Training Exercises: No small surprises in hospital drills
On a recent spring night, hospitals around the Chicago area unexpectedly found themselves in a perplexing situation. There were no mass casualties, no lines of ambulances transporting victims, no way to know for sure if a disaster had even occurred.
Without any warning, patients started streaming into emergency departments complaining of rapidly developing pneumonia-like symptoms. Most had fevers, nausea and shortness of breath. They were dehydrated, coughing and vomiting.
And they just kept coming and coming. Five at first, then 10, then 15. Soon some area hospitals had 25 patients complaining of closely related symptoms and demanding treatment immediately. As the victims poured in, the hospitals tried to determine what was happening. Was this a genuine disaster, or just a rare coincidence?
A complete surprise
Within an hour, the waiting areas were full at several area hospitals. The emergency department staff, many of whom regularly worked the after-hours shift and rarely saw mass influxes of patients like this, were scrambling to find places to put the patients.
Then the regional resource hospital called. A local nursing home had lost power and was sending over 25–30 patients on ventilators. Media were calling, heavy rains were making travel difficult for extra staff coming in to assist, and the hospital’s air-conditioning system was malfunctioning. What else could possibly go wrong?
As the hospitals hustled to treat the patients and enact their emergency management plans, the surprise disaster drill conducted by the Metropolitan Chicago Healthcare Council continued to play out. MCHC, an association of more than 140 hospitals in the Chicago area, regularly conducts disaster drills for its member hospitals and other local agencies.
But this year's drills were different. Each of the four drills was a complete surprise to the more than 50 participating healthcare organizations. Only one person, a drill coordinator, at each of the 44 participating hospitals knew anything about the timing of the drills. The non-hospital agencies that participated, including the Red Cross, local public health departments and the Chicago Office of Emergency Management and Communications, had only one hour of notice before the drills began.
To our knowledge, it was the first time that numerous hospitals in one geographic area of the United States participated in a disaster drill that hadn’t been announced ahead of time.
Two weeks, four scenarios
Each of the four disaster drills featured a different scenario. In the first of the four, the May 9 drill described above, terrorists released Yersinia pestis, or plague, in a downtown subway, infecting hundreds of subway riders. Over four or five hours, the drill brought together 14 hospitals and other healthcare agencies in what was perhaps the truest test ever of Chicago-area hospitals’ emergency response plans.
Over the next two weeks, MCHC exercised three other scenarios, involving 30 more hospitals and a total of 715 volunteer "victims." The other scenarios involved a group of campers exposed to contaminated water, foreign travelers who returned to the United States with Severe Acute Respiratory Syndrome and diners who ate contaminated food.
Each hospital that participated received between 10 and 30 victims who had fake symptoms and test results that corresponded to the specific biological organism in the scenario. In addition, some victims pretended to bring a pet to the hospital or pretended to be visually impaired and accompanied by their guide dog. These special patient cases added another challenge to the drills.
And when there were no more volunteer victims to send to the hospitals, MCHC had ready 36 additional scenarios, or injects, that hospitals could use to make the drills even more challenging. These ranged from the nursing home power failure to media inquiries to food shortages to flood-causing rains to a refinery explosion that caused 350 severe burn victims.
Added together, all these elements made this year’s drills more realistic than those in past years. By their nature, disasters are unpredictable and could occur at any time without warning. By making this year’s disaster drills more realistic, MCHC helped hospitals better test their existing procedures and their coordination with non-hospital agencies. We believe this coordination is essential to developing and evaluating effective disaster preparedness plans on a regional basis.
Requests for a challenge
The changes we made to this year’s drills, not announcing them ahead of time and adding in different patient scenarios, stemmed from requests by several member hospitals that we make the annual drills more challenging.
For decades, accrediting organizations and other agencies have required hospitals to test their emergency plans. With this regular drilling, many hospitals have become expert at handling mass-casualty disasters such as plane and car wrecks. Triaging and treating dozens of patients with visible injuries, especially when the hospital staff knows a month or more in advance that the victims are coming, wasn’t very challenging.
Two years ago, the Topoff 2 exercise, part of which was held in Chicago and its suburbs, raised the level of difficulty by using scenarios involving biological agents for the first time. But the scenarios, which were supposed to be secret, were published in a local newspaper months before the exercise, and hospitals knew exactly what to expect.
Last year, MCHC again drilled using scenarios with biological agents. This time MCHC was able to keep the infecting organisms a secret. Hospitals knew when the drill would occur, but they were challenged to test and diagnose the victims to determine the infecting agent.
Still, last year’s drills produced moments that were more theater than real life. Knowing that the drill might involve a lethal bio-agent, one hospital sent an army of staff wearing masks, gloves and the latest protective clothing to wait in the parking lot for its van of victims. As it turned out, the victims were suffering only from a bout of food poisoning, not some rare airborne illness as the staff had anticipated. This year we were able to avoid situations like that by keeping the timing and scenarios secret.
Efforts to enhance coordination
This year’s drills also provided a chance to test the coordination between hospital departments and other healthcare agencies.
This coordination, which is an essential part of any disaster preparedness plan, often is lost in announced drills, because organizations anticipate the drill by adjusting staffing levels or taking other measures to minimize the need for outside help. The unannounced drills made this anticipation impossible, emphasizing the need for emergency department staff to notify other healthcare professionals at the first sign of a disaster, especially when biological agents could have been involved.
During this year’s drills, most hospitals contacted their infection control departments for assistance. In turn, the infection control departments contacted the local public health departments, which were able to collect and analyze the reports and draw conclusions about the extent of the disaster.
The Chicago Department of Public Health activated the Health Alert Network for all hospitals in the city limits during each of the four drills, thus playing out the scenarios to their fullest extent. The HAN is a nationwide system established to help hospitals and other healthcare organizations communicate and coordinate resources during a disaster. In Illinois and parts of surrounding states, all public health, medical and emergency professionals and partners have access to the Chicago Department of Public Health’s secure han, through which the cdph sends informational alerts and fosters collaboration.
The American Red Cross used the drills to test its new patient-tracking system, assessing ways to make it easier for hospitals to submit patient reports. The Chicago Office of Emergency Management and Communications implemented its standard disaster operating procedures.
At the federal level, during the planning stage, MCHC worked with the federal Health Resources and Services Administration to ensure that the drills would satisfy the disaster preparedness training requirement of grants that hospitals are using to fund improvements in their disaster plans.
Naval Station Great Lakes in North Chicago, Ill., participated by providing hundreds of volunteer victims. Great Lakes, which is the National Disaster Medical System coordinating center for the Chicago and Milwaukee region, has supportf gave this year's drills very positive reviews overall. The majority of participants said that unannounced drills, while tough on staff, are valuable because they provide the truest test of disaster preparedness plans and expose the areas that need improvement. However, some hospitals felt that announced drills are helpful as well, because they provide more opportunity for instruction before and during the exercise.
Whether future drills are announced or unannounced, the benefits of these exercises are clear. Given the disaster threats we face each day, from hurricanes to terrorist attacks, it’s imperative that organizations do everything possible to prepare for those worst-case scenarios, even those we think and hope will never happen.
Linnea O’Neill is the assistant director of the Metropolitan Chicago Healthcare Council’s Clinical, Administrative, Professional and Emergency Services department, which conducts annual disaster drills for its member hospitals. She also is a registered nurse and has a master’s degree in public health.