Natural and manmade disasters frequently result in significant healthcare impacts, including patient surges and hospital evacuations. These disasters create a need for robust healthcare emergency management (HEM) exercises, a priority reinforced by the Joint Commission’s accreditation standards, which require hospitals to regularly conduct full-scale emergency exercises. Nevertheless, many emergency management departments continue to struggle with personnel and budgetary constraints, as their value is often overlooked until disaster strikes. As such, HEM practice can often be singularly focused on accreditation-based exercises such as those required by the Commission on Accreditation of Rehab Facilities and the American College of Surgeons. The demand placed on HEM continues to increase due to the combined effect of a growing patient population, expanding healthcare systems, increasingly frequent and severe natural disasters, and the ever-present threat of technologic and human-caused disasters. Hospitals and health systems need to be prepared, and full-scale exercises are the most comprehensive method for achieving this preparedness. By leveraging partnerships with clinical and information technology staff in their healthcare systems, and by utilizing emerging technologies such as generative artificial intelligence (AI), HEM practitioners can enhance their capacity to carry out these exercises.
As the most true-to-life exercise format used by emergency managers, full-scale exercises validate plans, policies, procedures, and capabilities through realistic simulation of all components of an emergency response. These exercises can shed light on strengths and weakness, resource requirements, and capability gaps. In HEM, exercises often focus on evacuation and surge events because these events result in significant disruption of hospital operations. It is increasingly common to see HEM utilize patient actors during their exercises to better simulate the social and medical complexity of actual patients and to add a level of realism to the exercise for healthcare staff, ensuring systems are accurately tested. Nevertheless, the clinical portrayal of patients during full-scale exercises has not kept pace with emerging technologies, significant clinical advancements, and improved patient care standards. Even as exercises address the big-picture aspects of emergency management, it is important for exercise directors to give careful attention to the individual patients that are at the core of any healthcare emergency response.
Advice for Building Simulated Patient Profiles
By improving clinical accuracy, introducing dynamic patient statuses, integrating electronic medical records, and harnessing quality data collection, HEM can refine its approach to exercise patient representation. The acronym PEOPLE provides a useful framework for improving the simulated patient profiles used in full-scale exercises.
Perspective
HEM must keep people as a core focus of exercises and trainings. When building a set of simulated patient profiles, a healthcare emergency manager must consider the patient population their system serves. This includes placing emphasis on ensuring the simulated profile set and corresponding actors have similar demographics to the identified population. Additionally, this includes medical complexity and the development of complex social considerations—such as parent-child interactions or even having someone conceal a pet in the emergency department—that could help prepare staff and systems.
Evaluate the Current Program
It is important to accurately evaluate the current program status before initiating improvements because understanding the current state of simulated profile sets allows healthcare emergency managers to identify strengths and weaknesses of the current system. This knowledge can then be used to scope the desired changes and ensure proper planning resource allocation.
Obtain Collaborators and Stakeholder Buy-in
To deploy an effective program, healthcare emergency managers do not need to reinvent the wheel. Sustainable program expansion leverages existing intra-hospital networks and promotes shared ownership among stakeholders. Healthcare emergency managers should identify key stakeholders based on the exercise location, goals, and objectives. Examples of valuable partnerships include nursing, medicine, information technology, and simulation centers.
Prioritize Representation and Accessibility
An essential aspect of all improvement efforts is the representation of the whole community, allowing exercises to accurately reflect the patients that healthcare systems serve. When seeking improvement opportunities, take into consideration race, ethnicity, language proficiency, and disability to ensure accurate representation. Consider leveraging stakeholders, such as employee resource groups or advisory councils in the planning stage to ensure appropriate implementation.
Lean into Learning
Continuous data collection and feedback loops allow programs to expand in meaningful ways by identifying strengths and weaknesses. Data collection can also be used to justify an increased exercise budget by quantifying improved preparedness or to identify the best use of limited planning resources.
Explore Avenues for Growth
As programs and health enterprises expand, consider new avenues for partnership, opportunities to scale up, and methods to increase process automation and efficiency. Evaluate federal, state, and local emergency preparedness resources and relationships that could support future full-scale exercises.
A Case Study of Hospital Evacuation Exercises
The Medical Intensive Care Unit (MICU) and Neonatal Intensive Care Unit (NICU) represent two of the most high-stakes environments in a hospital, caring for patients who are among the most vulnerable during a crisis. Conducting full-scale exercises in these units presents unique challenges, not only due to the acuity of patient populations but also because of the highly complex medical equipment that keeps these patients alive.
At New York University Langone Hospital—Long Island, the Emergency Management + Enterprise Resilience team (EM+ER) and clinical leadership both recognized the need to build upon past evacuation exercises by testing the system’s ability to evacuate the hospital’s most sensitive intensive care units. These exercises were designed to go far beyond regulatory requirements, providing a real-world stress test for both the clinical teams and support staff that would respond to a crisis.
A critical factor in the success of these exercises was the integration of highly detailed patient profiles, which reflected the medical and social characteristics of the MICU and NICU patient populations. Developed with close collaboration among EM+ER, nursing leadership, and physician leadership, these profiles introduced challenges that extended beyond typical medical considerations. During the NICU exercise, for example, high-fidelity simulation mannequins were accompanied by worried parents (played by actors) who engaged clinicians by asking questions and, at times, expressing panic and distress. While it was necessary for the patients to be played by mannequins so that staff could simulate real procedures and interventions, clinicians found that the parent actors helped them engage emotionally with the scenario, treating the simulation mannequins like real NICU patients.
Adding further complexity to these exercises were highly technical life support equipment in tandem with high-fidelity simulation mannequins. Patient profiles were designed with this equipment in mind. Clinical teams had to make rapid decisions as they prepared for evacuation, carefully preparing ventilators, IV pumps, and other devices to be moved alongside their patients. Several unexpected hurdles presented challenges. For example, MICU staff had to develop a strategy for maintaining the security of controlled substances as they were transported with a sedated patient on a ventilator. NICU staff had to ensure that a highly specialized oscillatory ventilator could operate for the duration of the evacuation without being plugged into an electrical outlet. These challenges required participants to engage their “clinical brain” rather than simply follow a checklist of evacuation tasks.
By pushing the boundaries of traditional emergency evacuation exercises, these full-scale exercises at NYU Langone Hospital–Long Island validated that emergency evacuations from even the most complex clinical units could be accomplished with proper planning, teamwork, and operational coordination. The lessons learned from these exercises will serve as a foundation for future resilience work, ensuring that even the most high-stakes units in the hospital are ready to respond when disaster strikes.
Hospital Emergency Management Remains Crucial to Preparedness
As demonstrated by recent disasters, HEM has an important role to play in ensuring that hospitals are prepared for complex crises. Full-scale exercises continue to be the gold standard for preparedness, and these exercises can more effectively prepare healthcare workers for disasters if they incorporate realistic patient profiles. Leveraging interdisciplinary collaboration, emergency management teams can exceed regulatory standards and strive for a culture of resilience and readiness. This can be accomplished with the integration of dynamic patient scenarios, electronic medical record functionality, and diverse patient representation. Future efforts in healthcare emergency management should focus on promoting patient simulation methodologies, expanding interdisciplinary partnerships, and enhancing exercise fidelity. By prioritizing realistic, patient-centered simulation, healthcare emergency managers can better protect patients and providers alike in times of unprecedented crisis.
Acknowledgments: This work would not be possible without the support of the entire team at the Department of Emergency Management and Enterprise Resilience at NYU Langone Health. In particular, the authors would like to express their deep gratitude to the exercise directors who have supported the improvement of these profiles over the last two years: Samantha Moorehead, Samia McEachin, Sofia Maimone, Sam Altenberger, Carlos Cruz, and Melissa Griffith. Also, thank you to our Medical Center Information Technology Department colleagues who made the electronic medical record integration possible: Corey Chaney, Lisa-Kay Smith, Natalie Louis-Jean, and team. Thank you all for being an essential part of this journey.
Kathryn Romanchuk
Kathryn Romanchuk, MScPH, MScPHDS, BSN-RN, is the emergency management fellow at the Department of Emergency Management and Enterprise Resilience, NYU Langone Health, New York. Her work extends from enterprise plan development and special event engagement to exercise development and disability-focused healthcare emergency management research. Kathryn has a background in emergency and trauma nursing and was nominated for a Daisy Award for her excellent patient care. She received dual master’s degrees during the COVID-19 pandemic from McGill University and l’Université de Bordeaux. Prior to working in healthcare emergency management, she completed a post-graduate education program at Harvard Medical School and obtained three Cancer Research Training awards with the National Cancer Institute.
Ben Kobliner
Ben Kobliner, MPA, is an emergency management specialist at the Department of Emergency Management and Enterprise Resilience, NYU Langone Health, where he works with clinical and operational teams to build emergency resilience through full-scale exercises and real-world incident management. His work focuses on improving hospital readiness for large-scale emergencies, including mass casualty incidents, disease outbreaks, and critical infrastructure disruptions. Previously, Ben heldroles at the United States Naval War College, the Providence Emergency Management Agency, and several fire and rescue agencies in New York and Rhode Island. Ben holds a master of public affairs from Brown University and is pursuing a master of business administration from the NYU Stern School of Business.
