No Hospital Left Behind

South Dakota - America's frontier. A vast expanse of small towns, farmland and big blue sky. When I left New York City and headed here, every comment my friends and coworkers made was about the dramatic transition. I'd been manager of emergency services for a large metropolitan hospital system in an environment target-rich for terrorists. Now I would manage emergency preparedness for an even larger, but prospectively "safer," system in the American heartland.

What I found on my arrival was an organization that had already established a solid foundation of preparedness. The team at Sioux Valley Health System was working in an atmosphere of great cooperation to realize a comprehensive preparedness goal that worked not only on paper, but in reality as well. This team effort epitomized the unified concepts of incident management.

Sioux Falls and Its Healthcare System

Sioux Falls is one of America's small big cities. It is growing rapidly: Its population, 124,000 in the 2000 census, is now estimated at around 150,000. Large corporations that have roots here are growing in size, and other corporations are moving in, creating jobs and expanding commerce. It is a multicultural city with an active population: There were at least 55 various public events planned for summer 2005. Some larger events, like the Sioux Empire Fair and a Christian music festival, bring an additional 200,000 people to the city.

Sioux Valley Health System is a vast hospital system with 24 hospitals, 94 clinics and numerous other related facilities spanning across South Dakota, Minnesota, Iowa and Nebraska. Sioux Valley is one of the largest employers in South Dakota and is constantly outgrowing and expanding its main campus in the heart of Sioux Falls. Sioux Valley Hospital is one of two major healthcare facilities in Sioux Falls, as well as a Level II trauma center.

Some might say that a hospital in South Dakota, in a city with a population 50 times smaller than that of New York City, has little to be concerned about regarding disasters. But the fact is that the American Midwest is plagued by weather events like tornadoes, floods, severe winter blizzards and cold, intense heat, thunderstorms and powerful winds. Moreover, in addition to the natural disasters, the state is a major agricultural center, with thousands of farms and ranches that rely on chemicals. These chemicals are transported via a major interstate system that spans across the state in all four directions.

The Preparation Process

One of the first things a planning team has to realize is that whether a disaster event is intentional or accidental, it will produce certain similar outcomes: physical damage, potentially large numbers of casualties and the spread of contamination. This is true whether it's intentional or accidental - imagine a chemical leak or spill producing many contaminated patients, all of whom need decontamination prior to treatment.

Sioux Valley's hazard vulnerability analysis (HVA) showed that for us, the probability of an industrial or transportation accident involving chemical spills was higher than that of a terrorist attack. We realized that if we began to look at intentional and unintentional events as similar CBRNE (chemical, biological, radiological, nuclear and explosive)/hazmat types of incidents, we could develop an "all hazards" approach to disaster preparedness.

Roles All Around

The first step to disaster preparedness for a hospital, as for any entity, is to identify what resources will be necessary to function in extreme circumstances. Normal hospital operations require coordination from multiple departments. Each department has a specific task during regular business. To think that such departments will not have roles in a disaster will lead to an ineffective plan.

Many hospital disaster committees are too small and do not encompass everyone who needs to have a role. This can lead to too many responsibilities on one person, and an ineffective overall effort. Departments that are active during normal patient care activities should also be expected to be active during large-scale events.

The focus of Sioux Valley has always been to serve the needs of the community. Realizing early on that emergency preparedness was going to be a large piece of that community service, Sioux Valley Hospital developed its emergency management committee in the early 1990s. The committee meets bimonthly (monthly during projects) and has 24 members representing the various departments that would be directly involved in a disaster response. In addition to developing and implementing a comprehensive disaster preparedness plan, the committee also ensures compliance with the numerous standards that affect hospital operations.

In 2003, President Bush issued Homeland Security Presidential Directive 5 (HSPD-5), which stated that all federal, state and local authorities must adopt and comply with the National Incident Management System (NIMS). NIMS is a template for a unified incident command system and ensures a more coordinated response across large geographic areas or when responding to multiple incidents in a single region. As a private entity, it was unclear initially whether Sioux Valley Hospital was affected by HSPD-5. However, JCAHO (the Joint Commission on Accreditation of Healthcare Organizations), the body that accredits healthcare entities displaying a certain level of quality, requires accredited facilities to adopt an incident command system (ICS). What was clear was that based on these requirements and our goal of community service, we needed to make a decision about our own internal incident command system. This process resulted in some interesting revelations. Revelation 1: Being part of a response system that includes HSPD-mandated agencies such as the fire service, EMS, law enforcement, and rescue and emergency management agencies, it only made sense that we look at adopting a compatible ICS. This would not only result in roles and processes compatible with our responder agencies, but it would also facilitate a better interagency communication network. This concept would work for all four phases of emergency management (mitigation, preparation, response and recovery), and it would work exceptionally well for interagency cooperation at the planning table and at the operations level.

Revelation 2: In developing our ICS implementation plan, we quickly realized that communications between incident scenes and hospitals was not always as comprehensive as they should have been. We had to figure out why. After reviewing multiple after-action reports and lessons learned from events and drills nationwide, it became obvious that this was not a local problem, but a nationwide problem that was coming up time and time again. Communications with hospitals nationwide seem to be a problem, and we would set out to discover the reasons.

Revelation 3: Incident command systems have gone through multiple metamorphoses over the years. Services went from Firescope to Fire Command to NIMS and, for hospitals, HEICS (the Hospital Emergency Incident Command System). We needed to find out what would fit best within our network. What we found was that these systems all integrated to some extent with each other, and what we needed to decide was just how to integrate them within our healthcare network, as well as make our network fit within the overall community response system. Fortunately, the response system was working toward the same goals.

Revelation 4: NIMS, at first glance, looks like it was not designed with healthcare networks in mind. However, if you look closely, it can be a helpful tool for network and resource management.

HEICS Integration

Preparedness was a top priority everywhere post-9/11, and South Dakota was no different. The state developed four regions for bioterrorism planning. Sioux Falls was in Region III, and Sioux Valley representatives became part of the Region III Bioterrorism Preparedness Committee. The benefit of this committee is that it brings together local emergency managers, health department representatives, hospital preparedness managers and others, as necessary, to work toward the level of preparedness needed to respond to any bio-event. The regional plan was established, and it was decided that as a region, we needed to adopt a single incident command system. Since HEICS had been introduced a year earlier by the state Department of Health in several train-the-trainer programs, it seemed only natural to continue with it.

HEICS has been an increasingly accepted standard for incident command in hospitals since its development in the 1990s, when it was derived from systems already in national use (see sidebar). It offers all the basics of incident command and features job descriptions that fit within the framework of most hospital networks. For all intents and purposes, HEICS is a brilliant piece of work.

The next question was how to effectively integrate our existing hospital disaster plan with the HEICS and NIMS frameworks. Based on our system's structure, we decided to integrate HEICS at the hospital level, with staff being trained in it as their primary ICS structure and in NIMS as an awareness program. It made best sense for us to implement an "area command" style of management with the corporate level executive team, as the team would provide planning and logistical resources for large-scale events. We would begin our training at the hospital level with the HEICS model rolled out for both the executive and lower levels of management, followed by a NIMS awareness component. The overall result would be a system-wide multidisciplinary incident command system that encompassed both HEICS and NIMS components. This system would be completely compatible with the field ICS system that was currently in place. This system would also be compatible with the unified and area command system at the Emergency Operations Center (EOC).

As the HEICS rollout began, ICS training was, per the plan, delivered initially to the executive staff, which would be our frontlines of disaster management. The execs were trained on HEICS and given an awareness level of NIMS in order to ensure that they could control an operation while communicating with those on scene and at the EOC. Should a large event occur, an area command system would be initiated to ensure appropriate resource management.

The executive staff completed their training with a tabletop drill entailing a simple deployment of the HEICS, filling job descriptions and appointing administrative staff and section chiefs.

The next step was to train middle management: all department directors, managers and supervisors. We held multiple sessions over a six-week period for more than 300 personnel. As well, we determined that since administrative assistants would fill support roles during disasters, they also needed to be current in any changes, so they were also grounded in HEICS and NIMS awareness, as well as pertinent disaster documentation.

The final step, still in progress at the time of this writing, is to train and prepare executives in resource management, area command and joint information sharing to ensure not only a smooth internal support structure, but a seamless system of communications with local emergency management officials.

In March 2006, multiple Sioux Valley network hospitals will participate in a multi-facility exercise. As a prerequisite for participation, all facilities taking part in the exercise must roll out the Sioux Valley version of Incident Command to their staff. Each facility will initiate its individual incident command process. The corporate department will then initiate an Area Command to provide resource management to all participating hospitals. The drill is intended to test our ability to communicate between command centers, move patients between facilities and coordinate our efforts as a network. It will also test the resource management functions in logistical support, resource management and procurement. One of the major realities unearthed during the response to Hurricane Katrina was that hospital networks may well be required to support themselves internally as local and regional resources may be cut off or redirected to other locations.

Communications

The result of all this on the regional front was that already-strong partnerships continued to flourish and information sharing began to reach a level that was truly exceptional. The communications issue continued to come up during the process, however, so we decided we needed to evaluate and strengthen our communications system. We decided to conduct a drill that would test our current system, as well as the South Dakota state radio system.

The state system is a comprehensive digital radio system that provides talk groups for responder agencies, as well as tactical channels that can be assigned to different agencies during a major emergency. The drill reassured us of the efficiency of the state radio system, but identified that the position of medical communications officer could be easily overwhelmed in a large event. It could be difficult, we discovered, for one person to efficiently notify and update hospitals. It was suggested that an additional person be assigned the specific role of communicating with hospitals, or that the hospitals send representatives to the EOC who could disseminate information back to their command centers. On the Sioux Valley side, the drill showed that the HEICS rollout was efficient, but there was some confusion regarding the job action sheets, which describe the roles and responsibilities of various personnel under HEICS. The existing job action sheets created redundancies within our hierarchy. We then formed a subcommittee that tailored all job action sheets to Sioux Valley Hospital operations. This finding should serve to advise other hospitals integrating HEICS that as good as the system is, it may require some fine-tuning to the individual organization's response structures.

Sioux Valley is the largest tertiary hospital in our health system, so it was decided that we would produce and disseminate HEICS and NIMS "tool kits" for other regional and critical-access hospitals. We conducted a train-the-trainer program for all these facilities' safety officers, and they went back to oversee their own rollouts, with Sioux Valley staff available as a resource if questions arose.

Contaminated Patients

Special circumstances aside, the primary role of any hospital system is to receive and treat patients. With the possibility of CBRNE events in the homeland, all receiving hospitals need to consider implementing decontamination facilities.

This can be a daunting task. Multiple factors come into play: respiratory protection, fit testing, protective clothing, decon showers, water supply, location, security and patient privacy are but a few. Luckily, the South Dakota Department of Health addressed one big issue by researching, purchasing and distributing respiratory and chemical protective equipment to all state hospitals. This equipment included hooded powered air-purifying respirators (PAPRs), as well as Tychem F chemical protective suits. The DOH provided training to all staff in respiratory protection, as well as the donning and doffing of PPE.

The next step for Sioux Valley was to develop and implement a hazmat operations course that was OSHA-compliant and also met the real needs of the system. What we developed was a four-phase decontamination training program consisting of three didactic sessions and one hands-on session. The didactic sessions covered basic hazardous-materials awareness, the hospital decontamination process (including a review of respiratory protection standards) and a CBRNE component. The hands-on phase included donning and doffing PPE, construction of portable showers and walking through the decontamination process. This course took approximately 8 - 10 hours.

Each decon team member was issued a procedures manual outlining all processes, pre- and post-entry evaluation criteria, guidelines for patients with special challenges, decontamination and triage of patients involved in radiation incidents, and other pertinent aspects. In addition, a special disaster level was created to identify events requiring decontamination and automatically mobilize the decon team to their staging area. Based on research and lessons learned from other incidents, it is generally assumed that there will be a 4:1 ratio of "worried well" to truly contaminated patients in such an event. In order to avert a potentially overwhelming influx of patients to the emergency department, Sioux Valley designated two decontamination sites. One is located near the emergency department, the other in another part of the hospital. While critical patients will be decontaminated and seen immediately in the ED, ambulatory and asymptomatic patients will be directed to the latter, secondary site, evaluated and then monitored for symptoms by clinical personnel.

We also decided that during an event requiring decontamination, once the process is activated, all arrivals will be decontaminated, regardless of field contamination/decontamination status. We believe this will ensure the safety of the hospital staff and other patients. In many cases, field decon may consist only of a gross process. The hospital process, conversely, must be thorough.

In August 2005, the Fifth US Army Civil Support Training group, along with the 323rd Chemical Company, teamed up with two area hospitals to run full-scale decontamination exercises at hospital facilities. These major military resources are available and will respond to civilian locations when requested. Preplanning the decontamination drill was a major learning experience and a lesson in gearing up our internal preparedness as well. As these resources are available to civilian facilities, they also make it plainly clear that they have a mobilization and response time of 24 - 72 hours. Hospital planners and emergency managers need to continue to develop and adhere to plans that are supported internally in the initial phases of an event. Planning on outside aid that may not arrive for several hours or days is the recipe for an ineffective plan.

What's Next?

Sioux Valley Hospital recently opened its Center for Prehospital Care and Disaster Preparedness. The Center will continue to work with regional and state agencies on planning and implementation projects, as well as providing training programs to emergency responders and healthcare personnel and assist other healthcare networks in their preparedness efforts.

In addition to such outreach, the Sioux Valley emergency management team continues to improve its level of preparedness. Some current projects include revision of our HVA program and development of a network-wide computerized resource management tool. The Executive Management Team has drilled the Incident Command System multiple times and Sioux Valley continues to drill within its walls. With each exercise, new and more efficient fine tuning results. In addition to training at the tertiary care center, multiple Incident Command programs have been rolled out to our Regional and Critical Access Facilities. Each of these programs culminate in a tabletop exercise that generates comprehensive discussion and opens multiple doors to more efficient response and the process of upgrading each facility disaster plan.

Conclusion

One of the biggest things to take from the Sioux Valley experience is that emergency preparedness is a constantly evolving arena. As the face of disaster changes, so must the knowledge, skills and protocols of people receiving the victims of disaster. Monitoring constant changes in technologies and knowledge bases is the recipe for a successful operation. As we move forward, we constantly review plans, ensure that all plans complement each other and develop policies and guidelines that will ensure an effective response. In addition, we continue developing and nurturing partnerships within our walls, as well as with responder agencies, emergency managers and regional and state resources and other healthcare facilities. These are essential to a healthy and effective response system. As partnerships develop, so do strong response plans. One of the things that has made the Sioux Valley plan so successful is the exceptional attitude toward a unified level of preparedness that the region's responder agencies have demonstrated.

The understanding that unified planning never ends is the catalyst for an effective and comprehensive response plan.

Greg Santa Maria is a nationally registered paramedic and former New York City paramedic instructor. He has been active in EMS since 1988 and involved in hospital disaster preparedness planning and training since 1996. Greg recently moved to Sioux Falls, SD, and is manager of prehospital care and emergency preparedness at Sioux Valley Hospital, University of South Dakota Medical Center. Contact him at santamag@siouxvalley.org.