Developing an All-hazard Tiered

Approach to Disaster Health Response across Nebraska

Nebraska Regional Disaster Health Response Ecosystem(NRDHRE)

Tonya Ngotel - University of Nebraska Medical Center

Justin Watson - Omaha Metro Healthcare Coalition

Disclosures

No Disclosures

ObjectivesAfter attending this presentation attendees will be able to:

• Describe the integration of multiple coalitions in developing an all-hazard tiered approach to disaster health response to large-scale mass casualty incidents overwhelming specialty care resources needed for infectious disease, chemical, burn, radiologic, trauma or pediatric injury.

• Discuss lessons learned in developing consistent policies and protocols across healthcare coalitions that involve the use of alternate care systems and volunteer surge personnel from inside and outside the regional health systems in addition to the delivery of conventional care.

• Identify components essential to improving statewide and regional situational awareness to encompass initial event recognition, activation of a centralized medical operations center to facilitate patient and bed tracking, and integration of clinical expertise into decision-making.

Regional Disaster Health Response System

In a disaster (e.g., earthquake, radiological event), thousands of Americans may require immediate medical specialty care, surpassing the care available in the community.

In response, the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) awarded 1-year demonstration grants to demonstrate how a new Regional Disaster Health Response System (RDHRS) could meet these needs in a disaster.

Two Projects

Demographics & ApproachWhy Nebraska?

RDHRS Goals

Key Response CapabilitiesApplicants must demonstrate the following capabilities in support of a coordinated, statewide and regional emergency response:

Each Capability consists of one or more Objectives.Each Objective contains one or more Activities.Each Activity has a set of specific items that must be addressed.

Executive Council

Coordinating Council

Grant Faculty

•Children’s Hospital•Omaha VA•Region 6 Behavioral Health•NEMA•Nebraska DHHS•Omaha Chamber of Commerce•UNMC Chancellor•Nebraska Medicine CMO•Community Representative•United States Air Force-STRATCOM

•Healthcare coalition coordinators•Emergency Services Representative•Trauma Coordinators•Trauma surgeon•Emergency Management •National Strategic Research Institute•Nebraska DHHS•Air National Guard

•Medical Director•Executive Director•Capability Leaders

Organization

Regional Engagement and Relationship Building

Southeast HCC Omaha HCCNebraska Department of Health and Human ServicesDept. of CorrectionsNebraska National GuardNebraska Public Health LaboratoryFusion CenterGovernor’s Policy GroupRROMRSNEMACounty EM (NAEMTRIMRSPhysicians MutualChildren’s Physicians and Children’s Specialty PhysiciansOmaha VA HospitalORAUSoutheast District Health DepartmentNSRITeam RubiconRegion 6 Behavioral HealthcareNebraska State Trauma Advisory BoardNebraska State Emergency Health Systems OfficeVA Nebraska-Western Iowa Health Care SystemOffutt 55th Medical GroupNeDHHS: DMAT/DMORT/ESAR-VHP/MRC TeamsNebraska Task Force 1Nemaha County Hospital Faith Regional Health Great Plains Health Bryan Health & Bryan Medical Center Nebraska Medicine - Bellevue Hospital CHI Health & CHI Bergan Mercy Hospital Methodist Health System & Methodist Hospital CHI Health

Nebraska Medical Reserve CorpsDouglas County Public Health Department Sarpy/Cass County Public Health DepartmentThree Rivers Public Health Department Lincoln-Lancaster County Public Health Department Mills County Public Health DepartmentThe Governor of the State of Nebraska Nebraska State Trauma System Douglas Co Emergency ManagementOmaha Fire Department/EMS Nebraska Medicine University of Nebraska Medical Center National Ebola Training & Education Center Region VII EMS & Exercise Committees National Strategic Research Institute Global Center for Health Security Center for Preparedness Education HEROES Program Nebraska Infection Control NetworkNebraska Public Health LaboratoryNebraska Regional Poison Control Center American Association of Poison Control Centers American Red Cross – Kansas/Nebraska/SW Iowa Region Omaha Chamber of Commerce Nebraska State Chamber of Commerce and Industry Nebraska Hospital Association Nebraska Healthcare Association Nebraska Nursing Facility Association Nebraska Assisted Living Association Nebraska Hospice and Palliative Care Association Licensed Practical Nurse Association of Nebraska Nebraska Association of Local Public Health Directors Public Health Association of Nebraska

Omaha Metro Healthcare Coalition (OMHCC)

Information Sharing and Collaboration

MOC/EOC Development

Broad Mission:Support/coordinate

effective health system operations in affected

areas

Role of the individual MOC needs clear definition:

• Bed Availability• Patient Tracking

• Medical Transportation Staging• Medical Asset Management

• Medical Public Information (with JIC)

Authority and Mission Assignments need to be defined & documented.

Consistency in plans at all levels (bed definitions, roles, authorities, etc).

Live vs. Virtual

Structure (ICS, EOC, MACC)

OMHCC Response Structure

Essential Elements of Information (EEI) Who needs to know the information? Who has the information? What will they do with the information?

Working with MGH on merged EEI set The draft includes sections on: baseline data general incident descriptors healthcare system status bio-threats HazMat Radiation special populations

Clinical Disaster Risk Assessment WorkshopA Clinical Disaster Risk Assessment Workshop was held with stakeholders from across the state to identify gaps in disaster preparedness. The data from the workshop was collated into a report to use as a tool to assess, improve, and align preparedness plans in the region.

Specialty Team Concept

Telehealth

Preparedness Metrics Example Metrics Only

Response Readiness Designation

Surge Capacity WorkshopsWorkshop Categories

Triage

Transportation

Hospital Surge

Outpatient Clinics & Alternate Care Sites

Enabling “at home” or “supportive care”

Communication

Coordination

Legal Reference Guide

Test Medical Surge and Situational Awareness Capabilities

• The readiness exercise must test and evaluate a majority of capabilities listed in:“Capability 2: Align Plans, Policies, Processes, and Procedures Related to Clinical Excellence in Disasters,” “Capability 3: Increase Statewide and Regional Medical Surge Capacity,” and “Capability 4: Improve Statewide and Regional Situational Awareness.”

• The exercise should also include initial event recognition and activation of the medical operations center to facilitate patient and bed tracking, and integration of clinical expertise into decision-making.

• The exercise should include a test of the implementation of alternate care systems in addition to the delivery of conventional care.

• The readiness exercise should use the newly developed readiness standards and capacity and capability analysis developed under Activity 1 of Capability 5.

Urban Evacuation Exercise-Table Top

A 7.0 Earthquake hits the region of Central Nebraska causing widespread damage to Buildings, Railways and Interstates. Initial reports are that injuries are primarily due to total collapse of buildings including a local hospital necessitating the movement of significant medical resources into the region. A sink hole has been reported in the downtown area of Omaha forcing the evacuation and transport of numerous traumatically injured personnel.

Module Events(s)

Module 1: Activation A sinkhole swallows a city block

Evacuation Planning

HICS/AC/UC Module 2: Response Evacuation Level Determination

Initiation of Evacuation

Evacuation Plan Implementation

Alternate Care Sites Module 3: Demobilization Family notification

Reunification Facility Closure

Rural Full Scale A semi tractor trailer traveling west bound on HWY 20 loses control and crashes into a passenger van due to heavy rain. During the crash the tanker is ruptured and begins leaking all over the roadway.

The tanker contains a chemical when mixed with water produces a toxic gas. Just a few miles north is the Johnstown Fair, in attendance are an estimated 2,000 people.

Phase Activity Type Event(s)

One Notional Initial On-Scene Actions

911 Calls start coming in for the accident on Hwy Local LE and FD arrive on scene, Hwy 20 is closed. Unified Command Established Scene size up for HAZMAT incident begins Rescue operations are started for the crash victims. Hospital notified of mass causality and chemical incident Critical Patients depart scene to Brown County Hospital. 911 call start coming in for County Fairgrounds, people ha become ill. Hospital notified of chemical incident Chemical patients arrive at hospital All Patients Triaged and Routed

Two Day 1- Roll Players

Patients Arrive at Point of Care

At-Risk Population Identification and Routing Regional Support Requests Surge Plan Criteria

PAUSE EXERCISE

Three Day 2- Paper

Patients

Surge Plans, Patients are Moved

Outpatient Tracking Medical Procedure Tracking Patient Reunification

Rural Functional Exercise-Testing Knowledge Center

Phase Activity Type Event(s) One Notification 911 Calls start coming in

Initial On-Scene Actions

Local Ambulance arrives on scene, Medical Flight Services Requested, Medical Update Local LE and FD arrive on scene, Hwy 10 is closed, LZ Identified and Marked Critical Patients depart scene Unified Command Established

Support EOC Activation HICS Activation

Other Patients Airlifted Additional Medical Assets arrive Less Critical Patients depart scene Coroner

Two Decision-making

All Patients Triaged and Routed At-Risk Population Identification and Routing

Notification Regional Support Requests Documentation Surge Plan Criteria

Three Information Management

Outpatient Tracking Medical Procedure Tracking

Notification Patient Reunification

Multiple charter buses collide on I-80 resulting in mass casualty incident including geriatric, pediatric and adult patients.

Affected patients requiring triage on scene, transport to appropriate facilities for treatment and care and reunification with family members.

Key Exercise OutcomesStrengths• Participants reported better

understanding of the EMTALA & HIPPA regulations

• Participating HCC members knowledgeable about the coalition response plan and protocols

• Coalition engagement and communication processes demonstrated to work well

• Use of Knowledge Center to track patients was efficient for affected hospital

• Legal reference guide was utilized during the exercise

Opportunities

• Identify additional alternative transportation assets for use in large scale incidents

• Expand opportunities to use Knowledge Center as a community

• Communicate more clearly to coalition members what the coalition and the coalition coordinators can do to assist during incident response

Challenges & SolutionsChallenges:

• Limited resources in many areas of the state identified during risk assessment workshops.

• Primarily rural/volunteer first responder base.

• Lack of access to specialized training needed to improve gaps identified in preparedness in rural and frontier areas.

• Varying opinions on coalitions authority, accountability or ability to implement.

• Lack of coordination between public health, healthcare and emergency management.

• Accelerated timeline.

Solutions:

• Clarify the intent, purpose and scope of specialized consultation

• Develop more robust medical operations centers which incorporate all key stakeholders

• Develop readiness metrics to support congruent standards across health care coalitions and regional disaster health response systems

• Leverage SIM NE to provide training solutions for coalition members

• Develop the EEIs with local, regional, and state input. Also include input from other states. Test the list with a blinded scenario based validation of the list.

What’s Next?• Expand NRDHRE efforts to additional states and regions

• Continue collaboration with Massachusetts General Hospital• Compare and contrast urban and rural approaches• Refine readiness metrics to encompass tiered approach

• Refine and test key strategies initiated in year 1 of the demonstration period• Deployable specialty teams• Telemedicine consultation • Governors policy group• Interoperable communications system

• Pilot test the readiness metrics and further develop the conceptual model for a Response Ready Designation Program

Contacts

Shelly Schwedhelm Executive Director – NRDHRE• 402-559-8766• SSchwedh@nebraskamed.com

Tonya Ngotel, UNMC• 402-552-9724 • tonya.ngotel@unmc.edu

Justin Watson, OMHCC• 402-599-9413• juwatson@nebraskamed.com