The emergency plan is a critical component of any exercise program, without which the exercise tests the individual’s reactions and knowledge, but not the system’s response. Failing to understand this, or ignoring it, continues to make exercises little more than shams in which the most experienced employees or leaders produce positive results, and that in turn creates a comfortable fiction of preparedness. All effective exercises are based on a written plan, followed by training of the staff involved in the plan – specifically including management-level decision makers, the staff on the ground that do the work, and backup personnel. An exercise can be evaluated in terms of the overhead expenses such as overtime or consumables and/or the visibility to the patient population. That general statement does not always apply, though, to hospital evacuation exercises, which are difficult to carry out in real time – for a variety of reasons. One of the principal reasons is that market forces have pushed hospitals over the last several decades to become leaner, so there is very little if any “extra” staff and resources to use for an exercise. In addition, because real life continues even during an exercise, patients continue to expect the same type and quality of care they have become accustomed to. This creates another problem for the hospital – namely, how to demonstrate the ability to stop work and move patients, hospital beds, and various medical systems without actually stopping the real work going on or subjecting the real patients being cared for to the strains, stresses, and risks of being moved to another ward or another hospital.
Theeal vs. the Real
In some ways, theeal is the full-scale exercise, conducted in real time using the real personnel and other resources that would most likely be available during an In the medical field, new programs start out all too often with full-scale exercises which the staff is not adequately prepared for, and end in frustration and finger-pointing actual emergency. Unfortunately, sucheal exercises are rarely carried out to this extent, primarily because of the high overhead costs that would be generated. Moreover, despite the understandable desire not only to demonstrate competence but also to do it as quickly as possible, a basic rule applicable to almost all exercise programs is that to be effective they must start both simply and build in complexity. In the medical field, regrettably, new programs start out all too often with full-scale exercises which the staff is not adequately prepared for, and end almost inevitably in frustration and finger-pointing.
Much of the impatience is fueled by: (a) the accreditation regulatory process mandated by the Joint Commission for Health Care (JCHCO); and (b) grant deliverables that require full-scale exercises of plans without allowing for differences from one agency to another in their ability to reach various levels of completion in the planning and training process. Independently of any grant process, the Department of Homeland Security (DHS), through its Homeland Security Exercise Evaluation Program (HSEEP), has been promoting a “building block approach” to the planning of exercise programs. That approach starts with a firm foundation of planning and training and builds up from there with discussion-based exercises such as tabletop exercises (TTX), ending finally with operations based exercises such as the full sale exercises (FSE) described earlier. The tabletop exercise can be used to test the decision process by presenting the TTX participants with a scenario to work through in a conference room setting. The advantage of this type of exercise is that it is independent of real time and can be stopped for discussion. Moreover, it has a low overhead and for all practical purposes is invisible to the hospital’s patient population. When the participants naturally relate to the scenario the focus moves from discussing the details of the scenario to determining the actions to take, deciding who has the authority to take specific actions, recognizing what the trigger points are for those actions, and agreeing on how those actions will be executed.
Beware of the Overly Dramatic Scenario
Any scenario that would force the hospital to evacuate a section, or even the entire hospital, can be used. One cautionary note, however: It is important to stay away from the obscure albeit exciting scenarios so frequently discussed in the popular media – an anthrax attack, for example. That may well be the topic of the day, and would certainly gain a lot of public attention. But the participants in the exercise will relate quickly and more easily to a simpler and much more likely scenario – e.g., severe weather, a fire, or the loss of electric power. Anyone doubting this thesis should remember that the school children from a school in the shadow of the World Trade Center on 9/11/01 were able to evacuate the school safely because they had practiced so many fire drills during school hours that they and their teachers knew exactly what to do. Lacking the budget, and the time, needed for full-scale exercises, many hospitals and other medical facilities improve their capabilities one small step at a time by exercising various components of an emergency plan. In a simulated hospital evacuation, for example, communications capabilities could be exercised by creating and promulgating a test message and timing the replies. This simple exercise has a low overhead because it would require little if any overtime work, and has low visibility to the patient population. Other component tests might be to set up the facility expected to receive the patients being evacuated and to care for a number of mock patients. Both of these tests would have a higher overhead, though, because real employees would be needed to set up and staff the facility, and mock patients would have to be provided. Some colleges and universities, and other civic and emergency organizations, probably could be tapped to provide the “patients,” but anything more than that might be too ambitious – and too costly as well.
Numerous Complications, But Other Options Available
By far the most difficult aspect of such an exercise, though, would be the actual movement of mock patients from one facility to another. There is no simple low-cost way to carry out that part of the exercise. Perhaps the only viable strategy for most facilities, in fact, is to carry out a “sample” evacuation – by moving patients from one floor of the hospital or one group of rooms to another. Fortunately, this process often could be carried out, even if there were no or only a few vacant rooms available, by putting the mock patients on stretchers or in wheelchairs in the hallways of the floor being evacuated. There are several complications involved in this plan as well, however. It would have a high overhead because of overtime work for the staff involved and, because the mock patients would be in the same area of the hospital as the real patients, there would be added security and confidentiality issues to deal with. In addition, the congestion in the hallways and the decreased availability of stretchers and wheelchairs would be highly visible to the real patient population. There are other exercise and training options available to hospital planners and administrators that are frequently ignored. One option is to always document real events as exercises. The JCHCO rules mentioned earlier and most grants explicitly allow for this, and these “real events” provide a high percentage of the always limited opportunities available for a hospital to “exercise” all of its real resources in real time. There also are certain occasions to test evacuation plans in real time. Renovating or painting a section of the building, for example, may offer an opportunity to exercise the hospital’s evacuation program by moving patients to another part of the building rather than to an off-site location. In accordance with the truism that no exercise or operation is complete until the paperwork has been done, all of the data, comments, and observations collected in the course of any of the exercises carried out should be incorporated into a revised and improved emergency plan, thus satisfying the ethical if not grant-driven or legislated requirement for staff input.
Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.