Emergency Management for Healthcare,

Volume III
Emergency Management for Healthcare,
Volume III

Emergency Response Planning

Norman Ferrier
Emergency Management for Healthcare, Volume III:
Emergency Response Planning

Copyright © Business Expert Press, LLC, 2023.

Cover design by Charlene Kronstedt

Interior design by Exeter Premedia Services Private Ltd., Chennai, India

All rights reserved. No part of this publication may be reproduced,

stored in a retrieval system, or transmitted in any form or by any
means—electronic, mechanical, photocopy, recording, or any other
except for brief quotations, not to exceed 400 words, without the prior
permission of the publisher.

First published in 2022 by

Business Expert Press, LLC
222 East 46th Street, New York, NY 10017
www.businessexpertpress.com

ISBN-13: 978-1-63742-221-2 (paperback)

ISBN-13: 978-1-63742-222-9 (e-book)

Business Expert Press Healthcare Management Collection

First edition: 2022

10 9 8 7 6 5 4 3 2 1
 Description
This series of books focuses on highly specialized Emergency Management
arrangements for healthcare facilities and organizations. It is designed
to assist any healthcare executive with a body of knowledge which
permits a transition into the application of emergency management
planning and procedures for healthcare facilities and organizations.
This series is intended for experienced practitioners of both healthcare
management and emergency management, as well as for students of
these two disciplines.

Keywords
emergency; disaster; mass-casualty event; healthcare; hospital; specialty
facility; triage; Disaster Plan; Mass Casualty Plan; Evacuation Plan; staff
training; university program; critical incident; Command-and-Control;
Incident Management System; disaster recovery
 Contents
How to Use This Series���������������������������������������������������������������������������ix
Acknowledgments�����������������������������������������������������������������������������������xi
Introduction����������������������������������������������������������������������������������������xiii

Chapter 1 Emergency Response Planning�����������������������������������������1

Chapter 2 Command Center Support Operations���������������������������23
Chapter 3 Dealing With Supply Chains������������������������������������������47
Chapter 4 Managing Surge��������������������������������������������������������������79
Chapter 5 Hazardous Materials Incidents Planning�����������������������109

Afterword�������������������������������������������������������������������������������������������143
Notes�������������������������������������������������������������������������������������������������149
References�������������������������������������������������������������������������������������������153
About the Author��������������������������������������������������������������������������������163
Index�������������������������������������������������������������������������������������������������165
 How to Use This Series
This series of books is intended to provide the student of emergency
management with a comprehensive introduction to the practice of this
discipline within the specialized context of a healthcare setting. It deals
with the practice of emergency management from the “ground up,” intro-
ducing all of the basic concepts and skills, but in the context of health-
care settings. Healthcare institutions, such as hospitals and specialty care
facilities, by their the very nature of their business, operate with variables
which are not normally found in the community at large, and therefore,
require more attention than normally occurs in community emergency
plans. All of the expected subjects will be covered in some degree of detail.
Each chapter will focus on a different aspect of emergency management,
always within the specialized context. That is not to say that the content
would not be applicable in other types of emergency management; in
fact, the opposite is quite true.
Each chapter contains both theory and practical applications.
In terms of chapter organization, in each case the applicable theory will be
addressed, followed by examples which are, wherever possible, specific to
the healthcare setting. The examples are then followed by the identifica-
tion of location-specific problems and by the development of appropriate
strategies to address and resolve each type of problem identified. Following
each chapter’s Conclusion, a series of student projects are recommended,
each with the intent of developing the student’s experience at the appli-
cation of practical skills. These are followed by a series of multiple-choice
questions, intended to provide the student with a knowledge check prior
to moving on to the next chapter. Finally, a list of recommended read-
ings, along with citations and end notes for the content of each chapter
are included. The author recognizes the fact that we live in an increas-
ingly digital world, and that good textbooks are becoming increasingly
expensive and difficult for both students and their learning institutions to
acquire. As a result, wherever possible, instructions have been provided in
each citation for accessing the appropriate reference information source
x How to use this series

online. Additionally, wherever possible, the recommended reading list

includes instructions to access the entire books digitally.
This series of books is not just intended for a student audience. Work-
ing Emergency Managers in both healthcare settings and in community
and government settings will hopefully find this information useful and
practical. As a result, the author has attempted to include actual examples
of the majority of the document types described in the various chapters
of this book. These are available digitally, on a copy-protected website,
access to which accompanies this book at the time of sale. The website is
formatted to permit the viewing of the documents, but not the printing
of those documents, and without the ability to modify the documents in
any way. As a major labor-saving device, the reader may purchase a pass-
word protected one-year renewable license, which will unlock the con-
tent of the website, permitting the full customization of each document
to reflect local realities, including specific site locations, local telephone
numbers, and even the logo of the reader’s institution. In essence, this
feature permits the rapid development of a comprehensive Emergency
Response Plan, and all of the associated documentation, for any type of
hospital or other healthcare institution. Information on obtaining such a
license is included on the inside leaf of this book.
 Acknowledgments
No body of knowledge is ever singular, and no book is ever written in
isolation. The author wishes to thank the following individuals; friends
certainly, but also both colleagues and mentors, for their reviews and
critiquing of material, and for their support and guidance in this project:

Eric Dykes, PhD, Professor of Emergency Planning and Disaster

Management (ret`d), University of Hertfordshire, Hatfield, UK, and Past
President, Institute of Civil Protection and Emergency Management, UK.

Gerald Goldberg, PhD, Professor of Psychology, York University,

Toronto, Canada.

Daniel Klenow, PhD, Professor of Emergency Management, University

of North Dakota, USA.

Margaret Verbeek, CEM, Past President, International Association of

Emergency Managers.
 Introduction
This series of books is intended to teach the skills which have been tra-
ditionally associated with the practice of emergency management. This
includes all of the skills involved in the assessment of risk, selection of
Command and Control models, the writing of an Emergency Plan, the
testing of that document by means of various types of exercises, and the
development of employee education programs which are intended to
strengthen familiarity with the Plan. However, no Emergency Plan is a
“blueprint” to guide a community or organization through its successful
response to a disaster. Every disaster is different in multiple ways and is
extremely complex. If we could simply preplan and preprogram every
type of emergency response from start to finish successfully, we would
be in possession of crystal balls, and the need for Emergency Managers
would be minimal.
This series of books differs from other well-written and useful emer-
gency management textbooks in two important respects. Firstly, it will
deal exclusively with the practice of emergency management as it should
occur specifically within a healthcare setting. Secondly, it will attempt
to introduce the use of contemporary mainstream business planning
practices to the practice of emergency management; something with
the potential to build bridges between the Emergency Manager and the
senior executive who has little knowledge or understanding of the subject.
The application of emergency management to a healthcare setting
is essential. It can be argued that any healthcare institution is, in fact,
a highly specialized community. It can also be argued that virtually every
type of service or agency found in a normal community has some type of
counterpart within the specialized community of a healthcare setting. It is
also important to remember that the vast majority of a community’s most
vulnerable population will typically be found within some sort of health-
care setting, whether an acute care hospital, a specialty care hospital, or
a long-term care facility. In order to mitigate against such vulnerabilities
and to protect those who possess them, a certain degree of understanding
xiv introduction

of the clinical context is required. The clinical context is, in the majority
of cases, a substantive source of each individual’s vulnerability. This is not
to say that the Emergency Manager must be an expert clinician, but they
do need to possess an understanding of relevant clinical issues. In emer-
gency management, the best Emergency Manager available cannot simply
be “dropped” into a hospital to work, any more than they can do so in an
oil refinery, a postsecondary institution, a busy international airport, or
any other highly specialized institution.
This series of books will attempt to introduce several new mainstream
business and academic concepts into the practice of emergency manage-
ment. These will include formal Project Management, applied research
methodology, Root Cause Analysis, Lean for Healthcare, and Six Sigma.
All of these concepts have a potentially valuable contribution to make to
the effective practice of emergency management. Of equal importance is
the fact that for many years the Emergency Manager has been challenged
to affect the types of preparedness and mitigation-driven changes that
are required within the organization or the community. Part of this has
been the challenge of limited resources and competing priorities, but an
equally important aspect of this has been the fact that the Emergency
Manager has typically used a skill set and information generation and
planning processes which were not truly understood by those to whom
they reported, and from whom they required project approval.
These mainstream business and academic processes and techniques
are precisely the same ones which are used to train senior executives and
CEOs for their own positions. As a result, the information generated is
less likely to be misunderstood or minimized in its importance, because
it comes from a process which the senior executive knows and uses every
working day. This “de-mystifies” the practice and the process of emer-
gency management, giving both the Emergency Manager, and emergency
management itself, dramatically increased understanding and credibility,
potentially making the Emergency Manager a “key player” and contribu-
tor to the management team of any organization in which they work, and
far more likely to be regarded as an expertise resource.
 CHAPTER 1

Emergency Response
Planning
Introduction
The successful Emergency Manager attempts to leave as little as possible
to chance. Creating an Emergency Response Plan for a healthcare setting
is, in many respects, simply another project. As such, it is very much
amenable to the processes described in detail elsewhere in this series,
including applied research methodology, Root-Cause Analysis, Project
Management, Lean, and Six Sigma. Each of these can have a significant
impact on both the project and the quality of the result.
That being said, the practice of emergency management has its own
major components, and these can provide the Emergency Manager with
further assistance, by identifying those issues which must be addressed in
order to create an effective and interoperable Emergency Response Plan.
Understanding each of these components, and the associated issues, is
essential; without careful analysis and understanding of these issues, and
the advance work need to resolve them, the Emergency Manager will
never really have a clear picture of what planning needs to occur. This
chapter will address the basic components of emergency management,
and the major issues which must be resolved prior to the creation of an
Emergency Response Plan.

Learning Objectives
On completion of this chapter, the student should be able to identify
the four major components of emergency management and describe how
each component works. The student should be able to describe how these
components influence the process of creating an Emergency Response
2 Emergency Management for Healthcare, Volume III

Plan. Finally, they should be able to understand and describe how these
components operate in a healthcare setting, in order to generate require-
ments for advance research, dialogue, and problem-solving, prior to
beginning to write an Emergency Response Plan.

The Fundamentals
In all types of emergency management, and in all types of settings, there
are four separate and distinct components to practice which have become
universal. These four components encompass the entire range of the
emergency management process from beginning to end and have been in
common usage for more than 30 years now. The first of these components
is mitigation1; the process whereby the Emergency Manager attempts
to treat existing risk exposures effectively, so that their effects are either
reduced or eliminated. This should always be the first component to any
emergency management practice.
The second component is preparedness2; those activities which accept
that a risk exposure is present, but which attempt to ensure in advance
that the organization or community has the ability to deal with the risk
exposure, should it occur. The third component is response; those activ-
ities directed at being able to deal with a risk exposure effectively and
safely, when it does occur. The fourth and final component is recovery;
those activities and measures which will restore the organization or com-
munity to an operating state of normal or “near normal” operations, after
a risk exposure has occurred, and has been addressed. Each of these four
components will be addressed separately, and in much greater detail, later
in this chapter.
There is a fifth component which has been proposed in some circles;
prevention, however, there is considerable debate among emergency man-
agement professionals regarding how and why this proposed component
differs from the accepted mitigation component.3 The four components
to practice are often depicted graphically as a cycle; however, the experi-
enced Emergency Manager recognizes that this model is not necessarily
rigid, and that opportunities to address some elements of each of the vari-
ous components may often occur even while another component is occur-
ring. To illustrate, opportunities for mitigation are often identified and
 Emergency Response Planning 3

put into place during both the response and recovery components, and
both mitigation and preparedness planning will often occur concurrently.

Mitigation
Mitigation is the modification of a vulnerable process or location within
the healthcare facility or the community, in order to either reduce the
amount of risk exposure, should a hazard event occur. It may also involve
the complete elimination of the possibility of occurrence for the hazard
event, thereby eliminating the risk exposure completely.
In some quarters, there is an argument for a fifth component of the
emergency management cycle, specifically, prevention. This, to some
extent, reflects the influence of FEMA being absorbed by the U.S.
Department of Homeland Security. As a result of the influence of cur-
rently dealing with terrorism, instead of simply natural and technological
disasters, there is a new emphasis on “prevention” being the first of the
five stages of homeland security, and on it receiving primacy over the four
stages of emergency management.4
There are those who argue that prevention refers to the elimination
of the event occurring, and is specifically associated with terrorism, while
mitigation deals with the reduction of effects, should the event actually
occur.5 However, the majority in the field, at least, thus far, continue to
believe that Prevention is simply the outcome of Mitigation performed
well,6 although sometimes varying by the extent to which the effects of
the hazard or risk event are eliminated.
As one example, consider the hospital’s vulnerability to interruptions
in the community’s electrical distribution system. Within a hospital, or
indeed, in many types of healthcare facilities, uninterrupted access to
electricity can be critical; there are often patients who are dependent upon
technology-based life support systems which are powered by electricity. In
addition, there may be patients who are undergoing critical procedures,
such as surgery or childbirth. There are patients who, while not in such
an immediate threat, would begin to suffer fairly quickly during a power
disruption, such as those in the newborn nursery.
There are also other critical processes with the potential to be disrupted
by a power outage, including the laboratories, diagnostic imaging, and
4 Emergency Management for Healthcare, Volume III

the Blood Bank. Finally, there are processes which, while not immediately
life-threatening, have the potential to substantially disrupt the business
of the hospital, including computers, digital telephones, paging systems,
food refrigerators, drug refrigerators, and in some cases, elevators. One
of the most vulnerable aspects of any hospital to power interruption
is the heating, ventilation, and air conditioning systems. Because of
their power demands, such systems are not universally included in the
emergency power “grid.” The vulnerability of a hospital to a power
outage is substantial, and such outages occur on a fairly regular basis in
many communities.

Figure 1.1  A hospital’s emergency generators; one of the most

essential and most misunderstood items of emergency equipment in
the facility

In an attempt to mitigate against such problems, most hospitals have

installed emergency power generators (see Figure 1.1). These generators
are designed to activate automatically, during any power disruption. Such
systems are often installed at the time of construction, and only rarely
revisited, apart from regular testing and inspections. The only time that
many such systems are updated is when the facility is undergoing major
renovations. One of the challenges with such systems is that while medical
technology, and therefore, the demand for electricity, continue to grow,
the emergency generator system often does not.
 Emergency Response Planning 5

Many of these systems are decades old, and the initial need for such
systems was seen to be the powering of a limited number of essential
devices in each location, but not the entire facility. In many cases, older
systems power as little as 20 percent of the facility’s daily needs, with just
a few emergency power plugs (often red) on each Unit, and it is common
to find systems which power only a single elevator, although the hospital
may have several. In newer facilities, such systems are designed to cope
with all of the power needs of the facility which were current at the time
of installation, but even these only rarely fully address the needs of the
building’s heating, ventilation, and air conditioning systems, which typi-
cally draw enormous amounts of power.
Potential mitigation measures include the installation of newer, more
powerful, electrical generators, to replace the older systems. When a facil-
ity is extensively renovated, it may be possible to greatly expand the num-
ber and distribution of emergency power plugs on the various Units, as
work progresses. Another relatively low-cost and creative way to mitigate
against electrical failure is to connect the healthcare facility to two sepa-
rate segments of the community’s electrical distribution grid, so that if a
power failure occurs in one portion of the grid, the hospital simply takes
its supply from the other point of connection.
It may also be possible to have battery “back-up” systems, or Unin-
terruptable Power Supplies (UPS) for essential devices, and such systems,
which have been common in computer networks for, are growing in use
with medical devices, as well. Indeed, it may be possible to add this fea-
ture to the specification process for a new device being purchased. Taken
collectively, the items described represent a “menu” of options, and a lay-
ered approach to mitigation against power failures, with all of the options
being possible, and even considered to be good ideas, with the only chal-
lenging factor being the cost of doing all of these things.
A recurring theme in the mitigation process is that of cost versus
potential benefit. No one would ordinarily simply refuse to upgrade a
hospital’s emergency power generators, for example, but a hospital is a
dynamic organization in a constant state of growth. There are many dif-
ferent items which various parties within the organization believe to be
a priority, and there is always a limited budget. The challenge is for the
Emergency Manager to justify mitigation measures in the face of many
6 Emergency Management for Healthcare, Volume III

other competing, and equally valid, priorities for the hospital’s limited
resources. Some mitigation measures may be easier to “sell” than others;
particularly if there is no immediate budgetary impact, or when both
parties can get what they require from the transaction.
To illustrate, the Emergency Manager wants to reduce vulnerability
to power failures in the hospital’s critical systems, and the Director of
Critical Care Services wants to upgrade the five-year-old cardiac monitors
in the Intensive Care Unit and the Recovery Room. If the Emergency
Manager can persuade the hospital administration to go ahead with the
purchase, but to also create a mandatory policy which adds UPS to the
specification list for both this purchase and all future technology pur-
chases, both parties win.
The Emergency Manager has achieved a change in policy which does
not create any substantial new budget demand but which ensures that
critical technologies have built in mitigation against vulnerability, and the
Director of Critical Care has the new monitors. Such mitigation measures
are easier to sell, because, on the face of it, they are not competing, and
there is no “hard” budget outlay to pay for the mitigation. In the process,
this type of cooperation may even begin to generate some new supporters,
or even “champions,” for the emergency management process.
The challenge of mitigation is to fix as many areas of vulnerability as
are feasible before any hazard event occurs. The problem is that, from the
perspective of many on the management team, the Emergency Manager
is still attempting to divert much-needed resources to an event which
“might never happen.” In all types of mitigation efforts, a sound business
case, suitably referenced and cited, will often be required, just as it is
for the rest of the hospital’s proposed projects. It may be that the Emer-
gency Manager can demonstrate that the cost of addressing the problem
if it occurs will be higher than the cost of mitigation against it, but if
the Emergency Manager cannot also demonstrate that the probability of
occurrence is also high, they may not be successful.
When mitigation is impossible or unfeasible, the Emergency Man-
ager must begin to consider the next stage of this process; Preparedness.
Indeed, it is often wise for the Emergency Manager to consider both of
these stages in parallel. An argument which accurately describes the cost
 Emergency Response Planning 7

of preparing for, responding to, and recovering from an event, instead of

mitigating against it, can be a powerful argument indeed.

Preparedness
When a risk exposure cannot be mitigated against, the logical response is
to engage in some level of preparation for its occurrence. The degree
of preparedness, along with the amount of associated time and effort
spent upon preparedness, will be determined by several factors. The first
of these should always be the findings of the Hazard Identification and
Risk Assessment (HIRA) research, described elsewhere in this work.
Along with this information, the Emergency Manager will need to
consider other variables, such as funding availability and staff availability
for preparedness efforts. Preparedness activities include a broad range
of areas, including the creation, approval, and regular updating of the
organization’s Emergency Response Plan, the acquisition of appropriate
resources for response to the incident, the education and training of staff,
and the testing of the Plan, by means of various types of exercises. Each of
these activities will be discussed in detail in subsequent chapters.
Many of the efforts directed at preparing the organization to cope
with an emergency will need to be research-based.7 It is almost impos-
sible to adequately prepare for an emergency event, without a complete
understanding of the event itself, its characteristics, and the experiences
of similar organizations, such as hospitals, when confronted with such an
event. To illustrate, the Emergency Manager may take the HIRA infor-
mation for the hospital and determine that tornados are a priority for
planning. Research would then be conducted to identify similar events
which affected other hospitals, preferably but not necessarily nearby.
After identifying the specific impacts on those hospitals through
research, the Emergency Manager would then employ the process of
Root-Cause Analysis, in order to identify the specific, underlying causes
of vulnerability for the other hospitals studied. Both isolated issues and
general trends in vulnerability would be identified, followed by an exam-
ination of the Emergency Manager’s own organization for the presence of
similar specific vulnerabilities or vulnerability characteristics.
8 Emergency Management for Healthcare, Volume III

Figure 1.2  As Emergency Management professionalizes and requires

greater academic credentials, the availability of good quality research
in the field will grow, and will influence preparedness and response
decisions

With this information, the Emergency Manager will be much more

able to effectively determine which mitigation measures are required,
any specific response resources that might be required, training required
by staff, including which scenarios to use in emergency exercises, and
any case-specific procedures that need to be added to the Emergency
Response Plan. The results of this research will also provide hard evidence
for the Emergency Manager to use in obtaining approval for preparedness
activities from the senior management of the hospital (see Figure 1.2).
Once again, the HIRA information will direct and drive the research
activities of the Emergency Manager, spending much more research time
and effort on high probability and/or high impact events first, and fol-
lowing up with research on those events which are less likely or lower
impact as the opportunity presents itself. Such activities can even lead
from a conventional, generic Emergency Response Plan, to more detailed,
case-specific annexes to the Plan. To illustrate, almost all hospitals have
a generic Emergency Plan of some description, but issues such as mass
casualty incidents, fires, and evacuations have sufficient probabilities of
occurrence and significant impact, that specific subplans for dealing with
such events are commonplace.
 Emergency Response Planning 9

Armed with a completed and approved Emergency Response Plan, the

Emergency Manager then focuses on the identification of specific training
and response resources required in order to prepare for emergencies in
general, and for specific scenarios. Partnership and advance dialogue with
both the community and with partner agencies are absolutely essential to
this process. The time to meet the Fire Chief is NOT when the hospital is
burning! Without such ongoing dialogue, both communities and health-
care organizations tend to develop expectations of one another which are
both unrealistic and somewhat distorted. This type of planning, usually
based upon erroneous assumptions, can lead to poor performance during
the emergency, or even to the outright failure of the Plan for either group.
There are a number of specific considerations which must be considered
and clarified well in advance of any emergency.
What are the expectations placed upon the organization to deal with
the specific emergency, should it occur? Does the community Emergency
Plan simply state that “all ill or injured persons will be taken to the hospital,”
or does it contain a rational, resource-based plan for the balanced
distribution of victims to several hospitals based upon clinical require­
ments, in order to balance the impact? It is astonishing how often
communities simply do not understand the capabilities or the capacity of
their local hospital, and simply assume that their hospital can handle all
of the victims, because no one has ever told them differently. To illustrate,
if your hospital does not have a neurosurgeon on staff, there is little point
to local Emergency Medical Service (EMS) bringing victims with head
injuries to your door, even in a crisis (see Figure 1.3).

Figure 1.3  Trauma Centers: Limited capacity is not always obvious to

other nearby hospitals
10 Emergency Management for Healthcare, Volume III

Similarly, while communities and regions are increasingly served by

hospitals with Trauma Centers, not all hospitals have such facilities, and
the ones which do have a limited capacity.8 Many hospitals assume that
all trauma patients will be taken to the local Trauma Center for planning
purposes, not apparently realizing that the moment that the Trauma Cen-
ter reaches its capacity (often about six major trauma patients arriving
simultaneously), the other hospitals will be “back in the trauma business.”
This becomes a point for addressing the twin issues of surge capacity and
surge capability, and how they will be expected to operate within the
organization’s Emergency Response Plan.9
The other aspect to this is the delivery of all patients to the local hospi-
tal and overwhelming it, particularly when there are other hospitals avail-
able within a reasonable transport range, with the resources to transport
those patients available. All of these factors can play a huge role during a
mass casualty incident, and how they have been addressed may represent
the difference between success and failure. The only time to resolve such
issues, and to clarify both expectations and procedures, is well in advance
of the occurrence of an incident.
Which processes and procedures will be internal, and which will be
addressed by outside agencies? To illustrate, if there is a hazardous materials
incident in the community, does the hospital expect the local Fire Depart-
ment to decontaminate all of the patients prior to sending them to hospital?
To what extent will decontamination occur? Will the Fire Department per-
form gross decontamination prior to transport, with the hospital expected
to perform a more detailed decontamination prior to triage and treatment?
Does the Fire Department expect the hospital to provide medical support for
their decontamination process, or will they use paramedics for this function?
If a hazardous materials spill occurs in the hospital, will the Fire Department
respond for containment and cleanup, or is the hospital expected to use a
private contractor? It may well be that the hospital cannot or should not rely
on others for decontamination of incoming patients, and the Emergency
Manager will be required to establish a process and a procedure for this.10
Does the local Fire Department even HAVE hazmat response resources
and training? In one true scenario several years ago, in a Canadian commu-
nity, a patient was critically injured in an explosion which occurred during
an industrial process and was also coated by an extremely toxic chemical
 Emergency Response Planning 11

“soup,” as a result of the explosion.11 The local Fire Department had no

hazardous materials response equipment or training, and, as the man
was clearly dying, paramedics rushed him to the local hospital, sickening
themselves in the process. Upon arrival in the Emergency Department, the
man began off-gassing toxic vapors, sickening staff and patients alike, and
forcing the evacuation and closure of the Emergency Department. The
now deceased patient was then moved to open air in the parking lot, where
he remained for several hours, while those involved attempted to figure
out how to manage his body safely. THIS is the level of disaster which can
occur when advance dialogue between partner agencies does not occur!
As a further example, if the hospital requires evacuation, does the
hospital have an expectation that local EMS will perform that evacuation?
Is that a realistic expectation, and has EMS agreed to this? If the event is
external, EMS is already dealing with the response to it, and also attempt-
ing to deal with all of the other emergencies which invariably occur in the
community, even during a crisis. Even if local EMS agrees to move your
most critical patients (evacuating the Intensive Care Unit, for example),
it is highly unrealistic in a community with four or five ambulances to
expect them to evacuate a 120-bed community hospital; other advance
arrangements will almost certainly be required (see Figure 1.4).

Figure 1.4  Hospitals relying on EMS for their evacuation may be an

unrealistic expectation, particularly during an existing crisis
12 Emergency Management for Healthcare, Volume III

Will EMS participation be limited to the collection of evacuees at the

hospital doors, or is there an expectation that they will go to the bedside
to move patients? Remember that ambulances are an extremely limited
resource in most communities, and every minute that an ambulance crew
uses to go to the bedside to collect the patient, is a minute in which
they are not moving one of your patients to another facility. Have you
ever taken the time to “benchmark” precisely how long it would take
to evacuate your facility? Where will your patients be evacuated to, and
have YOU made arrangements for this to occur? Have you negotiated
and signed advance agreements with partner facilities for the reception of
your patients during an evacuation? They are, after all, YOUR patients,
and only you have the specific details of their illnesses and treatment
requirements. Careful advance planning and dialogue with all partner
agencies are required, and a clear decision-making process should be
identified in advance.12
In 1979, in Mississauga, Canada, a freight train derailment resulted in
a large-scale hazardous materials release, forcing the evacuation of more
than a quarter of a million residents.13 Among these were the patients of
three acute care hospitals and six long-term care facilities. In a response
which could only have occurred in a socialized medicine system, a fleet
of 100 ambulances was assembled, with some of these having to travel in
excess of 100 miles to respond. There was no private patient transporta-
tion service at that time.
Working around the clock, in some cases for 30 consecutive hours
or more, the paramedics succeeded in moving all of the hospital patients
and nursing home residents, 2,600 patient movements in all, in a
24-hour period: a magnificent accomplishment. But this was not with-
out its problems; several hundred of the patients had to be moved
more than once, because they were evacuated to other hospitals or nurs-
ing homes which were subsequently evacuated themselves. Ambulances
were delayed as nurses photocopied patient charts to accompany the
patients; without the presence of a specific evacuation protocol, many
of the nurses treated the evacuations as they would routine inter-facility
transfers. The patients themselves were evacuated to locations across a
broad region of the province of Ontario, and it was several days before
 Emergency Response Planning 13

it was known exactly where each patient was. All of these issues also
resulted from a lack of advance preparedness and interagency dialogue.
What specific resources are required to appropriately address the emer-
gency? Does your hospital require additional patient handling resources,
such as stretchers and wheelchairs? Do you have a procedure in place for
gathering these resources from the various locations around the hospital
and bringing them to a fixed location during an emergency? Does staff
know this procedure, and when was it last tested? Have you predesignated
specific locations for the triage and treatment of incoming patients, or to
hold patients who are being evacuated? Have you obtained approval for
their use from the “owners” of these locations? Is there specific equipment
which is required in each location, where does it come from, how does it
get to where it’s needed, and who is responsible for the assembly of these
improvised resources? When is the last time that the assembly of each
was tested, in order to ensure that staff was able to perform this function
without problems?
What types of staff training are required? Does management staff
require training in a Command and Control model, such as the Incident
Management System, Hospital Emergency Incident Command System
(HEICS), or Hospital Emergency Command and Control System (HECCS)?
Have all staff received training in evacuation lifts and carries? Has designated
Emergency Room staff been trained in the appropriate emergency triage
procedures? How frequently is such training updated, and when was it
last tested? Does ordinary staff receive regular refresher training on the
Emergency Response Plan and the associated procedures? Does your
facility possess the qualifications and skill sets required to conduct such
training in house, or will it have to be contracted out? And what is all of
this going to cost? The questions are many, and the subject of preparedness
in a healthcare setting, if done properly, is a complex one!
Armed with the HIRA data, answers to all of the preceding questions,
and a solid grounding in advance dialogue with partner agencies, the
Emergency Manager is ready to begin to create a preparedness program.
This will include the creation of a new, state-of-the-art Emergency
Response Plan and case-specific procedures, resource acquisition, staff
training, and exercises to test the entire process. It is also important
14 Emergency Management for Healthcare, Volume III

to ensure that each step in this process is well-documented, as this

documentation will be invaluable during any accreditation process, or in
any legal process which follows an incident.

Response
Eventually, a hazard or risk event which has not been fully mitigated against
may occur. The success or failure to respond to this event will be determined
in large measure by the degree to which advance mitigation occurred, and
the success of preparedness programs. During the response phase of the
emergency, the role of the Emergency Manager will become supportive and
advisory, while others lead. The response resources, such as the Hospital
Command Center or Triage or Treatment areas, which should be already
identified in the Emergency Response Plan, will require assembly and acti-
vation, staffing will need to be assessed, and augmented, if required.
Many of the decisions which need to be made will be clinical, and it
is likely that in a hospital, members of the senior management group, or
preassigned staff (usually mid-level managers) with predesignated roles
under Incident Management System (IMS) or a similar command and
control model, will actually run the response. In healthcare settings,
such groups are usually highly clinical in composition, although the
participation of support services, such as administration, physical plant,
and logistics are absolutely essential. It is not necessary for the Incident
Manager to be a clinician, even in a hospital, but it is essential that
good clinicians are readily available to provide advice and to interpret
both clinical events and reports. In such situations, as in the community,
where the Emergency Operations Center typically supports a command
structure at the site of the incident, there is likely to be a specific person
in charge (usually in the Emergency Room) and the role of the Hospital
Command Center will be to support that person.
The response to the emergency may require fundamental changes
in the normal operating procedures of the facility. Whatever one might
think of institutional capabilities, emergencies are not “business as usual.”
EMS may be redirected to other facilities, in order to permit the hospi-
tal to focus more exclusively on dealing with the emergency. Hospitals
are boxes of finite size, and existing low priority in-patients may require
“decanting” to alternate venues of care, in order to provide space for the
 Emergency Response Planning 15

new victims. Elective surgery may be postponed or cancelled, and in true

mass casualty incidents, access to diagnostic and treatment resources,
including surgery, may need to be rationed or triaged.
Many hospitals develop a patient flow arrangement in which emer-
gency treatment occurs, and then patients are distributed to other facil-
ities, rather than being admitted, in order to balance the impact across
the entire local health network.14 “Just-in-Time” materials management
arrangements are likely to fail; a situation which is understandable, when
a hospital receives an entire weekly census of patients in a single after-
noon. Emergency re-supply arrangements will need to be implemented.
Arrangements for these measures will need to be made in advance, because
if they are not, they become much more difficult to arrange in the middle
of the crisis.
In such circumstances, the Emergency Manager may have numerous
responsibilities. They can and should be a trusted advisor and expertise
resource for the Incident Manager and the entire senior management
team. They may or may not have a clinical background, but they certainly
understand the context of the response to the emergency better than any-
one else in the hospital. The Emergency Manager can be a valuable point
of contact with the community’s response to the emergency, and to other
levels of government. The Emergency Manager, as an experienced project
manager, is also likely to be the most effective individual available to assist
a less experienced Incident Manager (remember, this is NOT their nor-
mal job) in the development and operation of an Incident Action Plan.
An effective Emergency Manager will also monitor process flow, such
as the Hospital Command Center Business Cycle meetings, and provide
advice to the Incident Manager on the maintenance of this essential
process, and will also monitor documentation of events, requests, and
decisions made, in order to ensure that an appropriate and comprehensive
record of the incident is available upon its resolution. An Emergency
Manager can also provide support to the planning function, and act as
a point of contact, or at least a point of introduction, for liaison with
outside agencies. The Emergency Manager will also, almost always, be
tasked with overseeing those background activities which support the
operation of the Hospital Command Center, making it as “seamless” as
possible; as always, a knowledgeable and sophisticated “generalist” instead
of a specialist!
16 Emergency Management for Healthcare, Volume III

Recovery
Once the response to the emergency has concluded, the focus will shift
to the return to normal or “near-normal” operations. In some cases, this
will be simpler than in others. If the hospital has simply received a large
number of patients, recovery should be relatively straightforward. As the
emergency treatment of each patient concludes, they will either be admit-
ted for observation and follow-up care, they will be transferred to another
hospital with more capacity to provide them with services, or they will
be discharged to the community, with or without community care sup-
port. Staff will be rotated out of service and provided with rest periods,
and then rescheduled to resume normal shift patterns. The “just-in-time”
inventory, probably utterly exhausted, will be replenished and restored
to normal operations. Finally, decisions will be required regarding a plan
and a timetable for the restoration of normal operations, including the
resumption of those services which were suspended in order to cope with
the emergency.
However, if the hospital has been directly affected by the emergency,
such as sustaining damage, the problem becomes much more complex.
Recovery will include dealing with insurance carriers, and possibly even
fundraising and public appeals for assistance. Reconstruction or extensive
repair of damaged facilities may be required. Essential medical electronics
and other medical devices may require replacement or reconditioning.
Basic equipment, such as beds, stretcher, and wheelchairs, may require
replacement. Staff who have been injured or killed may require replace-
ment. When a hospital has been severely impacted, it can take a year
or more to restore it to normal operations. If the hospital is the only
such facility in the community, there is likely to be a local expectation
that some reduced level of service will continue to be provided, albeit in
improvised facilities. When St. John’s Hospital in Joplin, Missouri was
destroyed by a direct impact by a tornado on May 22, 2011, the hospital
staff continued to operate for over a year from a portable field hospi-
tal, borrowed from the Missouri National Guard, which was set up in a
parking lot15!
Although the recovery effort may vary somewhat in its complexity,
the role of the Emergency Manager will be central. All of those who
participated in the event should be debriefed, and the results recorded
 Emergency Response Planning 17

Figure 1.5  An American hospital, following a direct tornado strike

for future use. An After-Action Report, summarizing the events in

chronological detail, problems encountered, solutions attempted, and
lessons learned, along with specific recommendations for future events,
must be created. All records relating to the response to the emergency will
need to be collected, collated, reviewed, and archived, ideally with the
hospital’s solicitors, against the potential for a public inquiry, inquest,
or other legal issues, since such documents are normally admissible as
evidence in many jurisdictions. Changes will also need to be made to
the existing Emergency Plan and associated case-specific procedures,
based upon the problems identified and lessons learned, in order to
ensure that the hospital is better prepared for the next emergency. All
of these activities are an essential part of the successful recovery of
the hospital or healthcare facility and are normally the duties of the
Emergency Manager.

Other Mandates
Before beginning to create the Emergency Response Plan for the orga-
nization, the Emergency Manager will also need to conduct research
into identifying those mandates placed on the organization from other
sources. These may include standards from Accreditation bodies,16 or leg-
islative mandates, usually from a state or provincial government. In some
18 Emergency Management for Healthcare, Volume III

cases, mandates may even come from the most senior level of government,
although these are less likely, in most jurisdictions. Which Accreditation
body is used by the organization? Are there specific standards, or merely
general guidance? How will the Emergency Response Plan be reviewed by
Accreditors, when they visit?
Legislative mandates may occur in specific emergency management
legislation, or they may occur in legislation intended to govern specific
aspects of the healthcare system, such as long-term care facilities,17
hospitals,18 or public health providers.19,20 What does the appropriate
legislation actually say? Does it consist of general guidance or specific
standards? What processes and measures need to be in place in order to
be in compliance with both the law and Accreditation standards? With
the answers to these questions, the Emergency Manager will have a much
more complete picture of the context in which the Emergency Response
Plan is to be created.

Conclusion
The four major components of emergency management, specifically miti-
gation, preparedness, response, and recovery have provided a highly effec-
tive framework for the creation of emergency plans and other emergency
management activities for more than 30 years. There is one significant
reason why they have endured so well in an evolving field; they work. By
understanding the issues which are generated by each for an Emergency
Manager in a healthcare setting, he or she will achieve an understanding
of precisely what is required of the planning process which is far more
comprehensive, and therefore, more effective. An Emergency Response
Plan really cannot be effective unless its creator understands, in detail,
what is being planned for, and how responses to these four issues will
occur. With this information used as the basis for creation, the Emer-
gency Response Plan becomes far more than a checkmark on an Accred-
itor’s list; it becomes an “evergreen” document which is easy to use, easy
to find information in, provides clear instructions, and makes sense. As
such, it becomes the first choice for any employee in a healthcare setting
to find information and instructions during a crisis.
 Emergency Response Planning 19

Student Projects
Student Project No. 1

Select a single point of vulnerability within a single hospital and study it

in detail. Using your research skills, create a list of potential options for
mitigation against this point of vulnerability, outlining the probable cost
of each. Rank these options, both according to cost, and according to
potential impact, and select a single option for implementation, explain-
ing your reasons for your selection. All information in the report should
be suitably referenced and cited, in order to demonstrate that the appro-
priate research has occurred.

Student Project No. 2

Select a single type of emergency event (mass casualty incident, evacuation,

etc.) and consider how each currently operates. Using research, outline five
different measures which could be implemented in advance, in order to
improve the management of the selected event. Describe the requirements
for their implementation in advance, and rank them according to
potential effectiveness. All information in the report should be suitably
referenced and cited, in order to demonstrate that the appropriate research
has occurred.

Test Your Knowledge

Take your time. Read each question carefully, and select the MOST
CORRECT answer for each. The correct answers appear in a section at
the end of the book. If you score less than 80 percent (8 correct answers)
you should reread this chapter.
1. Those activities directed at reducing or eliminating in advance the
potential effects of an identified risk exposure are called:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation
20 Emergency Management for Healthcare, Volume III

2. Creating an Emergency Response Plan, training staff, and conduct-

ing emergency exercises would be examples of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation

3. Triaging incoming patients or evacuation of a healthcare facility

would be examples of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation

4. Returning the healthcare facility to a level of normal or near-normal

operations, following a mass casualty incident would be an example of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation

5. One of the greatest challenges facing the Emergency Manager who is

attempting to implement mitigation measures in a healthcare facility
is the presence of:
(a) Indifference
(b) Competing Priorities
(c) Public Opinion
(d) Management Practices

6. The degree of complexity involved in a healthcare organization’s recov-

ery process following a crisis will often be directly determined by:
(a) Decisions by the Hospital Board
(b) Requests from the community
 Emergency Response Planning 21

(c) Whether the impact on the organization was direct or indirect

(d) Both A and B

7. During the emergency planning process, it is reasonable to invoke a

planning assumption that during many types of emergencies:
(a) “Just-in-Time” supply processes will be overwhelmed
(b) “Just-in-Time” supply processes will continue to function
(c) Alternate supply sources will be required
(d) Both A and C

8. The evacuation of a healthcare facility works best when:

(a) EMS is used to move the patients
(b) Patients can be discharged to the community
(c) All agencies have a clear understanding of expectations,
based on advance dialogue
(d) A formal Declaration of Emergency has been issued

9. An Emergency Response Plan will generally be more effective for a

healthcare organization, if the Emergency Manager has conducted
research to identify the:
(a) Historical weather patterns in the area
(b) History of disasters in the state/province
(c) Previous events which affected the organization
(d) Municipal by-law requirements

10. During mass casualty incidents, triage may be required, not only to
sort patients according to severity on admission, but also to:

(a) Locate hospital beds

(b) Provide access to limited resources
(c) Determine the clinically appropriate order of access to lim-
ited resources
(d) Provide accurate Census information to the Hospital Command
Center
22 Emergency Management for Healthcare, Volume III

Additional Reading
The author recommends the following exceptionally good titles as supple-
mental readings, which will help to enhance the student’s knowledge of
those topics covered in this chapter:

Baird, M.E. 2010. “The “Phases” of Emergency Management.” Background

Paper, University of Memphis, .pdf document, www.vanderbilt.edu/vector/
research/emmgtphases.pdf (accessed January 20, 2014).
De Lia, D. 2007. “Hospital Capacity, Patient Flow, and Emergency Department
Use in New Jersey.” Rutgers University, .pdf document, www.nj.gov/health/
rhc/documents/ed_report.pdf (accessed January 22, 2014).
Harvard School of Public Health. 2013. “Hospital Decontamination Self-
Assessment Tool.” Emergency Preparedness Bureau, Commonwealth of
Massachusetts, .pdf file, www.hsph.harvard.edu/policy-translation-leadership-
development/files/2013/01/Hospital-Decontamination-Self-Assessment-
Tool-2013.pdf (accessed January 22, 2014).
US Federal Emergency Management Agency. “Emergency Manager: An
Orientation to the Position.” Emergency Management Institute web-based
independent study course, http://emilms.fema.gov/is1a/index.htm (accessed
January 20, 2014).
Zane, R., P. Biddinger, A. Rich J. Gerber, and J. DeAngelis. 2010. “Hospital
Evacuation Decision Guide.” US Department of Health and Human Services,
.pdf document, http://archive.ahrq.gov/prep/hospevacguide/hospevac.pdf
(accessed January 22, 2014).
 Index
Accidents, 61
Accreditation body, 17–18
After-Action Report, 17
Bed-blockers, 85–87
Bed Clearance Task Force, 33
Bed clearance teams, 35–36
Bottlenecks, 85
Breakout rooms, 27–28
CBRNE, 112–114
Charge nurse, 35, 36, 89
Clerical support, 89
Clinical Acuity Special-Needs
Evacuation (CASE), 38
Cold zone, 128, 129
Command center, 23–24
breakout rooms, 27–28
decontamination areas, 29–30
discharge holding units, 32–34
evacuation holding areas, 34–35
facility support resources, 28–32
family information center, 26
fixed resources, 25
media information center, 25–26
mobile task forces
bed clearance teams, 35–36
decontamination teams, 39–40
discharge holding units, 38–39
evacuation holding units, 39
specialist evacuation teams,
36–38
strike teams, 41
role and purpose, 24
secondary treatment facilities,
30–32
staff reporting and staging, 26–27
support operation, 24–25
support resources, 25–28
triage areas, 28–29
Decontamination area, 29–30,
128–129
Decontamination teams, 39–40
Director of Critical Care, 6
Dirty-bomb, 113
Disaster, 11, 34, 86
Discharge holding units, 32–34,
38–39
Discharge Lounge, 33, 36, 89, 90,
101
Discharge Planner, 39, 89
Discharge task force, 89
Documentation, 14, 15, 89, 135
Emergency Department, 83, 94, 96
Emergency generators, 4
Emergency Medical Service (EMS),
9, 11, 12, 14, 81, 116
Emergency Response Guidebook,
122
Emergency response plan, 24, 65
mitigation, 3–7
overview, 1–2
preparedness, 7–14
recovery, 16–17
response, 14–15
Emergency re-supply, 70–71
EMS. See Emergency Medical Service
(EMS)
Equipment, repurposing, 99–100
Evacuation holding units, 34–35,
39
Family Information Center, 26
“Fast Track” approach, 98
Fire Code violations, 93
Fire Department, 10–11
Globalization, 63–64
166 Index

Hazard Identification and Risk evacuation holding units, 39

Assessment (HIRA), 7, 8, 13, specialist evacuation teams, 36–38
58–60, 74, 111, 118, 119, strike teams, 41
121
Hazardous materials, 109–111 Natural hazards, 61
accidents vs. deliberate events,
112–114 Outpatient Clinic, 95–96
activation, 124–125
commencing clinical treatment,
Patient flow arrangement, 15
132
People, repurposing, 100–101
decontamination area, 128–129
Personal protective equipment (PPE),
deliberate events, 116
40, 57, 66, 67, 122, 125–128
internal events, 116–117
Plan, do, study, analyze/act (PDSA),
personal protective equipment
50
(PPE), 125–128
PPE. See Personal protective
planning, 134–135
equipment (PPE)
rapid intervention team (RIT),
Preparedness, 2, 7–14
131–132
Prevention, 2, 3
resource identification, 120–124
Protests, 61–62
response planning, 117–120
safety officer role, 130
spill checklist, 136 Rapid intervention team (RIT), 41,
spills, 114–116 130–132
standing down, 133–134 Recovery, 2, 16–17
HIRA. See Hazard Identification and Recovery room, 85
Risk Assessment (HIRA) Resource, 56–58, 66–68, 120–124
Hot zone, 40, 41, 110, 123, 128, 129 Response, 2, 14–15, 67
Housekeeping, 89 Root cause analysis, 7, 50, 84, 91, 118
Rotating inventories, 68–69
Incident Management System (IMS),
14, 23–25, 81 Sarin, 30, 82, 113, 116, 132
Intensive Care Units (ICU), 90–91, SARS, 66, 67, 81–82
96 Safety Officer, 130
Inventories, excess, 52–53 Secondary treatment facilities, 30–32
Self Contained Breathing Apparatus
(SCBA), 126
“Just-in-time” delivery, 51, 53–54, 62
Space, repurposing, 97–98
Space usage, 91–93
Lean manufacturing, 50 Specialist evacuation teams, 36–38
Spills, 114–116
Mass-casualty event, 30, 36, 43, 52, Staff pools, 27
61, 79, 80, 81, 86, 87, 94, 95, Staff training, 13, 40, 99, 121, 127
97–99, 102, 104 Strikes, 61–62
Media Information Center, 25–26 Strike teams, 41
Mitigation, 2–7 Suicide-bombers, 114
Mobile support operation, 24 Supply chains, 47–48
Mobile task forces basics, 50–51
bed clearance teams, 35–36 benchmarks, 64–68
decontamination teams, 39–40 contingencies, 68–72
discharge holding units, 38–39 defined, 48–50
 Index 167
excess inventories, problem of,
52–53
Hazard Identification and Risk
Assessment (HIRA), 58–59
importance, 58
item/service, 54–56
just-in-time” delivery, 53–54
resource, 56–58
vulnerability, 59–64
Surge capacity, 79–82
Surge discharge, 85, 88–89
Surge management, 79–80, 102–103
capability, 94–95
designing for, 101–102
nontraditional space usage, 91–93
planning, 84–87
planning contingencies, 97
preparation, 97–101
services, suspension of, 90–91
surge capacity, 80–82
Tactical Exercise Without Troops
(TEWT), 92
Telecommunications failures, 62–63
Terrorism, 61
Traditional discharge methods, 35
Transport resource availability, 64
Trauma Centers, 9–10
Triage areas, 28–29
Twenty-four hour access, 69
Value Stream Map (VSM), 84, 85
Warm zone, 41, 128, 129, 130–132
Workarounds, 71–72