Presented by:Scott Aronson, MS

Principal Russell Phillips & Associates,

LLCsaronson@phillipsllc.com

www.phillipsllc.com

Offices in CA / CT / NY / OH / RI

2011: Impact on Northeast from Irene and the “Halloween Storm”

Recent Disaster Incidents Recent Disaster Incidents (*2011 RPA On-site Assessments)(*2011 RPA On-site Assessments)

Recent Disaster Incidents Recent Disaster Incidents (*2011 RPA On-site Assessments)(*2011 RPA On-site Assessments)

Northeast Blizzards – January 2011 (Northeast Blizzards – January 2011 (weekdayweekday))

MA Tornadoes - Springfield, MA area (MA Tornadoes - Springfield, MA area (6/1 – 6/1 – weekdayweekday))

Earthquake on the East Coast (Earthquake on the East Coast (weekdayweekday))

Hurricane/Tropic Storm Irene (8/28) & Lee Hurricane/Tropic Storm Irene (8/28) & Lee Flooding (Flooding (weekendweekend)) 7,000 patients/residents evacuated in NY alone7,000 patients/residents evacuated in NY alone CT hospital evacuation – generator fireCT hospital evacuation – generator fire

Snowstorm/Power Failure – October 29 Snowstorm/Power Failure – October 29 ((weekendweekend)) Storm Alfred – “Halloween Storm” Storm Alfred – “Halloween Storm”

The Joplin Experience The Joplin Experience

May 22, 2011 - 5:41 PMMay 22, 2011 - 5:41 PM

(Evacuation / Surge)(Evacuation / Surge)

The Joplin Experience The Joplin Experience

May 22, 2011 - 5:41 PMMay 22, 2011 - 5:41 PM

(Evacuation / Surge)(Evacuation / Surge)

Tornado vs. EarthquakeTornado vs. EarthquakeTornado vs. EarthquakeTornado vs. Earthquake Drop, Cover & HoldDrop, Cover & Hold Move Patients into central corridors Move Patients into central corridors

away from windows / doors to away from windows / doors to exterior exterior If unable to do so (e.g. higher acuity): Move If unable to do so (e.g. higher acuity): Move

away from windows and cover with blankets / away from windows and cover with blankets / overbed tablesoverbed tables If unable to do so: Cover patients with If unable to do so: Cover patients with

blanketsblankets

By all means, don’t stand in a door By all means, don’t stand in a door frame that has a door on it!frame that has a door on it!

Window ImpactWindow ImpactWindow ImpactWindow Impact

- February 1998 - February 1998

- Dept. of Army - Dept. of Army Waterways ExperimentWaterways Experiment

- Equivalent to 1000lbs - Equivalent to 1000lbs TNT at 275 feet distanceTNT at 275 feet distance

Hospital ImpactHospital ImpactHospital ImpactHospital Impact

St. John’s Hospital EvacuationSt. John’s Hospital Evacuation Fires and exposed electrical throughoutFires and exposed electrical throughout Evacuation of all patients in 90 minutes (~187)Evacuation of all patients in 90 minutes (~187) Generator failure – destroyed (roof lands on the Generator failure – destroyed (roof lands on the

power plant)power plant) Vertical evacuation completed in dark stairwells Vertical evacuation completed in dark stairwells

(NFPA 99 potential issue on lighting)(NFPA 99 potential issue on lighting)

LTC - Immediately Post Strike LTC - Immediately Post Strike LTC - Immediately Post Strike LTC - Immediately Post Strike

Moved patients away from flowing Moved patients away from flowing water (sprinklers)water (sprinklers) What is your shut-off valve strategy on Sunday evening? What is your shut-off valve strategy on Sunday evening?

Gas odor strong on exterior of buildingGas odor strong on exterior of building Concerned about evacuating outside Concerned about evacuating outside What is your procedure for HVAC shutdown / containment?What is your procedure for HVAC shutdown / containment? Coordination of staff by Nursing Coordination of staff by Nursing

Super and Charge Nurses – no Super and Charge Nurses – no leadership for 1+ hourleadership for 1+ hour

What was the Incident Command System used?What was the Incident Command System used? Staff Calm Staff Calm Patients Calm Patients Calm

Immediately Post Strike, cont’dImmediately Post Strike, cont’dImmediately Post Strike, cont’dImmediately Post Strike, cont’d

Nursing Homes: Large influx / surge Nursing Homes: Large influx / surge from communityfrom community Says “healthcare” so they must be able to treatSays “healthcare” so they must be able to treat

Established external treat and triage Established external treat and triage areaarea

Recommendation: No additional supplies neededRecommendation: No additional supplies needed Addressed lacerations, missing limbs, etc.Addressed lacerations, missing limbs, etc. Moved to hospital as quickly as possibleMoved to hospital as quickly as possible

Key Components to a Full Key Components to a Full Building Evacuation (FBE) PlanBuilding Evacuation (FBE) Plan

Key Components to a Full Key Components to a Full Building Evacuation (FBE) PlanBuilding Evacuation (FBE) Plan

Activation of Plan and Labor/Personnel Activation of Plan and Labor/Personnel PoolPool

Establishment of Internal Holding AreasEstablishment of Internal Holding Areas Patient Preparation on UnitsPatient Preparation on Units Marking of Patient Rooms (evacuated)Marking of Patient Rooms (evacuated)

Coordination of TransportationCoordination of Transportation Determination of Receiving SitesDetermination of Receiving Sites

Patient Tracking (internal and external)Patient Tracking (internal and external)

Joplin Evacuation RealityJoplin Evacuation RealityJoplin Evacuation RealityJoplin Evacuation Reality Emergent Emergent SituationSituationPatient Preparation Patient Preparation on Unitson UnitsMeds & Personal Belongings in Meds & Personal Belongings in bags / Charts on lapsbags / Charts on lapsMarker with last name on armMarker with last name on arm

Marking of Patient Marking of Patient Rooms Rooms Checked over and over again Checked over and over again (Door Tags Recommended)(Door Tags Recommended)

Immediate Immediate ThreatThreatPatient moved Patient moved vertically – all means vertically – all means employedemployed

Marking of Patient Marking of Patient Rooms Rooms Checked over and over again Checked over and over again

Joplin Evacuation RealityJoplin Evacuation RealityJoplin Evacuation RealityJoplin Evacuation Reality Emergent SituationEmergent SituationDetermination of Determination of Receiving SitesReceiving SitesNo coordinated supportNo coordinated support

Coordination of Coordination of Transportation Transportation (patients)(patients)Pick-up trucks and 4 door sedansPick-up trucks and 4 door sedans

All POVs destroyed at facilityAll POVs destroyed at facilityEMS on-scene 2 hours post eventEMS on-scene 2 hours post event

11stst ambulance transport at ambulance transport at midnight due to disastermidnight due to disaster

Immediate ThreatImmediate ThreatDetermination of Determination of Receiving SitesReceiving SitesNo coordinated supportNo coordinated support

Coordination of Coordination of Transportation Transportation (patients)(patients)Pick-up trucks, 4 door sedans Pick-up trucks, 4 door sedans and carriedand carried

All POVs destroyed at facilityAll POVs destroyed at facilityMinimal EMS Capabilities in Minimal EMS Capabilities in early phase due to early phase due to community/infrastructure impactcommunity/infrastructure impact

Joplin Evacuation Reality, cont’dJoplin Evacuation Reality, cont’dJoplin Evacuation Reality, cont’dJoplin Evacuation Reality, cont’d Emergent Emergent Situation Situation Coordination of Coordination of Transport. (equip) Transport. (equip) Pick-up trucks Pick-up trucks

Mattresses, wheelchairs, Mattresses, wheelchairs, meds (beds - next day)meds (beds - next day)

30 minute cycle30 minute cycle

Patient Tracking Patient Tracking Census Log - both endsCensus Log - both endsNo Patient Evacuation No Patient Evacuation Tracking Forms usedTracking Forms used

Immediate ThreatImmediate ThreatCoordination of Coordination of Transport. (equip) Transport. (equip) Pick-up trucks / Box Trucks Pick-up trucks / Box Trucks

Salvage OperationSalvage Operation

Patient Tracking Patient Tracking None in initial windowNone in initial window

126 Bed LTC - Surge Process126 Bed LTC - Surge Process126 Bed LTC - Surge Process126 Bed LTC - Surge Process

Standard Process (24 hour period)Standard Process (24 hour period) Discharges Discharges Additional Beds Additional Beds Surge to 110% or 139 Surge to 110% or 139

Residents (Residents (rare event to go higher than 110%)rare event to go higher than 110%)

110

115

120

125

130

135

140

Surge Process

Current CensusCensus Reduction2-4 Hours4-24 Hours

Catastrophic Surge (Joplin)Catastrophic Surge (Joplin)Catastrophic Surge (Joplin)Catastrophic Surge (Joplin)

Catastrophic Surge ProcessCatastrophic Surge Process Census Reduction (no time) Census Reduction (no time) Surge Surge Equipment & staff Equipment & staff

may or may not comemay or may not come

110

120

130

140

150

160

170

180

190

200

Surge Process

Current CensusCensus Reduction1 - 4 Hours

389 Bed Hospital (licensed) - Surge Process389 Bed Hospital (licensed) - Surge Process

Standard Process (24 hour period)Standard Process (24 hour period) Discharges Discharges Additional Beds Additional Beds Surge to 520 Patients Surge to 520 Patients

050

100150200250300350400450500

Surge Process

Current CensusCensus Reduction2-4 Hours4-24 Hours

Catastrophic Surge (Joplin)Catastrophic Surge (Joplin) Catastrophic Surge ProcessCatastrophic Surge Process Census Reduction (no time) Census Reduction (no time) Surge Surge Equipment, Staff Equipment, Staff

and Resources may or may not comeand Resources may or may not come

110310510710910

111013101510171019102110

Surge Process

Current CensusCensus Reduction1/ 2 - 4 Hours

The New England The New England Storms of 2011Storms of 2011

The New England The New England Storms of 2011Storms of 2011

June TornadoesJune TornadoesJune TornadoesJune Tornadoes

Tropical Storm IreneTropical Storm IreneTropical Storm IreneTropical Storm Irene

Hospital & LTC Mutual Aid PlansHospital & LTC Mutual Aid PlansHospital & LTC Mutual Aid PlansHospital & LTC Mutual Aid Plans Place and support continuity of care of Place and support continuity of care of evacuatedevacuated

patientspatients

Provide Provide supplies/equipment/ pharmaceuticalssupplies/equipment/ pharmaceuticals as as necessarynecessary

Assist with Assist with transportationtransportation of supplies/ of supplies/ staff/equipment/evacuated patients/familiesstaff/equipment/evacuated patients/families

Provide Provide staffingstaffing support (whether a facility is support (whether a facility is evacuating or staying)evacuating or staying)

Regional Medical Coordinating Center/Regional Medical Coordinating Center/Long Term Care Coordinating CenterLong Term Care Coordinating Center

Operating in MA and CTOperating in MA and CT

Regional Medical Coordinating Center/Regional Medical Coordinating Center/Long Term Care Coordinating CenterLong Term Care Coordinating Center

Operating in MA and CTOperating in MA and CT

Function of Function of Coordinating Centers Coordinating Centers

Function of Function of Coordinating Centers Coordinating Centers

Assist and coordinate patient placementAssist and coordinate patient placement Support patient tracking - “Support patient tracking - “Close the Close the

looploop” ” Assist with obtaining staff, supplies and Assist with obtaining staff, supplies and

equipmentequipment Assist with transportation of staff, supplies Assist with transportation of staff, supplies

and equipment and equipment Interaction with local, regional and state Interaction with local, regional and state

agenciesagencies

ENSURE EVERYONE IS ACCOUNTED FORENSURE EVERYONE IS ACCOUNTED FOR

Prioritization / CoordinationPrioritization / CoordinationPrioritization / CoordinationPrioritization / Coordination

Facilities Grouped for TrackingFacilities Grouped for Tracking Group 1:Group 1: Reported No Issues (no actions Reported No Issues (no actions

taken / not called)taken / not called)

Group 2:Group 2: Reported Issues (communicated Reported Issues (communicated with between 1-2 times daily for situation with between 1-2 times daily for situation updates and resource needs)updates and resource needs)

Group 3:Group 3: Did Not Report – Considered “ Did Not Report – Considered “at at riskrisk” until communicated with” until communicated with

Drains resources when the facility is “OK” and Drains resources when the facility is “OK” and did not reportdid not report

Actions in Irene and Halloween StormActions in Irene and Halloween StormActions in Irene and Halloween StormActions in Irene and Halloween Storm Reporting: Reporting: Online Emergency Reporting Online Emergency Reporting

completedcompleted

Situation Report: Situation Report: Provided 1-2 Times Daily Provided 1-2 Times Daily to DPH and Regional Partners (submitted to to DPH and Regional Partners (submitted to CMS/HHS)CMS/HHS)

““At Risk”: At Risk”: Members Communicated withMembers Communicated with CT: 21 out of 91 (Irene) / 62 (Alfred) / 118 bed vent CT: 21 out of 91 (Irene) / 62 (Alfred) / 118 bed vent

hospitalhospital MA: 47 out of 447 (Irene) / 54 (Alfred)MA: 47 out of 447 (Irene) / 54 (Alfred)

Activation: Activation: Full stand up on multiple Full stand up on multiple occasions for potential or actual Evacuating occasions for potential or actual Evacuating FacilityFacility

IRENE NOTE: IRENE NOTE: In CT - 4 of 91 had generator failures In CT - 4 of 91 had generator failures at one time or another (4.4%)at one time or another (4.4%)

One Hospital’s Irene ExperienceOne Hospital’s Irene ExperienceOne Hospital’s Irene ExperienceOne Hospital’s Irene Experience Preparation:Preparation:

Command Center activated – multiple operational Command Center activated – multiple operational period positions assignedperiod positions assigned

Tree clearing completed – vulnerable areasTree clearing completed – vulnerable areas Additional clinical, ancillary & support staff on Additional clinical, ancillary & support staff on

dutyduty Resources & Assets enhancedResources & Assets enhanced

Top off fuel tanksTop off fuel tanks Advance supply order receivedAdvance supply order received

Hospital Size: Hospital Size: 98 beds / LTC facility on 98 beds / LTC facility on campuscampus Irene: *43 inpatients and 5 ED patientsIrene: *43 inpatients and 5 ED patients

* due to decompression ahead of storm* due to decompression ahead of storm August 28 – Irene Strikes:August 28 – Irene Strikes:

0820 Power Fails / Emergency Generator working0820 Power Fails / Emergency Generator working 1527 Generator shorts and fails1527 Generator shorts and fails

CT Hospital EvacuationCT Hospital EvacuationCT Hospital EvacuationCT Hospital Evacuation

Generator Fire: Generator Fire: 750kw (750kw (suppressed with suppressed with extinguisherextinguisher)) Commercial Power Down / No ElevatorsCommercial Power Down / No Elevators

1532 Unified Command established with Fire 1532 Unified Command established with Fire Dept.Dept.

1547 Primary phone system fails1547 Primary phone system fails 1600 Decision to Evacuate1600 Decision to Evacuate

Evacuation commenced for ED patients (not Evacuation commenced for ED patients (not admitted)admitted)

1615 Electronic patient tracking system in 1615 Electronic patient tracking system in placeplace

1643 EMS Strike Teams activated and Dept. of 1643 EMS Strike Teams activated and Dept. of Public Health Licensure staff onsitePublic Health Licensure staff onsite

1905 Commercial power restored1905 Commercial power restored Evacuation Continues (CEO decision – on hill/wind Evacuation Continues (CEO decision – on hill/wind

gusts)gusts) 2200 Last patient evacuated2200 Last patient evacuated

CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)

Vertical Evacuation (EMS/Fire Vertical Evacuation (EMS/Fire equipment): equipment): No elevators / 3 flights of stairsNo elevators / 3 flights of stairs

Stairchairs Stairchairs BackboardsBackboards Scoop StretchersScoop Stretchers

Lighting Issues: Lighting Issues: Poor illumination from emergency lightingPoor illumination from emergency lighting Could not see >30’ into facilityCould not see >30’ into facility Fire Dept. supplemented stairwell lightingFire Dept. supplemented stairwell lighting

Pyxis Issues: Pyxis Issues: Access issuesAccess issues

CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)

Medical Records:Medical Records: Medical Records went with patient and a nurse Medical Records went with patient and a nurse

sent to each receiving hospitalsent to each receiving hospital Nurse copied medical records at Patient Accepting Nurse copied medical records at Patient Accepting

FacilityFacility 4 hours for first 33 patients and 2 hours for final 4 hours for first 33 patients and 2 hours for final

1010 Issue: Had commercial power / Records copied on-siteIssue: Had commercial power / Records copied on-site

Holding Area: Holding Area: One point of dischargeOne point of discharge EMS had equivalent of Medical Services OfficerEMS had equivalent of Medical Services Officer Hospital clinical handoff for Critical Care patientsHospital clinical handoff for Critical Care patients No clinical handoff or communications for No clinical handoff or communications for

Med/SurgMed/Surg Patient Families: Patient Families: All communicated toAll communicated to

CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d)CT Hospital Evacuation (cont’d) Distribution: Distribution: 7 hospitals and 3 LTC (7 hospitals and 3 LTC (not their not their

ownown)) Patient Tracking: Patient Tracking: EM Tracker / EMS Log at EM Tracker / EMS Log at

exitexit Activation: Major Communications Issue Activation: Major Communications Issue

Disaster Struck Facility: Disaster Struck Facility: Full ActivationFull Activation Patient Accepting Facilities: Patient Accepting Facilities: Limited to No ActivationsLimited to No Activations

EMTALA: EMTALA: Stacked up patients at 1 ED - Real concern?Stacked up patients at 1 ED - Real concern?

Close the Loop: Close the Loop: Hospital called everyone for Hospital called everyone for statusstatus

Mutual Aid Plan:Mutual Aid Plan: Design commenced in December 2011Design commenced in December 2011 Go live date of May 17, 2012 to tabletop and FSE in Fall 2012Go live date of May 17, 2012 to tabletop and FSE in Fall 2012

Major Success (Major Success (hospital, EMS, RESF8, Firehospital, EMS, RESF8, Fire):): 3 C’s – Communication, Coordination, Cooperation 3 C’s – Communication, Coordination, Cooperation

Emergency Generators (failure)Emergency Generators (failure)Emergency Generators (failure)Emergency Generators (failure)

How deep have you gone?How deep have you gone? Service Patient Care TowersService Patient Care Towers Service areas with High Acuity PatientsService areas with High Acuity Patients Do they parallel each other for redundancyDo they parallel each other for redundancy Do you have a quick connection pre-wired Do you have a quick connection pre-wired

with transfer switch?with transfer switch? Voltage / Kw / Service AmperageVoltage / Kw / Service Amperage Cable Run (in feet to the electrical service)Cable Run (in feet to the electrical service) Fuel SourceFuel Source Exact Location on Campus (back-up)Exact Location on Campus (back-up)

Hospital Surge – Halloween StormHospital Surge – Halloween StormHospital Surge – Halloween StormHospital Surge – Halloween Storm 520 Bed Hospital: 520 Bed Hospital:

80 – 120 additional patients 80 – 120 additional patients Excluding ED BoardersExcluding ED Boarders

Conversions (sample): Conversions (sample): Closed Unit – 25 bed patient care areaClosed Unit – 25 bed patient care area Rehab “Storage” Unit – 14 beds for “shelter Rehab “Storage” Unit – 14 beds for “shelter

boarders”boarders” Swing Unit – 22 beds housing discharged patientsSwing Unit – 22 beds housing discharged patients

Could not go homeCould not go home

Day Care Activated 24/7: Day Care Activated 24/7: All staffAll staff

Showers / Sleeping: Showers / Sleeping: Any staff who Any staff who required itrequired it

Electives: Electives: Cancelled in many areasCancelled in many areas

Hospital DecompressionHospital DecompressionHospital DecompressionHospital Decompression Frail Elderly / Medical Equipment / Clinical NeedsFrail Elderly / Medical Equipment / Clinical Needs

1.1.Standard Discharges - ???Standard Discharges - ???

2.2.Medicare Eligible – 3 day length of stay Medicare Eligible – 3 day length of stay requirement (major hindrance) requirement (major hindrance)

3.3.Medicaid Eligible – PASRR and AscendMedicaid Eligible – PASRR and Ascend Issue: Communication issue b/w hospital and LTC believing all of Issue: Communication issue b/w hospital and LTC believing all of

this was waivedthis was waived Solution: DPH Blast Fax and E-mail NotificationSolution: DPH Blast Fax and E-mail Notification

Payment under Respite Care provisionPayment under Respite Care provision

4.4.Private Insurance - 3-5 days / until can return homePrivate Insurance - 3-5 days / until can return home

5.5.Private Pay – 3-5 days / until can return homePrivate Pay – 3-5 days / until can return home Hospital / LTC rate discussionsHospital / LTC rate discussions

Emergency Reporting System Emergency Reporting System InformationInformation

Emergency Reporting System Emergency Reporting System InformationInformation

Key contact during eventKey contact during event Beds Status and TypeBeds Status and Type Operational Issues and SpecificsOperational Issues and Specifics Transportation Vehicles, Capacity & Transportation Vehicles, Capacity &

Deployment TimeDeployment Time Staff, Numbers / Type and Staff, Numbers / Type and

Deployment TimeDeployment Time Resources & Assets you can provideResources & Assets you can provide Resources & Assets you may needResources & Assets you may need

SuccessesSuccessesSuccessesSuccesses 100% accountability 100% accountability for all regional for all regional

facilitiesfacilities

Effectively activated to support evacuation or Effectively activated to support evacuation or imminent vendor / equipment needsimminent vendor / equipment needs

Prepared to support out of region facilities Prepared to support out of region facilities

Communication Process with DPH, Communication Process with DPH, Coordinating Centers and ESF 8Coordinating Centers and ESF 8

Communication Process with MembersCommunication Process with Members

Surge Plan with DPH and Bed Reporting Surge Plan with DPH and Bed Reporting UpdatesUpdates

ChallengesChallengesChallengesChallenges Regional Shelters vs. Regional Regional Shelters vs. Regional

Medical SheltersMedical Shelters Should the hospitals fully operate or locals? Age old Should the hospitals fully operate or locals? Age old

questionquestion

WebEOC / ESAR-VHP (credentialing)WebEOC / ESAR-VHP (credentialing)

Decompression of hospitalsDecompression of hospitals 1135 Waiver would have minimized obstructions to 1135 Waiver would have minimized obstructions to

decompress hospitalsdecompress hospitals Communications between hospitals and LTCCommunications between hospitals and LTC Hospital Evacuation: Hospital Evacuation: What is an emergency What is an emergency

to one may be a normal day to anotherto one may be a normal day to another

National Issue: Consistency in National Issue: Consistency in Handling Disaster EventsHandling Disaster Events

National Issue: Consistency in National Issue: Consistency in Handling Disaster EventsHandling Disaster Events

Single Facility Event / Isolated IncidentSingle Facility Event / Isolated IncidentExtremely challenging to preplan payer processExtremely challenging to preplan payer processFire or other immediate threat emergency forcing Fire or other immediate threat emergency forcing evacuationevacuation

Single Facility Event / Regional ImpactSingle Facility Event / Regional ImpactState typically has exhausted all resources prior to State typically has exhausted all resources prior to waiver requestwaiver request

Multiple Facility Event / Regional Multiple Facility Event / Regional ImpactImpactEasiest to secure 1135 Waiver Easiest to secure 1135 Waiver

Scott Aronson, MSPrincipal

Russell Phillips & Associates, LLCsaronson@phillipsllc.com

www.phillipsllc.com

Offices in: California / Connecticut / New York / Ohio / Rhode Island