheek campaign, Drexel College of Nursing and Health Professions in Philadelphia took the unconventional tack of staging a zombie apocalypse for their recent mass-casualty drill in August. The drill was part of a weeklong certificate program in clinical simulation.2

1 C. Zacharyczuk, “CDC Urges Physicians to BecomeMoreInvolvedinDisasterPrepared-ness Planning,” Pediatric Supersite, June 7, 2011, http://www.pediatricsupersite.com/view.aspx?rid=84453

2 C.Beeler,“ZombiesAttackinCenterCity–ButIt’sForaGoodCause,”WHYYNewsworks, August 15, 2011, http://www.newsworks.org/index.php/health-science/item/24925-zombies-attack-in-center-city-but-its-for-a-good-cause.

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While elaborating on emergency plans, keep in mind that traditional communications systems often fail or get overwhelmed in disaster situations. The ready.gov site recommends teaching family members how to use text messaging (or SMS—Short Message Service), which often works in spite of network disruptions. It also provides templates for “folding wallet cards” that are an easy way to store multiple contact numbers.

Be InformedThe final step toward personal emergency preparedness is to be informed. This can involve steps that may overlap with other disaster-planning activities. Here are some suggestions for being informed:

●● Hazard awareness: Be aware of specific hazards in your area and the appropriate responses. The CDC recommends conducting a “home hazard hunt” to identify potential risks and vulnerabilities in your own home. Major Web sites provide details on supplies and planning needed to respond to various types of external disasters, from biological threats to windstorms. This includes considerations for evacuation, shelter-in-place, quarantine/isolation, special health risks, and more.

●● Recovery efforts: It is equally important to know what to do in the aftermath of a disaster. This includes awareness of when it is safe to return, smart practices for cleanup efforts, coping strategies, mental health concerns, and related information.

●● Subscribing to emergency alerts: Subscription-based automated emergency alert systems complement public address networks and often provide early warning and additional information on weather conditions, road hazards, and other safety situations. Typically, subscribers have alerts sent to multiple contact points, such as phone, cell, text, and e-mail. Many college campuses, schools, businesses, and some entire communities offer this capability. Larger cities are also starting to implement such systems as well, including efforts to launch the Personal Localized Alerting Network (PLAN) in New York City. For more information, see “New York City First with National Alert PLAN” on page 13.

●● Other informative resources: As an alternative to written materials, numerous instructional videos are available, along with public service announcements in audio, video, podcast, and mobile text formats. Refer to “Disaster-Ready Videos, PSAs, and Podcasts” for details. And in this day and age where there’s an “app” for almost anything, emergency preparedness is no exception. Turn to

“Emergency Readiness—There’s an App for That.”

●● Pick a translation: The Ready.gov Web site provides a variety of pertinent resources translated into multiple languages—from Arabic to Vietnamese—for communities within the United States. See the “Pick a Translation” selections at http://www.ready.gov/.

Special Resources for KidsIt is well recognized that disaster preparedness can be a frightening concept for children. Some programs include special resources to make the process more comfortable for the young, including a “Be Red Cross Ready” kid-oriented Flash video at: http://72.3.171.147/#SITE and the Ready Kids Web site at: www.ready.gov/kids. The latter uses a cartoon mountain lion family to share the importance of emergency readiness. It also covers the steps to “create a kit, make a plan, and know the facts” from a kid’s perspective, and provides a “Readiness U” quiz, links to theme-related games, and parent and teacher resources. For the “Sesame Street” set, the site provides links to a “Let’s Get Ready” video and multilingual resources featuring Grover, Rosita, and other characters from the popular children’s television show. Another resource that may help attract kids to the emergency preparedness fold is “Disaster Hero,” a new game being released.

The American Academy of Pediatrics (AAP) has developed a “Family Readiness Kit,” a 35-page guide designed to help families follow its four steps to safety: understanding disasters and common hazards; creating a family disaster plan; completing a disaster checklist; and practicing and maintaining the plan. The guide stresses the importance of families as the first resources for preparation, protection, and recovery, and emphasizes the need for families to prepare child identification cards and a local emergency phone number sheet. Additionally, it outlines steps for making neighborhoods more disaster ready, and discusses the role of community and national resources in disaster preparedness. This guide, created with participation by disaster planning specialists and 250 families, is available in English and Spanish at http://www.aap.org/family/frk/frkit.htm.

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Templates to Take Along Everyone has the potential to be a patient—whether one is a health care professional or a member of the general public—especially with the increased risks that come with disaster and emergency conditions. One critical piece of the planning picture entails creating a personal medical information record that you carry with you. Because medical recordsare often not accessible in disaster situations, having this personal record available will provide health workers with interim information they need in order to provide care.

The CDC has created a Keep ItWith You (KIWY) PersonalMedicalInformation Form, which provides a concise template for supplying the key medical information you would need for treatment in emergency situations. To download this template, go to http://www.bt.cdc.gov/disasters/pdf/kiwy.pdf.

Another take-along template that can be helpful during disasters is the Personal Emergency Reference Card. This form is available from the American Medical Association (AMA) and can be used to record contact numbers for local emergency responders, utility companies, physicians, and hospitals; nonemergency contacts such as schools and clergy; and emergency meeting location(s). This is available as part of the AMA’s comprehensive reference guide on public health emergencies.1

1 American Medical Association, “Manage-ment of Public Health Emergencies: A ResourceGuideforPhysiciansandOtherCommunity Responders, Section 2: When Disaster Strikes,” January 2005, p. 5, http://www.ama-assn.org/resources/doc/cph-pdr/02_disaster.pdf.

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Disaster-Ready Videos, PSAs, and PodcastsInstructional videos on emergency preparedness are also available, with particular emphasis on underserved populations such as the elderly, those with disabilities, and pet owners. These videos can be found at http://www.ready.gov/america/about/instructional.html.

The Federal Emergency Management Agency has set up its own YouTube channel featuring a wide range of videos on disaster preparedness and response. To view the videos, go to http://www.youtube.com/user/FEMA.

The Centers for Disease Control and Prevention has developed a library of informative public service announcements (PSAs) for a wide range of disaster-related issues.These PSAs are available in a variety of formats, including audio, video, podcast, and mobile text. For more information and to subscribe, visit http://www.bt.cdc.gov/disasters/psa/.

Uniquely New York—Resources for the City The year 2011 was a busy one for emergency events in the New York metropolitan area—starting with massive snow and ice storms, moving to a summer earthquake, and going on to storm damage and f looding from Hurricane Irene. But the “bad” side of nature also brought about renewed public awareness on what it takes to be prepared for emergencies. When coupled with the tenth anniversary of the 9/11 and National Emergency Preparedness activities in September, it is no surprise that terms such as “go-bag,” “Zone A,” and “Code Orange” have entered the urban vernacular.

Contributing to this surge in emergency responsiveness is the New York City Office of Emergency Management (NYC OEM), which acts as the command center for cross-agency coordination of emergency planning and response and serves as a vital source for a wide range of community outreach and education programs. Another key driver here is the New York City Department of Health and Mental Hygiene (NYC DOHMH). These two organizations support critical resources directed at the unique landscape of the Big Apple:

●● Ready New York Web site: This NYC OEM-sponsored site provides information to help New York City residents stay safe while facing emergencies. The site and materials are available in multiple languages—including the 24-page “Ready New York: Preparing for Emergencies in New York City,” which comes in 11 languages, in audio format, online, or by mail by calling 311. This guide covers disaster planning and go-bag checklists; guidance on emergency evacuation and sheltering; precautions and tips about special hazards for the city; particular attention to seniors, those with disabilities or mental health issues, and pet owners; and subway preparedness. The Web site also provides information and links to the NYC Community Emergency Response Teams (CERT) and the NYC Citizen Corps Council, both of which train people from the community to support emergency response efforts. For these and more materials, go to the Ready New York Web site at http://www.nyc.gov/html/oem/html/get_prepared/ready.shtml.

NYC First with National Alert PLANThe Federal Communications Commission (FCC) announced a plan in the spring of 2011 to bring a new level of emergency alert capability to the residents of New York City. The BigApplewillbethefirstcityinthenationtoofferthePersonalLocalizedAlertingNetwork(PLAN).

This system is capable of sending “geographically targeted, text-like emergency alert messages about imminent safety threats to people withenabledmobiledevices.”PLANis designed so that it is not affected by user volume, which can often bring down mobile networks and block calls during emergency situations.

According to the FCC, PLAN alertswill be available by the end of 2011 to “90 percent of New York subscribers who have a PLAN-capable mobile device.” The mobile carriers thatcurrentlysupportPLANimplementation for New York City are AT&T,Sprint,T-Mobile,andVerizon.1 1 FCC News, “New York City Unveils First-

in-Nation Public Safety System; Enabled Mobile Devices Will Receive Emergency Alerts at Critical Moments with Potentially Life-savingMessages,”May10,2011,http://transition.fcc.gov/Daily_Releases/Daily_Business/2011/db0510/DOC-306417A1.pdf

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Ways to Protect Yourself, Your Patients, and Your Family continued from page 13

●● NYC DOHMH Web site: With its New York City AWARE program, the NYC DOHMH aims to keep New York City residents up to date and better prepared to handle public health emergencies and other hazards. This includes specifics on household preparedness, hazard awareness, and weathering storm-related power outages, as well as guides for dealing with mental health issues related to traumatic events and terrorism. It also looks at how temporary points of dispensing (PODs) would operate in city neighborhoods to dispense medicine to prevent or treat the community during a widespread disease outbreak or bioterrorist event. For more information on these resources, see the NYC DOHMH Web site at http://www.nyc.gov/html/doh/html/browse/browse-emergency.shtml.

Planning for the worst is not the first thing on most people’s minds—but perhaps it should be somewhere near the top of the list. As Benjamin Franklin warned, “By failing to prepare, you are preparing to fail.” In the case of emergencies, failure to prepare may be hazardous to your health. Whether you elect to “get a kit, make a plan, and be informed” or to rely on more localized planning resources, the keys to personal and family disaster preparedness are taking action—and starting that action today.

RESOURCES: 1 Mulligan-Smith,D.,T.D.Adde,“FamilyReadinessKit:PreparingtoHandleDisasters,”

American Academy of Pediatrics, p. 4, http://www.aap.org/family/frk/aapfrkfull.pdf.

14 WINTER 2011–12

Many smartphone applications (apps) are available to help people tune in, prepare for, and recover from disasters. These include various free/low-cost apps that link you to emergency radio feeds, information from the American Red Cross, and disaster readiness with checklists and shelter locations. Higher-cost apps such as DisasterAlert can provide real-time warnings for natural disasters such as earthquakes, keyed to your GPSlocation.1

FEMA App and 4FEMA Text Message Services

The Federal Emergency Management Agency (FEMA) launched the “FEMA App” in August; this is a free mobile app that helps people better prepare for emergencies. This app provides preparedness information for various types of disasters and lets users update checklists for emergency kits, store emergency meeting locations, review disaster response tips, view maps of emergency shelters nationwide, and access up-to-the-minute FEMA blog posts on potential disaster events. The app, designed to be accessible even if there is no mobile service, is currently available for Android mobile devices. FEMA plans to release versions for iPhone and BlackBerrydevicesaswell.2

FEMA also offers three text message services, which enable cell phone users to do the following:3

Locatethenearestshelterintheirarea:TextSHELTER + your zip code to 43362 (4FEMA)

Locatethenearestdisasterrecoverycenterintheirarea:Text DRC + your zip code to 43362 (4FEMA).

Subscribe to FEMA’s monthly tips on disaster preparedness: Text PREPARE to 43362 (4FEMA).

HHS Facebook App

The Department of Health and Human Services (HHS) is looking to leverage Facebook as a means for people to create their own emergency support networks. The idea is to encourage people to designate Facebook friends as “lifelines” with whom they can connect during disaster events. There would also be tools for creating personal emergency preparedness plans and sharing those plans with these lifelines. The HHS Assistant Secretary for Preparedness and Response has issued a Lifeline FacebookApplication Challenge to developers to create a mobile Facebook app with these features. The top three apps are expected to be released at the Health 2.0 Conference in 2012.4

1 P.Suciu,“DisasterPreparation:There’sanAppforThat,”CNBC,May9,2011,p. 1, http://www.cnbc.com/id/42802862/Disaster_Preparation_There_s_An_App_For_That.

2 S. Adamski, “New Digital Tools: FEMA App and Text Message Updates,” FEMABlog,August26,2011,http://blog.fema.gov/2011/08/new-digital-tools-fema-app-and-text.html.

3 Ibid.

4 HHS Press Office, “HHS Sponsors Contest for Facebook Personal Prepared-ness Applications,” HHS.gov Web site, August 22, 2011, http://www.hhs.gov/news/press/2011pres/08/20110822a.html.

Emergency Ready–There’s an App for That

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Ways to Protect Yourself, Your Patients, and Your Family continued from page 13

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The past decade has been strewn with devastating disasters across the United States, from the

9/11 tragedies in New York City, Washington, DC, and Pennsylvania, to the Gulf Coast Hurricanes Katrina and Rita in 2005. In 2006, federal major disasters were declared a record 52 times.1 According to the National Weather Service, 2011 has also proven to be a particularly volatile and costly year. As of mid-October, 10 major storms had hit the United States, causing more than $50 billion in economic damages and tying record storm-related losses set in 2008. These

“billion-dollar storms” included the late January blizzard in the Northeast and other regions, massive tornadoes and extensive flooding in the Midwest and Southeast, and drought-related wildfires in the South and Southwest.2 Hurricane Irene, which wreaked havoc across Eastern states in late August, was also costly. Industry estimates of $7 billion to $10 billion in storm-related costs place Irene among the top 10 costliest catastrophes in the United States to date.3

Looking to History for ChangesThe vast history of national and global disasters is marked by a fairly consistent pattern: catastrophic event followed by emergency response, analysis, and attempted process improvement—before the next event strikes. In his book chapter, “Emergency Management in the United States: Disasters Experienced, Lessons Learned, and Recommendations for the Future,”4 David A. McEntire, PhD, professor and author on disaster management issues, addresses this trend of disaster-reactive policy making. The 9/11 attacks led to the creation of the Department of Homeland Security (DHS), which refocused emergency efforts on terrorism and introduced the National Incident Management Strategy (NIMS) to “promote interagency communication and coordination.” In the process, however, the DHS absorbed the Federal Emergency Response Agency (FEMA) and essentially neutralized the agency’s budget and its capacity to respond to natural disasters. In the wake of FEMA’s dismal failures during

Lessons Learned from Hurricane Katrina and Other Disasters

Hurricane Katrina, the government restored FEMA’s “teeth” and instituted reforms, such as the Post-Katrina Emergency Management Reform Act and the Pets Evacuation and Transportation Standards Act, to deal with evacuation challenges and other problems encountered during emergency response to Hurricane Katrina’s victims. Even so, challenges remain with the nation’s complex, decentralized emergency management infrastructure, where effective disaster response involves a careful orchestration among DHS, FEMA, and other federal agencies; state and local government emergency management offices; businesses providing medical and insurance services and vital goods; nonprofit and other volunteer organizations, such as the American Red Cross; and ordinary citizens.5

As natural threats continue and potential new hazards emerge, McEntire calls on the United States to seize opportunities to improve emergency management response capabilities. He emphasizes the need to eliminate “major

policy swings that focus on one type of hazard alone and instead try to build a well-designed and comprehensive system of emergency management.” This requires moving beyond merely building disaster preparedness plans and reacting to situations, by taking a more proactive stance to

“reduce vulnerability.”6 (For example, this might also entail use of better predictive storm or other risk models, research, and preventive measures such as “storm seeding” and other innovations.) McEntire stresses the need to enhance capabilities through effective

“coordination and communication” and increased professionalization among all the “actors involved in emergency management.” This includes enhancing systems and technologies that support emergency response and resource tracking. In addition, there must be a focus on educating the general population about hazard vulnerability and disaster response, particularly among historically underserved and at-risk populations such as minorities and the elderly.

McEntire concludes that even as the United States has long served as a “model for emergency management programs around the world,” there is still much room for improvement in terms of developing a “coherent disaster policy” and providing the necessary “personnel and budget support [required] to be better prepared for future disasters.”7

In the aftermath of discussions and extensive analysis of FEMA’s poor handling of Hurricane Katrina relief efforts, policies changed and the agency underwent revamping. Today, those changes continue with lessons learned from more recent disasters, such as the tornadoes that ravaged Alabama and Missouri in the spring of 2011. One significant finding is the recognition that with today’s mobile, connected technology, the public and private sectors can be valuable resources for emergency information. In the same way, FEMA is looking to make better use of local emergency responders who are at the

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FEMA Turns to the Public for Help

Since assuming the reins two years ago, Federal Emergency Management Agency (FEMA) Administrator Craig Fugate has been streamlining operations to connect federal, state, and local emergency management personnel and deliver an agile team-based response to breaking emergencies. Other changes reflect a new respect for working more directly with the people in affected communities, rather than waiting for the bureaucracy to act. For example, when dealing with the tornadoes in Joplin, Missouri, FEMA personnel were able to deploy resources more quickly based on Twitter feeds and photos from various social media sites, rather than waiting several days for a broad assessment of the catastrophe. This reflects a new attitude and approach for the agency—one that recognizes the value of establishing a two-way dialogue with the public and views people from affected communities as “a resource and not a liability.”1

As part of this effort to streamline and deliver a more appropriate disaster response, FEMA is writing a new emergency response playbook with plans built around the needs of formerly marginalized populations, such as the elderly, chronically ill, and children, to ensure that they are better cared for in these events. This includes changing the meals ready to eat (MREs) to add packages for infants and children, including baby food and formula as well as other necessities. According to Fugate, FEMA is changing its perspective to “plan for who we serve, not who fits our plans.” In another sign of the times, the agency is working on a mobile Web page that storm victims can access from their smartphones.2

1 Needham, V. “FEMA Rewrites Disaster-Relief Playbook,” The Hill, July 8, 2011, 1-5, http://thehill.com/business-a-lobbying/170299-fema-chief-craig-fugate-rewrites-the-disaster-relief-playbook?tmpl=component&print=1&layout=default&page.

2 Ibid.

scene to enable faster assessment and deployment of resources, particularly in large-scale disasters. For more on these developments, see “FEMA Turns to the Public for Help.”

Key Takeaways for Health Care Disaster Planning If Hurricane Katrina taught us anything, it was the need for “better advanced planning, better communications, more rapid deployment of resources, and better coordination.” Although this is the general outlook from numerous government reports, it applies specifically to hospitals and other health care facilities, according to a study from the Urban Institute that examines the Hurricane Katrina experiences of New Orleans hospitals and other health care facilities. The study uses interviews with hospital officials, staff, and patients, as well as various published accounts, to outline challenges and potential improvements in the issues of hospital evacuation and disaster response planning.8

Although several Crescent City facilities chose to evacuate patients in advance of the storm, most did not. The Louisiana Hospital Association (LHA) estimates that about 11 hospitals rode out much of the storm, housing nearly 1,750 patients, more than 7,600 additional persons (staff, family members, and others who fled their homes), along with an undetermined and unexpected number of pets and animals. Why did they stay? First, the mandatory evacuation order for the city excluded hospitals. Furthermore, many felt that they could withstand the storm and that moving critical care patients was more dangerous than sheltering them in place. It was the loss of the levee systems and the duration of subsequent flooding that pushed many hospitals to the brink and revealed serious gaps in emergency response plans. The study authors acknowledge, “The calculus for whether to evacuate is complex, involving the cost and risk of evacuation, the certainty and anticipated severity of the event, and the time available for action.”9 Some of these factors could be addressed with improved advance planning and evacuation measures. Improving Emergency Management Planning Although the Joint Commission for years has required health care facilities to create internal emergency management and operations plans, events around Hurricane Katrina highlighted the importance of engaging with community emergency management teams to develop and coordinate area-wide disaster plans. For example, having a plan to evacuate patients by ambulance is not going to work if those vehicles are designated for use by emergency responders or other hospitals. A hospital’s plans for triage and evacuation of critical patients may also conflict with emergency management practices that dictate evacuating ambulatory women and children before those who are critically ill. Because of a lack of coordination during Hurricane Katrina, hospitals encountered these and other serious issues.10

As Dee Grimm, RN, JD, CEO of Emergency Management Professionals, observed in a recent webinar on community collaboration and hospital evacuations, “You should never be exchanging business cards at the start of a disaster. You should know who you are working with and have relationships in place before disasters start.” She emphasized this by noting the four Cs of emergency management, “communication, cooperation, collaboration, and coordination.”11 Beyond relationships with emergency management teams, hospitals must

Lessons Learned from Hurricane Katrina and Other Disasters continued from page 15

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What Is HICS?The Hospital Incident Command System (HICS) is an incident management methodology that assists hospitals and health care facilities with their emergency management planning, response, and recovery capabilities for unplanned and planned events. It can also be used to manage other facility-wide events, such as planned power outages, moves, and the like.

HICS was developed to standardize hospital emergency management and operations and create a consistent infrastructure that aligns with the terminology and command structure—namely, the Incident Command System (ICS) and National Incident Management System (NIMS)—used by the emergency response community.

The HICS approach offers an array of materials, instructional guidance, and training to enable hospitals and health care facilities to comply with emergency preparedness planning standards for accreditation by the Joint Commission. These standards require hospitals to maintain detailed emergency management/emergency operations plans and review and update these arrangements annually during accreditation reviews. (For more information on the Joint Commission, see www.jointcommission.org.)

The HICS resources are supported by the Center for HICS Education and Training, an organization sponsored by the Washington Hospital Center and Kaiser Foundation HealthPlan, and available at http://www.hicscenter.org.

work closely with other health care facilities, including nursing homes and long-term care facilities within their community, to forge mutual emergency response plans. Ideally, these provisions should take advantage of the unique capabilities and specialties of each institution, whether they be pediatric care, better communications systems, or safer locations outside a flood zone. This should also include contingency planning for catastrophic situations when a physical facility becomes unusable—such as what happened with the 2011 tornado that smashed St. John’s Regional Medical Center in Joplin, Missouri.

Another targeted improvement entails developing an accurate assessment of the infrastructure and resources required to sustain a health care facility during long-term disaster situations. Even though hospitals physically survived Hurricane Katrina, most were equipped to function for several days at most. They underestimated the resources needed (medical supplies, food, and water) and the impact on their physical plant from a loss of essential infrastructure—electric power, water, fuel, security, communications, and transportation. As a result of these experiences, emergency guidelines now recommend being prepared with a week’s supply of all essentials. For hospitals, these emergency provisions need to accommodate a large population increase that includes patients, their families, an influx of “storm refugees,” and regular and volunteer staff. For example, in the days following Katrina, hospitals in New Orleans as well as those outside the storm’s path, such as Woman’s Hospital in Baton Rouge, Louisiana, saw their populations double.12

It is noteworthy that family members joining patients at hospitals can be both “a boon and a bane.” Although families may help with critically ill loved ones, they may also interfere or become disruptive—particularly when evacuation prioritization sends those critical care patients to other facilities, leaving family members behind. Additionally, it is important to anticipate security needs to protect the safety of patients and staff and the security of vital medical supplies. During Katrina, for instance, staff members at one hospital were robbed at gunpoint by criminals looking for narcotics. It may also be necessary to protect parking areas as people seeking storm-safe parking in often-flooded hospital garages. Building security and lockdown procedures should be part of any evacuation plan to protect the facility and its contents and help ensure faster recovery efforts.13

The “communications meltdown” was a widely cited problem in Hurricane Katrina. With the failure of normal communications—telephone, cell phone, pager, Internet, and other electronic systems—many hospitals lacked alternate plans for communicating with staff and other agencies. Stories abound of desperate hospital staff slogging through flooded New Orleans streets to find someone with working communications: One hospital sent an e-mail to see whether its parent company in Texas could break through the communications gridlock; another turned to an OnStar satellite system in an employee’s car to reach outside assistance. Even if they found a way to make a telephone call, the lack of coordination among pertinent agencies left hospitals with no clear communications contact for emergency response and assistance.14 Such communications vulnerabilities are not unique to large-scale disasters. As a case in point, the recent earthquake that rattled the East Coast caused only negligible damage, but the related call volumes swamped cell phone networks, hampering communications for a short period and leaving some carriers to advise callers to use text messaging as a workaround.

According to a 2005 report on crisis communications, telecommunications failures are to be expected during disasters as a result of physical destruction of the network, disruptions in the network infrastructure, and network congestion.15 Hospitals can prepare for this by designating alternative communication channels, such as business radios or walkie-talkies, generator-powered internal phone systems, satellite phones, and dedicated ham radio systems, as well as low-tech options such as physical status boards or organized runner/messenger personnel.16 Also key is ensuring that communications lists are up to date and include alternate connection points such as e-mail addresses, contacts for staff members’ families, and the like.

It is clear that Hurricane Katrina uncovered significant gaps in emergency preparedness levels for hospitals and other health care facilities in New Orleans. The follow-up has led to renewed calls for hospitals to establish and maintain an up-to-date hazard vulnerability analysis or assessment (HVA) to identify potential risks and vulnerabilities and prioritize their planning efforts.17 The Hospital Incident Command System (HICS) (www.hicscenter.org) provides guidelines and matrices designed to assist hospitals with their HVA efforts and related emergency response and mitigation planning. For more information, see “What Is HICS?”

An integral part of hospital emergency preparedness concern is routine testing of disaster response plans to ensure they continue to meet a facility’s specific needs. In Hurricane Katrina’s wake, many backup generators were rendered useless by flooding, some ran out of fuel, and others could not power the full facility. Earlier reassessment and testing could have exposed some of these planning oversights. This testing extends to training hospital staff and conducting practice drills to ensure familiarity with the command structure and processes to maintain operations. Practice drills can often reveal process and procedural problems, enabling

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plans to be improved before trouble hits. For example, by conducting a live drill, one hospital could have identified the problems of relying on helicopter evacuations for critical-care patients such as the challenges of accommodating bariatric surgery patients or getting heavy ICU equipment up to the roof for evacuation when elevators stop working.18 As a result of the Gulf Coast hurricanes and other disaster experiences, many hospitals have taken measures to assess, plan for, and test their preparedness to respond to emergency situations.

Evaluating Evacuation Experiences Hurricane Katrina experiences have highlighted numerous flaws in health care emergency response—but they have also prompted reevaluation of evacuation handling. This is especially telling when comparing the extensive casualties for some facilities that did not evacuate—such as Memorial Medical Center and Lindy Boggs Medical Center—to the lack of fatalities for those who opted to move patients before the storm, such as St. Charles Parish Hospital, or soon after the storm, such as Tulane University Hospital and the Veterans’ Affairs Medical Center.19 With these experiences in mind, here are some considerations for evacuation planning and execution. (As a side note, the health care community is not the only area facing challenges with evacuations during emergencies. For more information, see “Oh No, I Won’t Go” on page 20.)

Shelter in place versus evacuate: For years, health care facilities have followed a “shelter in place” approach, thinking it was safer not to move medically frail patients, as most facilities were equipped to withstand severe storm conditions. However, Hurricane Katrina’s long-term power outages and acute supply shortages, along with the resulting deaths of the many critically ill patients who were not evacuated, have medical professionals rethinking this approach.20 According to a recent webinar, the decision to shelter in place or evacuate patients requires careful evaluation of a wide range of criteria, including the type and scope of the disaster, the amount of time available to evacuate (advance planning and actual evacuation timelines), particular patient populations (condition and care requirements), transportation strategies and logistics (options and criteria for emergency vehicle, bus, boat, helicopter, etc.), and the proximity and suitability of medical care, staffing, and resources at alternate care facilities (ACFs). This ACF assessment is particularly

WINTER 2011–12

The California Hospital Association’s Emergency Preparedness Web site (www.calhospitalprepare.org) serves as a clearinghouse for health care emergency preparation and response. The site includes planning information, training, and exercises, as well as tools and resources to help health care professionals and organizations prepare for hazards ranging from an active firearm assault to hazardous materials, infectious diseases, radiologic emergencies, and cyberthreats.

According to this site’s cyberterrorism page, 80 percent of hospital IT departments have experienced “one or more data breaches that involved the loss of patient-care information.” Cyberthreats originate from any number of sources. Thus, computer viruses and malware from an infected e-mail message or Web site can disrupt computer operations; hackers from around the world can infiltrate hospital networks and cause mayhem with activities; and compromised systems can enable electronic break-ins, along with the theft of medical records, Social Security numbers, and financial information.

These cyberthreats are an increasing hazard for every business, and health care facilities are no exception. In 2009, a hospital in Chicago had computer operations disrupted for more than a year from a “bad” e-mail attachment or Web link attacking its systems.1 And for two years, the Veterans Health Administration has battled malicious intrusions into various wireless medical devices at its facilities.2

Lastyear,theUCDavisHealthSystemconductedaseminaroncyberattacks,inwhicha computer security expert talked about various examples of health care cyberassaults, including outlining a potential cyberterrorism scenario in which hackers used “phishing” e-mails that infect hospital networks and triggered a series of events to alter patients’ records, doctors’ orders, and medication doses; shut down computer systems; and interfered with medical devices, intensive care monitors, and infusion pumps.3

Fighting this constant threat requires vigilance from everyone across the health care organization, not just from the IT department. Resources are available to help in this “cyberbattle.” These include the InfraGard collaboration for infrastructureprotection, a Cyber Security Evaluation Tool to assess network and systems security, and cyberforensics training and research, among others. The Federal Bureau ofInvestigation has also established special units for cybercrime investigation (see www.calhospitalprepare.org for links).

A Different Type of Disaster—Cyberthreats and Bioterrorism

1 UC Davis Health System. “Experts: Cyberattacks Threaten Hospitals,” posted August 11, 2010, http://www.ucdmc.ucdavis.edu/welcome/features/2010-2011/08/20100811_cyberterrorism.html.

2 Rhea, S. “Cyberbattle, Providers Work to Protect Devices, Patients,” Modern Healthcare, December 13,2010,http://www.modernhealthcare.com/article/20101213/MAGAZINE/101209930(subscriptionrequired).

3 Ibid.

Lessons Learned from Hurricane Katrina and Other Disasterscontinued from page 17

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important as the characteristics of a particular site, such as school, church, or civic building, will affect a facility’s medical capabilities. Additionally, even though various groups, from the Joint Commission to the Centers for Disease Control and Prevention (CDC), have offered design guidance, there is still no national ACF model or standard.21

Patient care, records, and tracking: Beyond the physical aspect of evacuation is the need to ensure quality patient care through effective triage, records handling, and tracking. For example, during Hurricane Katrina, many evacuated patients were separated from their health records—delaying medical care, consuming valuable staff time, and causing unnecessary confusion. Power outages made it difficult to access electronic records and backup paper procedures were not used consistently. Another problem was a lack of accurate records to track evacuated patients between facilities, resulting in medically sensitive evacuees such as newborns and Alzheimer’s patients getting “lost” or separated from their family members.22 The Joint Commission’s Emergency Operations Plan guidelines describe some processes and information that hospitals can use to help avoid these types of tracking issues for evacuated patients. HICS provides a series of forms that can be used in evacuation situations. For instance, the Patient Evacuation Tracking Form (HICS Form 260) provides a means for hospitals to record a patient’s basic medical information and needs as well as from/to facility tracking that is designed to accompany each patient. Other forms are available that can help health care facilities monitor the triage status of all patients at a hospital’s disaster staging site (HICS Form 254), or track the status and location of patients being evacuated to other locations (HICS Form 255).23

A Seat at the Table for Long-Term Care Although this discussion has focused on hospitals and medical facilities, the disaster preparedness picture for long-term care and skilled nursing facilities is a further area of concern. To address this issue, the Florida Health Care Association held several summits to evaluate what went wrong during the Gulf Coast hurricanes. An article on this topic reports, “Two-thirds of deaths in New Orleans were age 65 or older. Many of the deaths, including the tragedy at St. Rita’s, occurred after the hurricanes had passed.” This situation was partially attributed to the fact that long-term care facilities had “no seat at the table” for coordinating with community emergency response, other health care facility disaster plans, utility restoration priorities, or evacuation/sheltering needs. Subsequent efforts were successful in reclassifying nursing facilities as health care providers, earning them a voice in state and national emergency response discussions and priority restoration during power outages.24

A key change has been the introduction of more information and tools specific to the unique challenges of long-term care disaster response planning, including improved criteria for evacuation decision making. As nursing facility residents typically constitute an older, medically frail population with higher acuity levels, recommendations have been made to strengthen facilities to support shelter-in-place versus evacuation. Other recommendations echo common planning needs, such as evaluating a facility’s storm/flood risks; coordinating transportation and resources; and maintaining communications with community, staff, residents, and families. One addition specifies that when conducting planned drills, it is important to accommodate residents with complex medical conditions, such as cognitive impairment or equipment needs, such as oxygen or ventilators.25 For more information and related resources, see the American Health Care Association Web site, www.ahcancal.org.

WINTER 2011–12

The recent earthquake-related nuclear events in Japan have prompt-ed renewed questions about Americans’ readi-ness to handle a major nuclear or radiation emergency—radiation releases related to acci-dental or intentional (terrorist) events—at home. According to a survey reported in the journal Disaster Med-icine and Public Health Preparedness, the Uni-ted States is not doing very well on the preparedness scale for these types of disasters. With more than three-quarters of all states reporting, a recent survey found that 45 percent had not planned for even the “most fundamental” level of emergency preparedness—i.e., developing a response plan. As many as 85 percent of the responding states indicated “insufficient capability” to respond to certain types of radiation incidents. The exceptions were states with nuclear power plants, as they are required to maintain applicable emergency response plans.1

The Nuclear Regulatory Commission (NRC) has also been reassessing seismic risks for all nuclear reactors in the United States. Although this is routine for quake-prone regions such as California, this is the first time in many years that reviews are being conducted nationwide. Of the 104 reactors in use, 27 in the Eastern and Central regions were flagged as needing potential upgrades to address increased seismic perils. Interestingly, this review was started long before Japan’s nuclear disaster in March 2011 and the recent 5.8 earthquake that shook the US East Coast in August.2

Combined, these findings point to a need to improve preparedness in both the nuclear infrastructure and public health departments. The good news is that the US Department of Health and Human Services has created “playbooks” to assist state and local planners and responders (including health care professionals) in these efforts. These comprehensive plans cover 15 scenarios for all-hazards preparedness and response, including the hazards of a nuclear accident or detonation. It is hoped that these practical tools will provide responders and medical personnel with the resources and impetus for developing suitable preparations for managing nuclear and other radiation incidents.3

1 Barr,P.“Statehealthdepartmentsunpreparedforradiationemergency,surveyfinds.” Modern Healthcare, March 14, 2011, http://www.modernhealthcare.com/article/20110314/NEWS/303149848.

2 Cappiello,D.,andJ.Donn.“QuakeRisktoReactorsGreaterThanThought.”Forbes.com, September 2, 2011, http://www.forbes.com/feeds/ap/2011/09/02/general-us-nuclear-plants-earthquakes_8656759.html.

3 Murrain-Hill,P.,C.N.Coleman,J.L.Hick,etal.“MedicalResponsetoaNuclearDetonation:CreatingaPlaybookforStateandLocalPlannersandResponders,” Disaster Medicine and Public Health Preparedness 2011;5:S89-S97, http://www.dmphp.org/cgi/reprint/5/Supplement_1/S89.

Are We Ready for Radiation and Nuclear Hazards?

continued on page 20

20

Disasters and Children— Special Strategies for Pediatric Patients Similar to the elderly and other long-term care residents, children and pediatric patients have special medical needs that require a different disaster-planning approach, which has not been addressed in conventional emergency management planning. As the authors of one recent study point out, “despite the billions of dollars spent on homeland security since September 11, 2001, pediatric-specific preparations have lagged behind, resulting in deficient disaster readiness for children.” They note that children are not “mini-adults,” as their size and metabolic systems make them more prone than adults to dehydration, malnutrition, and fatigue. With their developing immune systems and ignorance of safe hygiene practices, children are also more susceptible to illness and disease in disaster conditions. Although children develop mental health issues related to disasters, they typically have fewer treatment options than do adults.

Perhaps the largest issue affecting children during major emergencies is the inadequate strategies for evacuating pediatric patients and assisting unaccompanied young children. Thus, during Hurricane Katrina, many hospitals did not have the proper supplies to assist premature newborns and hospitalized infants and young children. Many vehicular evacuations focused on getting pediatric patients to alternate medical facilities but could not always accommodate additional passengers, causing added anxiety over family separations. Children also were split from their families during general evacuations. In some cases, children were found wandering alone in flooded streets. Other children were separated from their families as a result of evacuation miscommunications. In the frenzy

of departure, many parents sent their children ahead on earlier buses, thinking all buses were destined for the same shelter. When adults were evacuated later and sent to different shelters, there was no strategy in place for reuniting families. Other issues included a need for better resources and strategies for assisting unaccompanied children who do not speak English and children with special health care needs (CSHCN).26

In response to Katrina-related events, some resources have been developed to address pediatric disaster planning. This includes Emergency Medical Services for Children (EMSC), which provides information and training to assist health care facilities and EMS agencies to serve CSHCN during emergency events. Programs have also been created for specific events, such as the pediatric and family readiness information on bioterrorism available from the American Academy of Pediatrics (AAP) Web site at www.aap.org. The study authors enumerate several additional pediatric resources, but they say that pediatric disaster preparedness in the United States needs an “informed voice speaking proactively on behalf of all pediatric care issues.” They note that children “make up nearly 30 percent of the population” and see Hurricane Katrina as an “urgent wake-up call for the pediatric community and its leadership” to address these issues. The study concludes with a series of recommendations that include conducting a full assessment and overhaul of pediatric disaster preparedness strategies, developing an Office for Pediatric Disaster Preparedness, and gaining support for these efforts from all levels of the government and health care professional organizations.27

Other Lessons Learned—Liability and LitigationAfter hurricanes pass and flood waters recede, health care institutions, like other businesses, must brace themselves for potential long-term financial and legal ramifications. For example, following Hurricane Katrina, some hospitals discovered they did not have appropriate property/flood insurance coverage, forcing them to foot the bill for damage from hurricane- or wind-driven storm surges or flooding.28 (According to industry estimates, insurance typically covers only about 50 percent of costs for storm-related damages.) More recently, in the wake of Hurricane Irene’s catastrophic 2011 flooding up and down the East Coast, even less insurance recovery is anticipated, with under 40 percent of the costs associated with Irene’s flooding expected to be picked up by insurers.29 Others found that their business continuity insurance was insufficient to pay for key recovery expenses, such as data-recovery efforts and the round-trip costs of evacuating and returning patients to their facilities. Although this may represent a minor setback for some institutions, others might not recover. For instance, after Hurricane Ike swept through Galveston Island in 2008, one hospital never reopened after finding its $1 million business continuity policy unable to pay for a recovery price tag of $7 million in damages and unanticipated costs.30

For these reasons, health care facilities should be careful to audit their insurance coverage and data-recovery processes regularly, as part of overall disaster planning. In “Disaster Planning for Health Information,” the American Health Information Management Association (AHIMA) recommends investigating what other facilities are doing and contacting data-restoration companies to develop an accurate assessment of costs associated with recovering patient records and other pertinent health information. AHIMA also emphasizes the need to make certain that contracts with data restoration companies comply with HIPAA privacy and security rules for business associates. These include safeguards to prevent use or disclosure of protected information and indemnification of the health care facility for losses related to unauthorized disclosure.31 (For more information, visit the AHIMA Web site, www.ahima.org.)

Lessons Learned from Hurricane Katrina and Other Disasterscontinued from page 19

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During disasters such as Hurricane Katrina, media coverageoften highlights stories of hardy (or foolhardy) souls who ignore evacuation edicts, preferring to stay behind (and possibly perish) rather than leave their homes or pets. In 2007, the Harvard School of Public Health polled more than 1,000 people in hurricane-prone South and Southeast coastal areas and found that 31 percent of respondents would not leave if ordered by the government to evacuate. Nearly half of those polled lived in locations that had been damaged by hurricanes in the preceding three years. Some cited safety and security with regard to leaving their homes or living in shelters. Other issues influencing evacuation decisions included misinformation about food safety, lack of long-term preparedness for family emergencies, food, and water supplies, and assistance requirements for minorities and low-income residents.1

1 Harvard School of Public Health “Survey of Hurricane Preparedness Finds One-Third on High Risk Coast Will Refuse Evacuation Order,” press release, July 24, 2007, pp. 1-3, http://www.hsph.harvard.edu/news/press-releases/2007-releases/press07242007.html.

Oh No, I Won’t Go

21

From a legal standpoint, disaster-related cases can often take a long time to surface and resolve. In late 2009 and beyond—more than four years after the hurricane—victims of Hurricane Katrina were still working out financial settlements in various cases involving groups such as the US government and the Army Corps of Engineers. In March 2011, the highly publicized class-action lawsuit against Tenet Healthcare Corporation’s Memorial Medical Center reached the docket. This case alleged that the hospital had failed to plan properly for the care and/or evacuation of patients in disaster situations and, as a result, 45 patients died. Before jury selection could be completed, the case was settled out of court for an undisclosed amount.32

In 2007, the American Health Lawyers Association released an analysis of the key legal and operational issues that affected the health care community during Hurricane Katrina. This study found that developing a comprehensive disaster preparedness and response plan can go a long way toward mitigating litigation risks for health care providers. Regarding emergency planning, the study also emphasized the need for health care facilities to be knowledgeable about their responsibilities during emergency declarations and about emergency credentialing for physicians

and other health care workers. Also addressed were steps for following (and documenting adherence to) plans for patient evacuation, proper medication handling, and consent-to-treat situations. The study further outlined various hospital decommissioning procedures and impacts; recovery practices, including computer systems and medical records; unique academic medical center issues, such as handling research subjects, trainees, and research award changes; and federal and other financial assistance programs.33

Preparing for Disasters to ComeWe have illustrated here some positive outcomes in health care disaster response resulting from experiences with natural disasters such as Hurricane Katrina. But what about other types of threats—particularly nuclear, biological, radiologic, and cyberthreats? For further insights on health care preparedness in these areas, refer to “Are We Ready for Radiation and Nuclear Hazards?” and “A Different Type of Disaster—Bioterrorism and Cyberthreats.”

From Gulf Coast hurricanes or devastating tornadoes in the United States to typhoons, earthquakes, or nuclear incidents worldwide, there is much to be learned each time disaster occurs. By taking lessons from history and applying accepted practices for disaster preparedness and response planning, hospitals and other health care facilities can be better equipped to weather whatever events should come their way. For a look at how the New York area is applying some of the valuable lessons learned, see the article, “Insights on Emergency Preparedness and Response in New York,” in this issue.

RESOURCES: 1 Belmont,E.,J.A.Belt,R.G.Cowart,etal.“HealthLawyers’PublicInformationSeries:

LessonsLearnedfromtheGulfCoastHurricanes,”AmericanHealthLawyersAssociation,May2007,p.5,http://www.healthlawyers.org/Resources/PI/InfoSeries/Documents/Les-sons%20Learned.pdf.

2 NationalClimaticDataCenter(NCDC)Website.“BillionDollarU.S.WeatherDisasters,”http://www.ncdc.noaa.gov/oa/reports/billionz.html (accessed November 22, 2011).

3 Cooper, M. “Hurricane Cost Seen as Ranking Among Top Ten,” New York Times, August 31, 2011, p. 1, http://www.nytimes.com/2011/08/31/us/31floods.html.

4 McEntire, D.A. “Emergency Management in the United States: Disasters Experienced, LessonsLearned,andRecommendationsfortheFuture,”Comparative Emergency Man-agement: Understanding Disaster Policies, Organizations, and Initiatives from Around the World. Emmetsburg, MD: Federal Emergency Management Agency, 2009, http://training.fema.gov/EMIWeb/edu/CompEmMgmtBookProject.asp.

5 Ibid.

6 Ibid.

7 Ibid.

8 Gray,B.H.,andK.Hebert.“AfterKatrina,HospitalsinHurricaneKatrina:ChallengesFacing Custodial Institutions in a Disaster,” Urban Institute, July 2006, p. 13, http://www.urban.org/UploadedPDF/411348_katrinahospitals.pdf.

9 Ibid., p. 14.

10 Ibid., pp. 17-18.

11 Wadzinski,J.,D.Grimm,M.Saruwatari,etal.“ConductingHospitalEvacuationthroughCommunityCollaboration,”AmericanHospitalsAssociationSolutionsandLiveProcess,July12,2011,p.41andaudioQ&Asession,http://wm.yourcall.com/AHA/AHA_Wadzin-ski_071211.wmv.

12 Friedman,E.“DisasterPlanning:WhatHaveWeLearned?”Hospitals & Health Net-works, August 1, 2006, p. 2, http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006August/060801HHN_Online_Friedman&domain=HHNMAG<http://www.hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/PubsNewsArticle/data/2006August/060801HHN_Online_Friedman&amp;domain=HHNMAG>.

13 Ibid., p. 4.

14 Ibid., p. 2.

15 Townsend,A.M.,andM.L.Moss.“TelecommunicationsInfrastructureinDisasters:Prepar-ing Cities for Crisis Communications,” Center for Catastrophe Preparedness and Response, andRobertF.WagnerGraduateSchoolofPublicService,NewYorkUniversity,April2005,p. 6, http://www.nyu.edu/ccpr/pubs/NYU-DisasterCommunications1-Final.pdf.

16 Rubin, J.N. “Recurring Pitfalls in Hospital Preparedness and Response.” In Preparing Hos-pitals for Bioterror: A Medical and Biomedical Systems Approach, edited by J.H. McIsaac, p. 6. New York: Academic Press, 2006.

17 Belmontetal.,op. cit., p. 5.

18 GrayandHebert,op. cit., p. 16.

19 Ibid., pp. 4-10.

20 O’Reilly,K.B.“Katrina’sLegacy:RethinkingMedicalDisasterPlanning,”American Medi-cal News, September 6, 2010, p. 2, http://www.ama-assn.org/amednews/2010/09/06/prsa0906.htm.

21 Wadzinski, et al., op.cit., pp. 13-16, 24-28.

22 GrayandHebert,op.cit., p. 17.

23 Wadzinski et al., op.cit.,pp.25,43,andaudioQ&Asession.

24 Connole,P.“DisasterPreparednessinaPost-KatrinaWorld,”Provider, February 2011, pp. 22-24, http://www.ahcancal.org/News/publication/Provider/CoverFeb2011.pdf.

25 Ibid., pp. 24-33.

26 Dolan,M.A.,andS.E.Krug,“PediatricDisasterPreparednessintheWakeofKatrina:Les-sonstobeLearned,”Clinical Pediatric Emergency Medicine 2006;7:59-62, http://www.acf.hhs.gov/nccd/reports_studies/additional_information/Pediatric%20Disaster%20Prepare-ness%20Katrina.pdf.

27 Ibid., pp. 62-64.

28 Belmontetal.,op. cit., p. 6.

29 Cooper, op.cit., p. 1.

30 Wadzinski et al., op.cit.,audioQ&Asession.

31 Cunningham, P. “Disaster Planning for Health Information (Updated),” AHIMA, pp. 1-3, http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_048638.hcsp?dDocName=bok1_048638 (accessed July 20, 2011).

32 Fink,S.“LawsuitAgainstNewOrleansHospitalSettlesShortlyAfterTrialBegins,”Pro-Publica, March 23, 2011, pp. 1-2, http://www.propublica.org/article/lawsuit-against-new-orleans-hospital-settles-shortly-after-trial-begins/single.

33 Belmontetal.,op. cit., pp. 1-65.

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Developing a comprehensive disaster

preparedness and response plan can go

a long way toward mitigating

litigation risks for health care providers.

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Insights on Emergency Preparedness and Response in New York

“Teamwork divides the task and multiplies the success.” —Author Unknown

T o assess health care emergency preparedness from a local perspective, infocus interviewed individuals from across the emergency management spectrum in New York. Within this group, there was surprising consistency on the importance of

forming coalitions, as well as some revealing insights on the benefits of working together in emergency situations.

GREATER NEW YORK HOSPITAL ASSOCIATION’S COLLABORATIVE ROLE IN EMERGENCY RESPONSE The Greater New York Hospital Association (GNYHA), a coalition in and of itself, has been actively assisting its member institutions with emergency management efforts for decades, providing resources, initiatives, and advocacy to enhance emergency preparedness.

Susan Waltman, Esq., Executive Vice President and General Counsel for GNYHA, noted, “When it comes to emergency management, the principal focus needs to be on coordination, communication, and collaboration. Underlying plans are exceptionally important, but there is a lot to be gained from coordinated planning, having constant communication among the main players—whether it’s within the institution or among agencies—and really having a collaborative response.”

Ms. Waltman is responsible for legal, regulatory, and professional matters involving GNYHA and its affiliated corporations. This has led to her close involvement with emergency management and preparedness efforts.

“Too often a plan is written and then ends up on a shelf,” she related. “It is really about having the ability to work closely with colleagues and understanding the pattern of decision making. It is important to meet and

talk regularly with those entities with which you need to work during a disaster so you know who you will be working with, and what you can offer each other.”

This approach served GNYHA well as it engaged in collaborative, coordinated emergency preparedness for years. Being prepared took on added urgency over the course of 1999 as GNYHA prepared for an array of events related to Y2K computer concerns.

“The Y2K preparation seems silly now, but we literally met every other week with hospitals, emergency management, and health agencies, going through different ‘what-if ’ scenarios, from power outages for medical devices to computers that wouldn’t work. What came out of this was a mechanism for communicating easily and readily, no matter what the circumstances could be. So when 9/11 occurred, those relationships

were already in place,” Ms. Waltman explained.

With a desk at the Office of Emergency Management (OEM), GNYHA is expected to be there in anticipation of any planned event or in response to any major emergency. This has enabled the group to interact with OEM and other agencies as though it was a governmental agency. “We can face a disaster or emergency at any time, whether it is natural or a terrorist attack,” said Ms. Waltman. “As a result, we’re constantly planning and interacting. You can never anticipate how a specific disaster might unfold, and that’s why the relationships and joint decision making before, during, and after are key.”

Hurricane Irene and a Coordinated Emergency Response During the 2011 preparations for Hurricane Irene, GNYHA staffed and managed the New York City Healthcare Evacuation Center in conjunction with city and state health departments and OEM personnel. The center provided evacuation support, which focused on transportation, staffing, and coordinated decision making.

“As emergency response depends on a solid chain of command, it is important that those who are comfortable making decisions have the authority to do so. We found it to be exceptionally helpful to have Dr. Nirav Shah, New York State Commissioner of Health, with us, as he was able to recognize the flexibility that was needed to obtain safe placements for patients,” Ms. Waltman related.

Following Hurricane Irene, staff at the Center were asked to evaluate their support efforts for hospitals and the larger interagency system. Initial observations focused on evacuation timing, transport, and patient beds.

“The timeline in NYC’s coastal storm plan calls for evacuating health care facilities well in advance, and before the public at large [evacuates],” said Ms. Waltman. “Then, when all you see is sunshine outside, you wonder

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about the timing. But after seeing the time it takes to identify the different issues involved for hospitals and nursing homes—different kinds of patients, different types of critical care beds, and the time it takes to transport them—it is understandable why the plan calls for evacuation to take place so far in advance.”

Transportation plans were also flagged for improvement, with the idea of using buses as an alternative to ambulette transportation for some ambulatory nursing home patients. This would free up ambulettes or ambulances for sicker patients. Another important lesson was that a hospital or nursing home could more readily accommodate additional patients if staff were available to accompany patients.

She noted, “Hospitals came up with some creative solutions and approaches to accommodate patients. For example, one facility took a unit that would not be in use during the hurricane (as it was used for certain elective procedures) and offered it intact for evacuating hospitals to bring in their own staff and treat their patients as if they were back at their home hospital.”

In addition to a full debriefing for members and other agencies, this kind of feedback will be part of the OEM’s post-event “hot wash” for health and medical area agencies and groups in the future. GNYHA hopes to collect more of these shared experiences and creative approaches to help all members refine their emergency response capabilities.

Collaborative Resources and Initiatives “After 9/11, we realized that although we had done a lot with preparedness, we had to be better prepared for bigger events,” said Ms. Waltman. “We needed a planning process that reached to the highest levels of our institutions with the ability to command institutional resources in major disaster situation—and at the same time, we needed very significant assistance across the region. That’s when we created the Emergency Preparedness Coordinating Council.”

This council tackled various collaborative initiatives to assist members with everything from communications to bed counts. For example, it was instrumental in developing the Health Emergency Response Data System (HERDS), a centralized data collection system to inventory available beds in times of emergency and to help streamline patient relocation activities during evacuations. The council also recognized the importance of having more robust communication systems. Today, NYC hospitals

use 800-MHz radios, over their own channel, as the ultimate communication mechanism if there is a disaster such as the blackout of 2003 or the recent earth tremors. In addition to communications, GNYHA supports efforts such as ongoing emergency management training and programming, and valuable resources on its Web site (www.gnyha.org). Although these materials are designed to help members become better prepared for emergencies, the goal is ultimately all about coordinating efforts—such as holding a meeting with an NYPD lieutenant who talks about Mumbai and how that terrorist attack unfolded, learning how that city responded, and then applying its lessons to New York City. “By way of experience, we are practiced in interacting with members in emergency situations. We know with whom we should be speaking with at each of our members, but at the same time we respect the Incident Command System. We recognize the importance of having decision makers close by in emergency situations. No two emergencies are exactly the same, but by taking opportunities to expand our coordination, communications, and collaboration, we can help make a difference in our response,” Ms. Waltman concluded.

BRONX-LEBANON HOSPITAL CENTER’S EMERGENCY ACTION PLANNING At Bronx-Lebanon Hospital Center, the Department of Safety is charged with multiple responsibilities, some of which include, but are not limited to: fire and life safety, general safety and monitoring the fire command station; and coordinating emergency management and response planning. To support these efforts, it has called on resources ranging from GNYHA assistance and the New York City Department of Health & Mental Hygiene (NYC DOHMH) and Hospital Emergency Preparedness (HEPP) to the Joint Commission’s Emergency Management Chapter, according to Fifi DuBois, the Center’s Department of Safety Manager.

“At Bronx-Lebanon, we took our environment into account, for example, geographic location we’re in, and let that be our driving force to how we developed our Hazard Vulnerablity Analysis (HVA) and put our emergency action plan (EAP) together. With two main campuses and multiple satellite locations, our plan has to incorporate everyone to ensure we will have the necessary staff in case of emergencies,” she said.

To assess readiness, Bronx-Lebanon regularly

reviews its EAP and conducts drills. For instance, it recently ran a live drill scenario to test hazmat decontamination (decon) training. Because the hospital is at the crossroads of three major highways, including Interstate 95, its scenario involved a tour bus collision with a tanker truck carrying hazardous chemicals.

Ms. DuBois explained, “We let senior leaders know and then called the external drill, pulled our teams together, and tested our expediency and competency. We like to drill as much as we can to find our weaknesses so we can correct them. The bottom line is that we work very hard to establish our preparedness because, in the long run, this will help ensure the readiness of our community.”

The hazmat decon process places limitations on what staff can do. Hazmat “suits” make it challenging to move and lengthen even the simplest tasks. This particular drill highlighted the need for additional staff to be trained. As an authorized instructor in FEMA emergency preparedness training, Ms. DuBois plans to rectify this through further training sessions to build a team who can suit up and act. Putting the Plan into Action “With Hurricane Irene, we convened our onsite Emergency Management Committee,” said Ms. Dubois. “We were able to put our contingency plans in place and ensure that safety and patient-care would continue uninterrupted and that staff would be take care of. We were prepared.”

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Under its EAP, Bronx-Lebanon staff members were prepared to “defend in place,” meaning to stay onsite at the hospital, thanks to its stable infrastructure. Because people were still “a little rattled” after the East Coast earthquake earlier that same week, this “in place” approach helped minimize their exposure to the brunt of the storm. Departments were staffed and prepared to stay for three days if needed to maintain necessary staffing levels.

“When there’s an immediate or pending emergency, our employees ratchet up to the occasion with everyone pulling together from the various departments. All our ancillary services were appropriately staffed to provide necessary support functions,” she stressed.

Bronx-Lebanon has an added level of support through participation in the Bronx Emergency Preparedness Coalition, a group of Bronx-area hospitals. This coalition provides a memorandum of understanding so if any member hospital has to reach out in an emergency or disaster situation, all members are prepared to respond. Ms. DuBois herself participates in a National Preparedness Monthly Coalition Discussion Forum, an online site at which members can share or request information about their emergency preparedness activities. (For more information, see http://community.fema.gov/connect.ti/READYNPM.)

“We work hard in terms of timing and staffing to coordinate with the local EMS, police, and fire department. One of my future goals is coordinating community effort and drills, by bringing all those agencies in along with some of the local community boards. They are all part of preparedness because we will be depending on them should disaster strike,” Ms. DuBois explained.

In 2010, Bronx-Lebanon invited community members and boards to a town hall meeting to expand awareness of what Bronx-Lebanon emergency preparedness plan is, how it would affect the community, and what the community could expect. This was the first community review of the hospital’s EAP. It was well received and helped inform the community of what hospitals can and cannot do. “The more the community is prepared ahead of time, the more receptive and helpful it will be when and if residents have to present themselves to the emergency room,” she said.

The Communications Challenge As with other New York City health care institutions, the Center finds communications in an emergency to be challenging. Therefore, Bronx-Lebanon has a connection to the OEM via the 800-MHz radio channel, cell phones, and computers, along with analog landlines as backup for incident command.

“In the 2004 blackout, analog landlines were the only phones that worked,” Ms. DuBois noted. “Today, we are looking to get additional radios, as well as a ham radio for redundancy. During this recent decon drill, we saw that communication can drop to near zero when you are in a hazmat suit; radios can give these team leaders a way to communicate.”

Communication is an issue, but not an insurmountable one. The same applies for patient electronic health records, which are often inaccessible during disasters. Therefore, if the system fails, Bronx-Lebanon returns to paper methods. This is a standard practice, written into each department’s individual EAP procedures and is practiced.

“When it comes to communications, we’ve looked at most everything and can’t think of anything that would pose a problem or that we haven’t found a way

around, with the exception of human nature,” said Ms. DuBois. “When an incident occurs, it is human nature for most people to be concerned about their homes and their families. So to guarantee that they will be able to be available to help us in an incident, we (the Center) needs to have these concerns addressed.”

As part of its monthly new employee orientation process covering fire, life and safety, Bronx-Lebanon includes information on being prepared, both on site and at home. It also conducts e-workshops for community outreach on fire and home emergency preparedness. This is also an area it will be looking to improve as part of the EAP.

When asked about the most significant factors affecting Bronx-Lebanon’s emergency management efforts, Ms. DuBois replied, “What helps the most is having senior leadership buy-in and support emergency preparedness. For without it, you can make all the effort in the world but it won’t matter. At Bronx-Lebanon, they offer 100 percent and give us the support we need, despite the tough financial market. Of course, the most positive thing that could come out of any emergency preparedness efforts is to never have to use them in the first place.”

BETH ISRAEL MEDICAL CENTER’S EMERGENCY MANAGEMENT EFFORTS Beth Israel Medical Center, like Bronx-Lebanon and other institutions across the city, is actively engaged in a number of emergency management efforts, according to David Blacksberg. Mr. Blacksberg is Administrative Manager for Emergency Management at the center, which is part of Continuum Health Partners and includes two campuses, Petrie Campus and Kings Highway Division; the Phillips Ambulatory Care Center (PACC); St. Luke’s-Roosevelt Hospital; and the New York Eye and Ear Infirmary.

“The Joint Commission set the standards for disaster planning more than thirty years ago, and we have long focused on emergency management. However, once 9/11 took place, that focus really took shape with greater government involvement and more individual awareness and understanding,” said Mr. Blacksberg.

He pointed out that emergency management planning includes six key elements: communications, resources and assets, safety and security, staff roles and responsibilities, utilities management, and patient clinical and support activities. Like others, Beth Israel makes use of the hazard vulnerability assessment (HVA) to identify and understand what incidents pose vulnerablity and how to react to them. Although Beth Israel reviews its emergency operations plan (EOP) annually, the more telling reviews come after conducting an exercise or experiencing an incident.

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Said Mr. Blacksberg, “We conduct exercises several times a year and review things that went well and things that need improvement. This helps us understand what elements of the plan need to be changed or updated. We take the same approach with any incidents that might occur.”

Practice Makes Perfect: Exercises to Test the EOP What types of exercises are run at Beth Israel? In April 2011, it conducted a Continuum-wide hurricane tabletop drill, in which key stakeholders were located around tables in their respective command centers, at conference rooms around the facilities. They were presented with a specific scenario, such as a hurricane, and everyone assumed their roles and discussed what should be taking place.

“The great thing with a tabletop exercise is that it offers a stress-free environment; there’s no right or wrong, as it is simply a discussion,” commented Mr. Blacksberg. “From there, we will often conduct a subsequent functional exercise with more hands-on activities taking place. For example, we conducted a hazardous materials exercise and then followed up with a functional exercise to set up our decontamination showers. This assures that everyone knows their roles in the set-up process and everything in the unit is in proper working condition.”

After the functional exercise, Beth Israel might launch a full-scale exercise, such as a hazmat event. This would entail activating the command center and presenting the specific scenario to key stakeholders and players such as the hospital’s vice president, chief of operations, chief of nursing, and so on. The various incident commanders then would have to act out what they would actually do during the incident—for example, establishing full communications between the command center and those who are dressed in their hazmat suits; making phone calls and sending e-mails; and evacuating volunteers who are acting as patients. Beth Israel conducted a series of hazmat exercises last year. In January 2011, it ran a full-scale, fire-related incident at PACC in conjunction with the New York Fire Department.

Mr. Blacksberg noted, “While it can be challenging to work around regular operations, we try to run several exercises a year. We often do the exercises in that order: tabletop, functional, and full scale. If we go right into a full-scale exercise, it can be challenging because people may not always be exactly aware of what needs to take place. Sometimes we do go right into the full scale, and sometimes we do the functional first.”

Capturing Lessons Learned: Communications and More What has been learned from these exercises? In many cases, communications jump to the top of the list as an area that can use practice and improvement—despite the fact that Beth Israel has plenty of redundancy in its communications, with regular digital landlines, analog backup landline phones, cell phones, two-way radios, and four different methods for maintaining Internet connections.

“Communications are always a focal point, as they are key to maintaining hospital operations; maintaining patients, visitor, and staff safety and security; and maintaining the highest standard of care possible. It is also important that everyone understand their roles and assigned responsibilities. With staff turnover in the health care industry, people may be new or performing a different role. We want to maintain and improve the response levels we have so that a person’s reaction becomes more intuitive,” Mr. Blacksberg explained.

“We have good working relationships with external agencies too,” he continued. “This includes GNYHA, where we maintain communications with them even if it is a smaller incident taking place. We also communicate with OEM and the NYC DOH, sharing in various emergency management meetings, participating in conferences, and taking advantage of opportunities to learn from each other with regard to creating and maintain our plans in areas such as pediatric safety, ICUs, evacuations, and mass fatality management.”

Hurricane Irene: An Exercise Comes to Life When Beth Israel conducted its hurricane tabletop exercise early in 2011, little did it know that Hurricane Irene would be a reality several months later. Although it experienced several minor Irene-related incidents at its facilities, the real impact came from the influx of patients from other hospitals that were evacuated. Between its Petrie and Kings Highway locations, Beth Israel handled more than 80 additional patients from some 15 different facilities across the city. Thanks to solid emergency management planning and tight communications, it was able to streamline tracking and administrative processes to minimize the effects of evacuation on these patients.

As Mr. Blacksberg related, “Being part of the Manhattan Emergency Management Coalition, we have close working relationships with NYU Medical Center and other health care facilities. We asked NYU for specific information so we could provide their patients with appropriate health care. NYU gave us the name, sex, age, and diagnosis for each patient, enabling us to process most as direct admits to facilitate the transition, and reduce the surge on our emergency department. We also activated our Rapid Patient Discharge Assessment when the evacuation was first announced, so that patients who could be discharged and sent home safely were released on Friday before evacuations began.”

Beth Israel helped develop, and is part of, the Manhattan Health Care Emergency Management Coalition (Petrie and PACC); the Kings Highway division is part of the Southern New York Partnership. Both of these coalitions, along with others such as the Bronx Emergency Preparedness Coalition, encompass New York-based hospitals as well as other health care-based groups such as smaller ambulatory care centers and clinics. As evidenced by their recent evacuation experiences, these coalitions enable a level of unprecedented coordination and collaboration among members that can streamline efforts for emergency management and response.

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“As our work with our staff; our community partners such as the fire and police departments, OEM, DOH, and GNYHA; and our coalition members continues to grow and gain positive momentum, we look forward to working every day to create and maintain partnerships and deliver the highest level of care for all New Yorkers and visitors,” Mr. Blacksberg concluded. EVACUATION CHALLENGES AND KUDOS FOR MJHS It is one thing to prepare and perform emergency drills, but the ultimate test comes when disaster is at your doorstep. This was the case for MJHS (formerly known as Metropolitan Jewish Health System) when Hurricane Irene came calling on Coney Island. On August 25, 2011, Mayor Michael Bloomberg issued an evacuation order for Zone A, low-lying areas including Coney Island and Manhattan Beach in Brooklyn, as well as other low-lying and beach areas around the city. During his announcement, the mayor stressed, “Our first obligation … is to protect the most vulnerable New Yorkers—hospital patients, those in nursing homes and homes for the aged, and New Yorkers who, because of age or infirmity, are homebound.”1

Within the designated evacuation zone, five hospitals and eight nursing homes were instructed to start evacuations the following morning and to aim for completion that evening. This directive affected two MJHS facilities: Shorefront Center for Rehabilitation and Nursing Care and Menorah Center for Rehabilitation and Nursing Care. In less than 24 hours, all 655 patients at Shorefront and Menorah, accompanied by 165 staff, were relocated to 48 facilities before Hurricane Irene unleashed her full fury Saturday afternoon. Once the “all clear” was sounded on Monday, a massive return effort ensued—and all patients were back at Shorefront or Menorah by Tuesday evening.

What does it take to execute an evacuation effort on this scale? In a posting about the event, Carol Altieri, Vice President of Corporate Affairs and Long Term Care, wrote, “All patients left with paperwork compiled in marathon sessions by late-working staff—describing patient illnesses, medications, and the equipment accompanying them, such as IV pumps, feeding tubes, and nebulizers. In some cases, mattresses and beds were shipped. Residents were even given a ‘care package’ that included a tasty meal-to-go.”2

Success for this effort was also attributed to the dedication and commitment of MJHS staff members, many of whom returned early from vacations, canceled days off, and worked virtually nonstop in 24- to 36-hour shifts to ensure the safety and security of patients. This did not stop with those working at the Shorefront and Menorah facilities, but extended to MJHS Home Care and Hospice and Palliative Care staff and their patients who were in harm’s way.3

Putting Emergency Planning to the Test Said Ms. Altieri, “Given the abbreviated time line for evacuation, one of the first tasks was activating our chain of command. Each facility’s administrator was responsible for delegating activities, including designating teams for transportation, monitoring and tracking patients, clinical needs, overall logistics, dietary needs, caregiving and care-comforting teams, as well as admissions and placement.”

The next challenge was determining where and how to move patients. This was facilitated by executive leadership at MJHS with assistance from the Continuing Care Leadership Coalition (CCLC) of New York, which is the long term care affiliate of GNYHA. As with other health care institutions in New York, the long-term care community has established coalitions such as CCLC that can provide valuable help during emergencies.

CCLC lent assistance by soliciting members and identifying other health care institutions that could take patients and residents. The coalition also helped coordinate efforts with the OEM on behalf of Menorah, Shorefront, and the other long-term care institutions being evacuated.4

“As far as we’re concerned, CCLC president, Scott Amrhein, and director of government relations, Diane Barrett, are heroes. In working through this evacuation, their support and involvement was a critical part of our success.

With their help, we were able to learn which facilities had beds available and also obtain ambulances to transport residents,” Ms. Altieri remarked.

Collaborative assistance with medical transport was particularly important. Because there were 13 large health care facilities in the evacuation zone, ambulances were at a premium as hospitals and other facilities required the same services. Even with a dedicated medical transport service, the sheer logistics presented by the limited timeframe

and the number of patients being evacuated severely taxed area transportation systems. MJHS’s transport partner helped press additional ambulance services into use, and the OEM also relaxed licensing restrictions to permit ambulances to cross county lines and, when medically feasible, carry two patients, rather than just one at a time.

Moving Forward In dealing with the many challenges, MJHS’s evacuation response efforts were clearly aided by the “three Cs” of emergency management, with excellent coordination and communication of its emergency action plan among staff, along with the collaborative assistance of CCLC member facilities and other business partners. Reflecting on MJHS’s experiences during the evacuation, Ms. Altieri added, “This was our first evacuation at Shorefront or Menorah; the biggest challenge was really the hurricane itself and Mother Nature’s short notice. We already knew that our staff would step up with dedicated efforts for a different kind of rapid-response-action. Because Shorefront and Menorah are 24-hour facilities, we also knew that staff would concentrate on doing whatever needed to be done for the good of the residents and patients—and that is exactly what they did.”

RESOURCES: 1 “MayorBloombergUpdatesNewYorkersonCityPreparationsforHurricaneIreneand

Steps New Yorkers Should Take to Prepare,” press release, August 25, 2011, p. 1, http://www.nyc.gov/portal/site/nycgov/menuitem.c0935b9a57bb4ef3daf2f1c701c789a0/index.jsp?pageID=mayor_press_release&catID=1194&doc_name=http%3A%2F%2Fwww.nyc.gov%2Fhtml%2Fom%2Fhtml%2F2011b%2Fpr307-11.html&cc=unused1978&rc=1194&ndi=1.

2 Waters, A. “Riders and Heroes of the Storm,” MJHS Facebook page, posted September 13, 2011, http://www.facebook.com/note.php?note_id=213602988698755.

3 Ibid.

4 Ibid.

It is one thing to prepare and perform emergency drills, but the ultimate test comes when disaster is at your doorstep.

Insights on Emergency Preparedness and Response in New Yorkcontinued from page 25

WINTER 2011–12

27

The Quarterly Journal for Health Care Practice and Risk Management

From the Chief Medical Officer

Disaster can strike at any time—from earthquakes and mudslides in the West, to tornadoes in the South and Midwest, to hurricanes, f loods, and blizzards in the North

and East. Adding to these natural disasters are perils that can occur anywhere: radiological events, bioterrorism, infectious disease outbreaks, and criminal activities. Still, it is important to understand that some of the most common causes necessitating health care facility evacuations are actually internal emergencies—such as fire and hazmat situations—that jeopardize patient care and affect the ability of health care providers to continue “business as usual.”

As any good scout knows, “being prepared” is wise advice—and is particularly critical when it comes to those responsible for the public well-being. Many communities coordinate periodic drills to help ensure that the safety network of police, fire, first responders, rescue workers, and health care professionals is prepared and can operate smoothly in an emergency. The Centers for Disease Control and Prevention (CDC) has an entire Web site devoted to protocols and practice drills for biological outbreaks and f lu pandemics. As massive catastrophes such as the World Trade Center attacks or Hurricane Katrina attest, however, there is much room for improvement in our nation’s emergency preparedness.

How would US health care institutions and physician practices respond if a disaster struck tomorrow? Are you aware of your responsibilities as a health care professional? How would your practice survive? Could you get up and running quickly to provide care during a crisis? Do you have procedures in place for dealing with fires, f loods, or break-ins? How would you handle an armed intruder looking to steal drugs? What about more common types of emergencies, such as power outages and brownouts, with their potential effects on electronic health record (EHR) systems and office equipment?

We hope this issue of infocus provided a solid perspective on the state of emergency preparedness. The ability for health care providers to use the lessons learned from the past allows us to identify and share the “best practices” of the future. Through our committee processes, we continue to focus on the clinical aspects of patient safety and quality, with an emphasis on sharing solutions that come from our shared experiences. In addition to our clinical experiences, we can all learn from our responses to events that have an impact on our business and personal lives.

The constant theme is the ability to focus our efforts on training—creating effective communication and teamwork. Our March 2012 conference seems to be right on target in defining new training methods—spotlighting the idea of collaboration and inspiring all physicians, nurses, administrators, and health care providers to work together and share responsibilities. Whether in the clinical setting or in an emergency, we need to be prepared for the high-stress/high-stakes world of ensuring patient safety and quality.

David L. Feldman, MD dfeldman@fojp.com

Editor-in-ChiefDavidL.Feldman,MD

Managing EditorLisaSokol

Senior WriterDiane Desaulniers

ContributorsWilliamT.Buckley IreneKassel,RN,BSNNancyKozuchowski,RN,MS,CPHRMDeborah Wenger

Editorial BoardPeterKolbert,Esq.JoelGlass,Esq.PatriciaKischak,RN,MBA,CPHRMSteven Macaluso, Esq. LoretoJ.Ruzzo,Esq.

Design & Production ManagerGlennSlavin

Risk Management Advisory BoardClaudiaColgan,BSN,BSEdLouisI.Schenkel,MS,JDSheila Namm, RN, MA, JD, CS Tina H. Weinstein, Esq.

Voluntary AttendingPhysicians (VAP) ProgramAll questions concerning coverageshould be directed to Alice Walsh,VP,Underwriting&PhysicianServices, Hospitals InsuranceCompany, Inc. at 800.982.7101.

Recommendations contained ininfocus are intended to exemplifythe application of risk managementand quality of care principles.They are not intended as standardsfor, or requirements of, clinicalpractice. For specific legal advice,consult an attorney.

infocus is published by:FOJP Service Corporation28 East 28th StreetNew York, NY 10016.

FOJP Service CorporationRisk Management Advisorsto the Health Care andSocial Services Community

© 2011 by FOJP Service Corporation

WINTER 2011–12

The ability for health care providers to use the lessons

learned from the past allows us to identify and share

the “best practices” of the future.

FOJP Service Corporation28 East 28th StreetNew York, NY 10016

25th H

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nce Training for Patient

Safety and Quality

www.fojp.com/conference.html

Hilton New YorkGrand Ballroom (3rd Floor)

1335 Avenue of the Americas (6th Avenue and West 53rd Street)

New York City

WednesdayMarch 7, 20128:00 am – 2:00 pmThis year’s speakers include:

Kenneth L. Davis, MD President and Chief Executive Officer, The Mount Sinai Medical Center

John Foley Performance Expert Former Lead Solo Pilot, U.S. Navy’s Blue Angels

Colleen O’Connor Grochowski, PhD Associate Dean for Curricular Affairs, Duke University School of Medicine

Richard Satava, MD, FACS Professor of Surgery, University of Washington Medical Center Senior Science Advisor, U.S. Army Medical Research and Material Command

Alison H. Page, RN, MSN, MHA Chief Executive Officer, Baldwin Area Medical Center, Baldwin, Wisconsin