Emergency Preparedness

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EMERGENCY PREPAREDNESS: PLANNING AND MANAGEMENT

25

Emergency preparedness is an essential component of healthcare organizational preparedness, against both intentional acts of terror and naturally occurring crises that have the potential to cause serious harm to large portions of the population. The events of September 11, 2001, provided the stimuli to evoke fear in the lives of many, and the response to the events resulted in identifying the healthcare challenges and complications that arise during disasters.1 In 2013 alone, healthcare organizations endured several natural and manmade disasters, including the Christmas week ice storms in Southern Ontario, Canada resulting in generator failures; an immense F5 tornado that destroyed Moore, Oklahoma; the floods in Southern Alberta, Canada forcing patient evacuations; and the cowardly bombings at the Boston Marathon that proved the resilience of that city and its healthcare system. This was followed by the West Texas fertilizer plant explosion that shattered half of the town, and the super typhoon that struck the Philippines, leaving a swath of death and devastation in its path. Disasters disrupt the environment of healthcare and alter the demand for healthcare services; therefore it is essential that healthcare leaders ensure emergency preparedness is integrated into daily functions and values.2

REGULATIONS FOR HEALTHCARE EMERGENCY PREPAREDNESS For several decades, the United States and Canada National Fire Protection Association (NFPA),3 Canadian Centre for Occupational Health and Safety (CCOHS) and the Occupational Safety and Health Administration (OSHA) have specified the level of preparedness expected by organizations inclusive of healthcare. In the United States, the Centers for Medicaid and Medicare (CMS) Conditions of Participation (CoP) specify emergency preparedness standards and performance requirements for organizations that bill CMS for patient care services. Under CMS deeming authority, recognized hospital accreditation bodies such as The Joint Commission (TJC),4 Det Norske Veritas (DNV), and Healthcare Facilities Accreditation Program (HFAP) evaluate compliance with CMS standards. The Commission on Accreditation of Rehabilitation Facilities (CARF) is an international, nonprofit organization that also provides standards and surveyors to ensure standard compliance specifically in the rehabilitation venue. The Accreditation Canada and the Qmentum accreditation program5 provide a comprehensive set of standards to address emergency preparedness in healthcare in Canada.6 All of these accreditation programs generate an equally comprehensive set of emergency preparedness expectations resulting in improved disaster response capabilities and capacity. The International Association for Healthcare Security and Safety (IAHSS) has developed the following basic industry security guidelines relative to healthcare emergency management. These guidelines generically incorporate the recognized hospital accreditation bodies’ requirements for emergency preparedness. Hospital and Healthcare Security. http://dx.doi.org/10.1016/B978-0-12-420048-7.00025-8 Copyright © 2015 Elsevier Inc. All rights reserved.

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08.01 EMERGENCY MANAGEMENT (GENERAL) Statement Healthcare Facilities (HCFs) will develop and maintain an emergency management program to identify and address threats/hazards/emergencies that may impact the facility and its operations.

Intent a. A multidisciplinary team should be appointed to develop, maintain and approve the emergency management program. The team should have express support of the facility’s CEO along with authority for the program. b. Security should have a clearly defined role in the HCF’s emergency management program. c. The emergency management program should be based on the four phases of mitigation, preparedness, response and recovery. d. The facility should conduct a comprehensive hazard/risk vulnerability analysis (HVA) to identify and prioritize threats/ hazards/emergencies that may impact facility operations. HVAs should be reviewed annually and whenever a new threat/hazard/emergency emerges or preparedness activities change. e. Multidisciplinary emergency response plans should be developed to address the potential threats identified by the HCF. f. Emergency response plans should have an all-hazards incident command system (ICS). Emergency response plans should address not only immediate and short-term response by the HCF but the possibility of emergency operations lasting for days, weeks or even longer. g. HCF staff should receive education and training in emergency management consistent with their most likely role in responding to the event. h. Emergency response plans should be exercised both for training purposes, so staff understands their roles and responsibilities and feel comfortable in those roles, and to identify and document the plans’ strengths, weaknesses and areas for improvement. i. Emergency plans should include community involvement—other HCFs, emergency responders and government agencies. j. Emergency plans should include provision for the care and well-being of HCF staff and their families.

References - Hospital Incident Command System Guidebook, August 2006 - 2010 Environment of Care: Essentials for Healthcare, The Joint Commission, Oakbrook Terrace IL. - National Incident Management System (NIMS) http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf Approved: November 2008 Last Revised: October 2011

Current emergency preparedness best practices and policy guidance in the healthcare industry are also available from the American College of Healthcare Executives (ACHE),7 the American Osteopathic Association (AOA), the Food and Drug Administration (FDA), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Office of the Assistant Secretary for Preparedness and Response (ASPR).

EMERGENCY MANAGEMENT PLANNING Successful emergency management planning must include all key stakeholders within the healthcare organization as well as representatives from external agencies and organizations. An Emergency Management (EM) Committee inclusive of representatives from hospital administration, medical staff, emergency management, security, safety or risk management, engineering, nursing, and members of other support services such as pharmacy, materials management, and housekeeping, should be

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established to manage program sustainability and effectiveness. The members of this committee should have a basic understanding of emergency management and the incident command system. The organization should appoint someone responsible for emergency management oversight. This individual acts as a liaison between the organization and governmental and other healthcare agencies, and is often the chairperson of the EM Committee, responsible for overall emergency management compliance. Additionally, this individual coordinates risk analysis to identify points of vulnerability, and ensures appropriate mitigation, preparedness, response, and recovery efforts are in place organization-wide.8 The security professional plays an integral piece in the risk analysis. The EM professional is trained to focus globally, whereas the security professional is focused on security-related risks and associated impact on the healthcare organization. Security provides awareness and educational programs and workshops, analyzes department functions for security risks, provides a visible deterrence to crime, prohibited activities, or suspicious activities in public and nonpublic areas, and is constantly alert and vigilant for activities which could result in injury to a person or damage to or loss of property. The security professional, like the EM professional, must maintain positive working relationships with the employees of the organization along with local public safety agencies and administration. In some organizations, the security administrator may be the EM lead or vice versa.

HAZARD VULNERABILITY ASSESSMENT Incorporating an all-hazards approach to preparedness, beginning with an annual hazard vulnerability analysis (HVA), helps organizational leaders identify prospective hazards and evaluate the impact on the ability of the organization to sustain care and treatment during an emergency.9 The results of the HVA indicate a realistic understanding of an organization’s vulnerabilities, and assists healthcare and community leaders with focusing on planning and resource efforts through the evaluation of mitigation, preparedness, response, and recovery process, for each emergency identified in the HVA. Information from these assessments contributes to the development of the response plans, and subsequent scenarios to be included in an organization’s emergency management exercises. The HVA should be a multidisciplinary process that includes leadership, physicians, nurses, and the EM committee, because of its diverse membership. It is also important to involve the community and gain their perspective on potential threats.10 Community partners might include local police and fire chiefs, city leaders, and EMS providers, other area hospitals, as well as nongovernmental organizations, such as the Red Cross, Salvation Army, and the National Guard. An all-hazards approach to the HVA means the organization will evaluate all possible disasters that could affect the hospital and community it serves. There are many preexisting HVA tools available that can be modified to fit the organization’s requirements. One frequently used tool was created by Kaiser Permanente (KP). The KP tool divides the hazards into four categories: natural hazards, technological hazards, human hazards, and hazardous materials. The multidisciplinary team evaluates each of the potential hazards for probability based on known risk, and historical data. The time to marshal an onscene response, scope of response capability, and historical evaluation of response success is taken into consideration when scoring the response category within the tool. The next evaluation determines the human, property, and business impact. When assessing the impact, both the short-term effects of an emergency and the long-term effects, along with business continuity, must be considered. Issues to consider should include the potential for staff or patient death or injury, cost to repair property or set up temporary replacement facilities, and interruption of critical supplies and patient care services.

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Finally, the team will weigh the effects of the organization’s mitigation and preparedness efforts. This category evaluates the status of current emergency response plans, training, availability of backup systems, and community resources. Once the HVA is completed, the highest risks are prioritized and the organization prepared for those events. Many healthcare organizations have offsite locations associated with their patient care mission. These may be in a geographically separate location, or have inherent risks associated with them, different from the main hospital location. Therefore, offsite and community-based locations should have their own HVA conducted annually. While most potential hazards and vulnerabilities will have an impact on security operations, there are several events where security takes the lead. Examples of these events include, but are not limited to, infant abduction, active shooter, hostage situation, VIP situations, civil disturbance, bomb threat, terrorism, and mass casualty events. Three of the commonly identified security vulnerabilities are people, process, and infrastructure. Security professionals should have extensive knowledge other evaluators may not have in security specific mitigation, preparedness, and response and recovery procedures relative to these hazards and are integral to the HVA process.

MITIGATION AND PREPAREDNESS ACTIVITIES Prevention is frequently thought of as those actions taken to avoid or stop an emergency and mitigation as those actions are taken to decrease the impacts posed by hazards. Once the organization has identified the potential hazards and vulnerabilities that may impact the ability to provide safe patient care, the multidisciplinary team should review mitigation and preparedness activities that can reduce the impact resulting from each potential event. These activities are designed to reduce the risk of and potential damage from, an event, and build capacity by identifying resources that may be used if an event occurs. Both structural and nonstructural hazard mitigation strategies can be employed to reduce risk. Structural mitigation often consists of reinforcing, bracing, or strengthening any portion of the building that may become damaged or cause injury. The following are a few examples of structural mitigation strategies:   • Floods – elevate and reinforce the facility, build retaining walls on slopes, bolt the foundation and reinforce the walls • Wildfire – use fire resistant materials such as noncombustible roofing materials • Tornado – follow local building codes and use wind resistant design on exterior walls and doors, use shutters on windows • Manmade Terrorist Events – install exterior columns made of steel or concrete at entrances or other locations to restrict unauthorized vehicle access.   Nonstructural hazard mitigation reduces the threat to safety posed by the effects of the event on the nonstructural elements, such as building contents, internal utility systems, interior glass and ceilings. This includes all contents of the structure that do not contribute to its structural integrity, such as emergency power generating equipment, plumbing, HVAC, fire protection system, security detection systems, such as door locking and cameras, medical equipment, and hazardous materials. Many organizations will

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retrofit, replace, relocate, or create a backup plan as part of their nonstructural mitigation activities. The following are a few examples of nonstructural mitigation strategies:   • Earthquakes – brace light fixtures and ceiling tiles that could fall or shake loose • Tornado – install shatter-resistant protective film on windows to prevent glass from shattering onto people • Bomb Threat – training and education to reinforce policy and procedure, exercises to test response.   Organizational hazards can change often, therefore vigilance and ongoing assessment must be incorporated to maintain the highest level of preparedness. The security professional and the EM professional conduct ongoing hazard mitigation and preparedness evaluations through environmental rounds, lighting and landscape surveys, risk assessments and evaluations, and training and exercises.

EMERGENCY OPERATIONS PLAN/EMERGENCY RESPONSE PLANS A comprehensive Emergency Operations Plan (EOP) or Emergency Response Plan (ERP) should describe the philosophy and principles of the facility’s Emergency Management program, as well as the procedures for effectively responding to and recovering from an adverse event occurring within the hospital or affecting the community. When creating the plans, an all-hazards approach should be taken, to include hospital leadership, identifying capability limitations and response efforts for a loss of community support event, with a focus on the four phases of emergency management as noted in Figure 25-1.11 The plans should describe how the organization will mitigate the risks, plan preparedness activities, respond to an event, and detail recovery efforts. Alignment with community partners is also essential to facilitate coordinated, large-scale responses. For organizations with more than one location, plan modifications may be necessary to reflect local response capabilities and resources. The EOP/ERP should include tiered levels of activation. The nature, scope, and duration of a disaster will determine the necessary level of activation, correlated to the level of organizational response. A three-level system is often used and can be defined as follows: Level 1: Minor incident affecting the hospital, and may have casualties from outside the organization, or a small incident within the facility. This level can be handled by the current level of staffing on duty at the time of the event, and the hospital command center may or may not be activated, at the discretion of the administrator on duty. 5(63216(

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CHAPTER 25  EMERGENCY PREPAREDNESS: PLANNING AND MANAGEMENT

Level 2: Major incident in the community or within the hospital itself that requires additional staffing resources in specific areas of the hospital. This level may be activated also when the facility will be receiving patients requiring some support for the emergency department, or in advance warning severe weather situations. This may involve a partial activation of the hospital command center. Level 3: Event of significant impact to the hospital that requires additional resources from community partners and full activation of the hospital command center. The organization may be receiving large numbers of patients, or be experiencing significant issues that have occurred within the facility requiring extensive support.

INCIDENT COMMAND SYSTEM As part of the EOP, an incident management system must be in place to direct and coordinate actions and operations during and after disasters. The Incident Command System (ICS) was developed in the 1970s by an interagency task force working to coordinate response efforts to combat wildfires in California. Prior to its development, response to major events exposed vulnerabilities in inadequate communication because of conflicting terminology, lack of standardized management structure that would allow integration of resources, lack of personnel accountability, and lack of systematic planning. To meet those challenges, ICS was designed to be usable for managing all routine or unplanned events of any size or type, by establishing a clear chain of command, allowing different agencies to be integrated into a common structure, provide logistical and administrative support to operational personnel, and to ensure key functions were covered, while avoiding duplication of efforts. There are a few incident command systems available, and one commonly used in the United States is the Hospital Incident Command System (HICS), sponsored by the California Emergency Medical Services Authority. The Hospital Incident Command System is a standardized all-hazard incident management system, that enables hospitals and community partners the capability to work together on organizing resources, staff, and facilities, in an effort to efficiently and effectively respond to an event outside of the normal operations of the organization. The incident command system is divided into sections and primary functional roles. The Command section provides overall direction of the response by establishing response objectives for the system. The Incident Commander (IC) is the only position always activated in an incident. The IC sets the objectives, develops strategies and priorities, and maintains overall responsibility for effective performance of the ICS for the developing event. During an event where multiple organizations may have leadership responsibilities, such as in a fire response, bomb threat, and active shooter or hostage situations, Unified Command (UC) is initiated to allow multiple stakeholders to actively participate in incident management. Unified Command brings together lead personnel from each major organization involved in the incident to coordinate an effective response, while maintaining their own jurisdictional responsibilities. Unified Command may be established to overcome divisions formed by geographic boundaries, governmental levels, and functional or statutory responsibilities. The Operations section of the incident management system is responsible for managing the tactical operations that achieve the incident objectives. The Operations Chief directs strategies, specific tactics, and resource assignments. The Security Branch Director reports to the Operations Chief in the ICS structure. The Security Branch Director coordinates all activities related to personnel and facility security such as access control, crowd and traffic control, and law enforcement interface. This role is most frequently filled by the lead security administrator for the hospital, but depending on circumstances and

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duration of the event, can be filled by other security personnel, or those acting in a security role. Staff must be trained for the security role in the ICS structure, and indeed for any ICS position they may be required to fill. The Planning section of the incident management system collects and evaluates information for decision support, maintains resource status information, and overall incident documentation. The Logistics section of the incident management system provides support, resources, and other essential services to meet the operational objectives. Finally, the Finance section of the incident management system monitors costs associated with the incident, while providing accounting and cost analyses. Each of the sections can be subdivided as needed to meet the demands of the incident, and to manage span of control for proper safety and accountability.

CRITICAL AREAS OF EMERGENCY MANAGEMENT Healthcare organizations must evaluate capabilities in six critical areas of emergency management, including Communications, Resources and Assets, Safety and Security, Staff Responsibilities, Utilities Management, and Patient Clinical and Support activities, when creating the emergency operations plan. The evaluation should take an all-hazards approach to emergency management that supports a level of preparedness sufficient to address a range of emergencies, regardless of cause, complexity, scope, or duration. Creating a plan for managing each of these areas will decrease vulnerable capabilities, and enhance the organization’s ability to sustain operations during an event.

Communications In the event community infrastructure is damaged, or a hospital’s facilities experience debilitation, communication pathways are likely to fail. Hospitals must develop a plan to maintain communication pathways, both within the hospital, and to critical community resources. The EOP should describe how the hospital will communicate information and instructions to its staff, and how it will notify external authorities during an emergency. The organization will need to maintain communication with patients and their families as well as the community, and frequently the media. Communications to suppliers of essential services, equipment, and supplies during an emergency will also be critical to managing operations. There are a number of different levels of communications redundancy employed within healthcare organizations. These include overhead page, hand-held radios, pagers, telephone, cellular phone, house wide email, Amateur Radio Operators (HAM Radio), Satellite phones, and mass notification systems. The National Communication System (NCS) offers a wide range of National Security and Emergency Preparedness (NS-EP) communications services that support non-profit organizations in emergency communications. These services include:   • Government Emergency Telecommunications Services (GETS) • Telecommunications Service Priority (TSP) Program • Wireless Priority Service (WPS) • Shared Resources (SHARES) High Frequency Radio Program.   Specific methods used for communicating will depend upon the scope and duration of the emergency. More than one type of communication may be necessary to assure effective communication occurs.

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An emergency code system is often utilized to communicate when emergency response procedures have been initiated. Several states have begun to adopt standardized, plain language emergency codes to reduce variation of emergency codes among hospitals, increase competency based skills of hospital staff working in multiple facilities, increase staff, patient and public safety within hospitals and campuses, and align standardized codes with neighboring states. For example, the Missouri hospitals categorize emergency codes into four categories; Facility Alert, Weather Alert, Security Alert, and Medical Alert, and within each category specific events are announced using recommended plain language. As an example, severe weather would be announced as a Weather Alert along with the descriptor and location and any other important instructions. Several emergency codes continue to be announced with color descriptors such as Code Pink for an infant abduction or Code Silver for an active shooter. In Canada, color codes are utilized almost exclusively. Some provinces have had success standardizing these codes within their province and there has been a clear move toward Canadian code standardization for fire, bomb threat, chemical spill, cardiac arrest, mass casualty, evacuation, violence and missing patient-related events. Other events, including utilities failures, active shooter and missing or abducted infant continue to elude a nationally standardized code. In Australia, Australian Standard 4083-2010 Planning for Emergencies in Healthcare Facilities, prescribes a national set of emergency codes for healthcare. It is interesting to note that few of these color codes align with the Canadian standards. When deciding whether to implement plain language emergency communications, healthcare organizations should review available research and best practices, and implement the appropriate mix of code and clear text combinations appropriate for the environment. Collaboration will be necessary to ensure staff has appointments or work assignments which create a situation where they work, or respond to emergency situations in several buildings, so they will not be confused by different emergency notification systems.

Resources and assets Hospital leaders and emergency planners understand and recognize the limitations of resources, assets, utility systems, and lack of supply chain capacity that take place during emergencies. Within the EOP, healthcare organizations should identify resource gaps and establish agreements with external support entities to mitigate deficiencies. This can be accomplished by creating an inventory of personal protective equipment, water, food, fuel, medical supplies, and medications, and build a process to monitor and manage resources and assets during an event. The hospital should monitor daily usage of critical resources and update the inventory annually. Resources should be safeguarded against theft, spoilage and waste in an effort to preserve vital assets. Rotating resources and assets will help prevent expiration and degradation. Once resources become inadequate, the hospital will need to establish procedures to curtail or limit services, and evaluate the need to fully or partially evacuate the facility.

Safety and security Restricting the access of individuals into, throughout, and out of the healthcare organization during an emergency is crucial to the preservation of safety and security of patients, staff, critical supplies, equipment, and utilities. The safety and security section of the EOP should include procedures for the following:   • Total building lockdown • Ingress and egress identification • Establishing restricted areas

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• Internal movement of patient supplies and waste • External traffic flow into and away from the hospital • Hazardous waste management.   Hospital security personnel must establish a system to communicate with local law enforcement, and the authority having jurisdiction (AHJ) when additional security support is required. Facility personnel may also be designated and trained as facility security labor pool, to respond to an event requiring immediate support. Upon activation of the emergency operations plan, security will also play a key role in visitor management. Movement by visitors and other nonhospital personnel should be restricted to a minimum, and redirected to a collection point. If the hospital is still operational, several types of visitors may seek access, including traditional family and friends of current patients, good Samaritans, licensed personnel responding to assist, employee family members, media and people who are looking for a safe haven from a communitywide disaster. Preset areas should be designated for family waiting, media, labor pool and licensing verification. Vehicular access to the facility should be monitored and controlled by security, including access to the emergency department and other designated staging areas, to prevent grid locking the facility. In the event of a building evacuation, pre-established traffic patterns, pick up locations, and staging area will be essential to overall efficiency and safety of the patient evacuation process.

BOMB THREAT As part of the EOP/ERP annexes, all healthcare facilities should have policy and procedures for handling a bomb threat. Prevention is the first step to be taken against a bomb situation. These steps are the same security safeguards that should be in everyday use to protect the organization against other security risks. In other words, the proper functioning of the day-to-day protection system is the first line of defense against the bomb threat. To be more specific, locking equipment rooms, switchboard rooms, utility closets, and storage areas reduces risk. Limited access, access controls, noting suspicious people and vehicles, and providing emergency equipment are all part of the everyday protection system. One of the most important aspects of properly managing a bomb threat is to specifically establish organizational authority. Authority and responsibility for handling the initial crisis must be designated to a position readily available 24 hours a day. This position should be the Incident Commander. Logical choices for this role might be the nursing supervisor, the house officer, or the security shift supervisor. A bomb threat can be received in numerous ways. The most common method is by telephone, and the most common recipient of such information is the switchboard (PBX) operator. Telephone operators, and others who are likely to receive these calls, should be trained to keep the caller talking as long as possible and to ask key questions, such as where the bomb is located, when it will go off, why it was placed, what kind of bomb it is, and other questions that may keep the caller on the line. The person who receives the call should make notes or activate a recording device. Not all threats indicate a bomb has been placed somewhere in the facility. The threat may indicate a bomb “will be” placed in the facility. When this type of threat is received, access controls must be expanded, and the organization may decide to examine property being brought into the facility. Bomb threat information received must be communicated to the designated authority within the organization, which in turn activates the EOP/ERP. The first step in the notification procedure must

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CHAPTER 25  EMERGENCY PREPAREDNESS: PLANNING AND MANAGEMENT

always be to notify the appropriate law enforcement authority. In most cases, the law enforcement authority and facility management will decide jointly the type and extent of search required. It is not practical, or possible, to conduct an all-out search in every case. An all-out search includes everything from checking every patient’s belongings, to removing all suspended ceiling tiles and all ventilation grille work. It is presumed people who carry bombs are well aware of the danger of premature detonation, and therefore in most cases they will want to get into the facility quickly and to get out even more quickly—which generally precludes an elaborate hiding process. If sufficient organizational personnel are available, the search should be conducted by staff rather than by the police or fire department. The proper role of the outside support agencies is to assume control if a bomb or suspected bomb is located. Employees should conduct the search for two basic reasons. First, staff are in the best position to know what belongs and what does not belong in a given area. Staff are more knowledgeable of the layout of the facility, and either have the capability to enter locked or controlled areas or know how to obtain access. The use of in-house personnel to search avoids unnecessary confusion and minimizes disruption. Experts believe bomb threat callers are frequently interested in stirring up as much activity and causing as much disruption as possible. Thus, one objective of a bomb search is to carry out the search in a smooth, routine manner, while taking every threat seriously. In bomb threat situations, the administrative person handling the threat may decide to advise only selected staff and patients. In general, patients should not be told of the problem unless absolutely necessary. Experience has shown patients often set off a chain reaction detrimental to the entire process. Patients may respond by calling their families. In turn, the family may decide to come to the facility or call the facility for detailed information. This reaction can tie up needed communications lines and hinder response capabilities. Whether a search is full or partial, areas of responsibility must be assigned. Search personnel are assembled as a group so the search coordinator can relate to them the information received and assign specific areas to specific personnel. This information may also be communicated by telephone or through a public address system with a code term such as “Mr. Search” or “Code Green,” or via electronic means. A complexity that must be taken into consideration is the staffing pattern of the facility. When all departments are fully operational, the facility can be more easily and quickly searched than when departments are closed and locked. During the nonoperational period, security, maintenance, and environmental services personnel may be assigned an expanded role in the search effort. Floor plans, divided into specific search areas, are used in some facilities. Personnel are given a map of the area for which they are responsible. In other organizations, these assignments are made from an administrative checklist that defines the areas. However the parameters of the search are defined, the person responsible for searching a given area must always report back to the command center when the search has been completed. The primary concern is for personal safety rather than property. If the search produces a bomb or a suspected bomb, the cooperative efforts of security and public safety agencies come into play. Facility employees should never touch a suspected bomb. The investigation and removal of any suspect object is the responsibility of the public safety agency. Security’s basic function is to seal off the area and to commence evacuation if necessary. The decision to evacuate rests with the hospital incident commander, working in cooperation with the public safety agency involved. A safe distance for evacuation is generally considered to be a 200-foot radius from the suspected object, including the floors immediately above and below.

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ACTIVE SHOOTER PREVENTION AND RESPONSE The frequency of mass shooting events continues to increase. Approximately every few weeks, a shooting occurs at a school, hospital, governmental facility, and other workplaces frequented by many people. Often mass killings involve a failed safety net; jobless, homeless, and frequently those who slipped through the mental health system. What is happening in the healthcare setting is a reflection of what is happening in our community as noted in Figure 25-2. The unemployment rate shows companies continue to downsize their workforce, leaving people without jobs and money to support their families. Domestic disputes often spill into the healthcare setting. An increase in addiction to drugs and alcohol leads to aggression, theft and unexpected acts of violence. Finally, there is a large gap in available mental health funding and facilities, to receive much needed treatment. Treatment facilities are experiencing financial troubles and disappearing from our communities as the need for services continue to rise. This problem has been exacerbated in Colorado, where the state department of health and human services reported that, in the 20-year period from 1990 to 2010, the state lost 60% of its inpatient psychiatric beds. This has been a decrease from 1241 in 1990 to 503 in 2010.

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CHAPTER 25  EMERGENCY PREPAREDNESS: PLANNING AND MANAGEMENT

FIGURE 25-3 Shootings in healthcare from 2006–2013. Source: Tom Aumack, CHPA, HSS Security Program Manager at Cheyenne Regional Medical Center.

Hospital shooting statistics indicate a higher number of incidents occurring in hospitals with 300 beds or less as noted in Figure 25-3. These smaller hospitals typically have less security presence compared to larger medical centers, and tend to be community-based healthcare facilities. Historically, incidents involve male shooters who present with multiple weapons. These incidents are over in minutes and most end prior to law enforcement arrival. These shootings can be suicidal intentions or mass shooting events that most frequently occur during daylight hours, inside buildings, and in populated areas. Shooters usually fit into one or more of these three categories of aggressors.   Type I – Stranger: This offender does not have a legitimate relationship with the business or employees. The self-motivated terrorist falls into this category. Type II – Customer or Client: The offender is receiving service and the victim is a service provider. Often seeking revenge and has a planned assault. This is the most common category in mass shooting events. Type III – Co-worker: This offender is a colleague or co-worker often disgruntled about disciplinary actions or termination. Often seeking revenge and has a planned assault.   Warning signs such as unexplained increase in absenteeism, depression or withdrawal, along with increased mood swings and noticeable increase in alcohol or illegal drug use are often present prior to a shooting event. Additionally, one may notice an increase in anger management issues at work, or in a social setting, talk of personal problems with loved ones, and an increase in comments regarding violence and firearms. Behavioral health issues are often present but can be hard to detect. There are several prevention strategies that can be employed to decrease risk and increase safety, as noted in Figure 25-4. Access control is a good starting point in terms of visitor management, and after hours building restriction. However, if the aggressor is an employee, they may have the security code or access to the facility. Video surveillance is primarily used for evidence collection, and can provide a

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FIGURE 25-4 Prevention strategies for the active shooter.

false sense of security when employees believe someone is watching every camera, and will send help if an emergency occurs. Duress alarms are good for areas where employees work alone, but they need to be tested to ensure the response is the one expected, in terms of resources and response time. Finally, mass notification systems have been implemented throughout the country. It is important to be able to warn occupants and coworkers of an active shooter situation. There are three active shooter response strategies: Get Out, Hide Out, and Take Out. Getting out of the area is always the best option if available. Having a planned escape route in mind, and playing the “what if” game in a number of situations, including the office, clinic, patient care unit, and main gathering areas such as waiting rooms will increase the chances of getting out. While exiting, all belongings should be left behind, and others encouraged to follow, while warning everyone to get out. The mental mindset should be that of a raging fire situation where you must get out or lose your life. Activating the fire alarm system is not recommended in these situations as a method to warn building occupants, because doing so will bring more people out into the hallways, creating more targets for a shooter. If staff cannot get out, then they should be trained to hide out. The second response option is to barricade self and others behind locked doors. Occupants can utilize room furniture to barricade the doors. It is important to make the room look unoccupied, by shutting off the lights, silencing phones, and remaining calm. In patient care areas, patients should be moved into locking utility or medication rooms for safety where possible. In patient rooms, patients and visitors should be moved into the bathroom, and the room door barricaded with the patient bed, and any other furniture available in the room. Shooters only have a few minutes to accomplish their plan and opening up rooms that appear to be empty is a waste of time. As a final option, training should focus on taking out the shooter. Create a distraction and have a plan to take him down during the split second he is not focused. Throw items such as hot coffee, chairs, fire extinguishers, which can also spray from a few feet away. The goal is to disrupt and then incapacitate the shooter. This is situation of last resort and requires commitment to the action and execution of the plan. Once law enforcement arrives, it is important to know what is expected so not to interfere with their job, which is to neutralize the threat. Training should remind staff law enforcement will proceed directly to the incident location, and will not stop to assist injured persons. This will include an expectation that

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both plain clothed and uniformed officers will respond with a variety of weapons. Police training dictates anyone can be a suspect, so they may shout commands and force people to the ground. Police are taught “hands kill” so individuals should immediately raise their hands, drop everything they are holding and spread fingers.

PATIENT DECONTAMINATION In compliance with OSHA regulations,12 each organization has a responsibility to build patient decontamination capacity, including trained staff members and available decontamination personal protective equipment (PPE) and facilities. In January 2005, OSHA published Best Practices for Hospital-Based First Receivers. This OSHA document provides guidance to hospitals and first receivers regarding the selection and use of appropriate PPE. Best practices presented in the document indicate the minimum PPE that OSHA anticipates will generally be needed, for protection of first receivers faced with a wide range of unknown hazards. The decontamination function is usually located near the emergency room, and includes a process for patient care while minimizing risk to employees. The most important goal is to protect staff, visitors and victim(s) from accidental injury, due to spreading of hazardous chemicals from the victim to them. Secondly, is to decontaminate and treat victims of chemical injury. This requires attention to situations that suggest the possibility of bioterrorism, and identify resources and protocols in that regard. In all cases, regardless of the victims’ degree of injury or distress, the goal of protecting staff, visitors and victim(s) must take precedence over decontaminating and treating victims. Once the organization receives notification indicating a known/suspected or potential hazmat victim is being transported to the facility, they should activate the EOP/ERP for Hazmat Decontamination. Contaminated victims should be held outside of the facility, and not allowed in the hospital until decontamination has occurred. Once the EOP is activated, a decontamination team, consisting of properly instructed and attired personnel should assemble to perform patient decontamination. The emergency parking lot should be secured and evacuated to allow for patient decontamination. Additionally, rescue vehicle traffic patterns will need to be adjusted to remain outside the contaminate zone. The door into the facility from the ambulance bay should be secured to ensure contaminated individuals do not enter, until they have been decontaminated. This entrance must remain secured/ guarded until the decontamination processes have been accomplished, and the hot zone (site of contaminated patients) has been cleaned and restored to ready condition. Establishing a hot and cold zone for the decontamination process reduces the risk of cross contamination and increases staff safety. The hot zone is the area where the risk of secondary decontamination is the highest, and personnel must put on personal protective equipment before entering it. This zone includes the transport vehicle, decontamination area, and the ambulance or designated emergency entrance. The cold zone includes all other areas of the hospital and property. Responding to a hazardous material event requires using appropriate personal protective equipment (PPE). Identifying the components of the required level of PPE is based upon a given situation involving contamination, according to the OSHA as hospital first receivers’ guidance. There are four basic levels of PPE (A, B, C, and D). The components of each determine the level of protection provided by each set. Determining factors include identification of the hazard(s), routes of potential hazards to the responders including inhalation, skin absorption, ingestion, and eye or skin contact. One of

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the most critical components of the PPE is respiratory protection. Levels A and B require a full-facepiece Self-Contained Breathing Apparatus (SCBA), or approved positive pressure supplied air respirator. Level C, most commonly used in healthcare patient decontamination, utilizes a powered air purifying respirator (PAPR) rather than a SCBA. Level C utilizes a chemical resistant suit along with the PAPR and allows for extended operations. The following components constitute Level C equipment:   • Powered air purifying respirator (PAPR) • Chemical resistant clothing • Inner and outer chemical resistant gloves • Chemical resistant boots • Chemical resistant tape to secure gloves and boots to the suit.   Finally, Level D PPE is limited to coveralls or other work clothes, boots, and gloves. This level is appropriate when the mission assigned does not require respiratory protection.

STAFF RESPONSIBILITIES The number of staff needed to support critical hospital operations should be determined and include in the EOP. Contingency staffing plans, staff reassignment and modification of job duties, is not uncommon during an emergency. Cross-trained tasks should be defined and practiced during an emergency exercise, and may include patient transportation, supply distribution, communication runners, and decontamination duties. Depending on the nature of the emergency, the ICS will establish mechanisms to meet the needs of staff, such as housing, transportation, food and water, stress debriefing, and childcare. Staff needs to be aware of their individual and department roles and responsibilities during an event. Additionally, the organization should assist staff with personal emergency plans to ensure the minimum staffing can be met.

UTILITIES MANAGEMENT Diverse types of emergencies can compromise or disrupt an organization’s essential utility systems. An element of advance preparation is identification of an alternate means of providing for vital utilities, such as steam, electricity, HVAC, medical gases, and water. Healthcare organizations often have redundant hook-up locations on the facility for water, negotiated relationships with primary supply chain vendors, and memoranda of understanding (MOU) with other organizations, to accomplish redundancy in major utilities. If a major utility is compromised, and the outage is widespread throughout the community, the organization must have a loss of community support and resource conservation strategy, to maintain a safe patient care environment. Loss of Community Support is defined as a sustained disruption, failure, or loss of support from the local community, lasting at least 96 hours. During the initial period following an emergency, community resources are most often prioritized to restore power, provide security, manage debris, clear roads, and restore water and sewage systems to the community. Medical facilities are typically viewed as hardened facilities with integral backup systems and procedures, and thus not an immediate priority for local community emergency support. Support from state and federal agencies should not be anticipated before 96 hours post-event.

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Strategies and options that promote institutional resiliency to withstand an event that disrupts community support for a 96-hour period should be included in the EOP. Healthcare organizations will respond to such an event, by evaluating the incident and its impact on operations and the environment of care, by reviewing how the facility will be able to manage the six critical areas of emergency operations: communications, safety and security, resources and assets, staff, utilities, and clinical/support services. The organization should respond to the event, utilizing strategies that may include partial or complete evacuation, service curtailment, resource conservation, and/or resource supplementation from sources outside its geographical area. Hospitals must build critical system redundancies to support continued operations in the event of a disaster, and maintain caches of some emergency supplies/ equipment. Emergency supply and equipment inventories should be monitored periodically and systems should be in place to protect them. Emergency supply inventories should be reviewed annually by the emergency management committee and modified based on changes in the facility’s hazard vulnerability analysis, resource availability, and/or evolving technologies.

PATIENT CLINICAL AND SUPPORT The basis of emergency planning is to protect life and provide care, treatment, and services to those in need during an emergency. Once the emergency operations plan is activated, the organization must implement processes to triage patients, schedule patients, assess and treat patients, and admit, transfer, discharge or evacuate patients.13 Each department must identify critical functions, resources required to support them, and recognize changes in staff roles and responsibilities, in order to provide the level of patient care required to address the emergency. The healthcare organization must have clear, reasonable plans in place to address the needs of patients during extreme conditions, when the hospital’s infrastructure and resources are taxed. Consideration should be given to the potential need for alternative care sites for patient treatment, effective patient identification and tracking systems, and patient transportation options.

EVACUATION If the nature, scope, and/or duration of the emergency are such that the facility can no longer sustain patient care, treatment, or service, then it may become necessary to evacuate all or part of the facility. Hospital evacuation, both pre-event and post-event, can result from different types of disasters and reasons. Any of the natural, technological, human, or hazardous materials hazards evaluated in the HVA process, could result in structural damage or the loss of a major utility, resulting in a decision to evacuate. A hospital evacuation requires time, and labor-intensive resources and material, at levels that most hospitals do not possess for routine emergencies. The physical aspects of evacuation typically shift healthcare professionals from providing care to tasks with which they are less familiar, or often unprepared. Transportation resources and evacuation routes may be unavailable, or designated to other public safety issues. Necessary staff may be diverted from their primary healthcare focus, or unavailable, due to the need to evacuate their own families and homes. Furthermore, the full scope of the threat may not be known or may be constantly changing and often extremely difficult to predict. Any evacuation

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decision has elements of risk and benefit. It will be important to evaluate both, in order to make the best evacuation decision. The decision to partially or completely evacuate a hospital is a complex issue that needs to balance the nature of the threat against the risk the patients and staff would face by remaining in place. The risks associated with some hazards, such as flood, are often better known or more predictable than other hazards, such as a hazardous materials release in which the toxicity of the agent and its movement may be completely unknown. The risks to patients, staff, and visitors must be considered in deciding if and when to evacuate. Evacuating too soon may place patients and staff needlessly at risk if the potential threat does not materialize. Evacuating at the same time as the general public may increase the risk to patient health, if traffic congestion and other road complications increase travel time. Finally, evacuating too late increases risk if patients do not arrive at their destination before the event occurs. There are a number of complexities associated with evacuation, and conducting a critical infrastructure self-assessment and reviewing lessons learned from historical events can better prepare the organization. Although preparedness and exercising are required, it is not possible to model the entire evacuation event. Threats change over time, internal and external resources change over time, and there is potential for resource competition for limited resources if the event is community wide. Furthermore, depending on the patient population served, the risk of evacuation may outweigh the risk of remaining in that patient care area. When conducting a predisaster self-assessment of critical infrastructure, organizations should include the following:   • Municipal Water • Steam • Electricity • Natural Gas • Boilers/Chillers/Heating Ventilation and Air Conditioning • Powered Life Support Equipment • Information Technology • Telecommunications • Security.   Water plays a critical role in maintaining the environment in which organizations care for patients. An overabundance of water and insufficient water will produce vulnerable situations. Hurricane Katrina, Superstorm Sandy, and the 2013 floods in Southern Alberta, Canada were among the worst natural disasters in history, resulting in healthcare evacuations and hospital closures. Moreover, when the municipal water supply fails, the organization loses nonpotable water required for toilet flushing, and cooling and heating applications, often forcing evacuation. Municipal water is needed to generate steam, and some organizations use incoming steam to generate electricity. Large steam production plants pipe underground steam to often huge academic medical complexes that include tertiary care hospitals, medical schools, research laboratories, and ambulatory care areas, making an evacuation more complex. Redundancy in these types of critical infrastructure is rare, and weather conditions play a big role in evacuation decision-making algorithms, especially if the boilers go out in the winter or the chillers go out in the summer. Electricity plays a large role in the evacuation decision, because prolonged loss can lead to HVAC loss, along with essential medical technologies such as monitors, CT scanners, dialysis machines, ventilators, and incubators. Security systems designed to keep occupants safe may also be compromised in

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a sustained electrical outage. Hospitals have backup generators that require fuel and, depending on the number and size of the backup generators, it should be determined what length of time they can sustain the required electrical load. When creating evacuation plans, the time required to empty the building needs to be determined, including actual movement of patients from their room to a staging area, from which they are loaded into a vehicle for transport to another hospital or alternative care site. As well, the time it takes to print out a patient discharge summary, obtain 24 hours of medication, and staffing levels all need to form part of the evacuation timeline calculation. Nights and weekend shifts frequently have less patient care staff and security personnel available to assist with patient preparation procedures. The amount of time it takes to transport the patients from the staging area to receiving hospitals is also a determining factor, including the number of transportation resources available, road conditions, and location of the hospital that can accept and properly care for the patient population. Emergent evacuation procedures should abide by the general Rescue, Alarm, Contain, and Evacuate (RACE) method regardless of the incident. When a situation arises that requires occupants to immediately leave the area, the person in charge of the affected space should order the unit evacuation, and shall implement the following procedure:   • Rescue: Anyone in instant danger or harm’s way shall be rescued, if it can be accomplished without undue risk to staff. • Alarm: Direct a staff member to sound the alarm, make appropriate notifications, or call the Emergency Operator (Dial 911). • Contain: Put distance and/or shielding between the threat and the area/building occupants. • Evacuate: If the previous steps are not sufficient to mitigate the problem and the threat remains, area/building occupants should be evacuated without delay.   The major difference between emergent and nonemergent (i.e., urgent or planned) evacuations is the time available to mobilize staff and resources, plan actions and destinations, and control the overall process. Evacuation activation levels should correspond to the levels of EOP activation, and are based on the projected impact the particular evacuation would have on the hospital. Once information is received indicating a situation or event that may require relocation of patient care or ancillary service activities from all or a portion of the facility, the organization should go on alert for potential evacuation. Once there is a need for horizontal evacuation of patients, visitors, and staff from an area of the building, a level one EOP activation should be considered. A common scenario associated with this level includes a fire in a single room, requiring occupants of that space to move horizontally to an adjoining smokefree compartment. This level of evacuation can be accomplished quickly, using resources such as standard wheelchairs and patient beds already in place, or readily available on the unit. A level two evacuation occurs when there is a need for vertical evacuation. A common scenario associated with this level includes a fire or smoke condition affecting an entire floor, requiring occupants of that space to move vertically to another floor in the hospital. The impact on the organization increases significantly, because of the need to move patients down stairs, with the planning assumption the elevators might be inoperable. Moving patients to another floor requires considerable additional staffing resources and specialized equipment for patient movement. An entire building evacuation would be considered a level three. This would likely be the result of an uncontrolled fire or failure of a mission critical system for an extended duration.

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Once an entire building evacuation order is given, the organization should begin evacuation triage to determine the amount of staff needed to move each patient, type of movement and evacuation devices required, which loading areas to relocate to, and destination facility of each patient. Three essential components are: a process that is quick and can accurately assess, be marked in a standard way, and documented for resource allocation and tracking purposes. The following three patient mobility levels should be considered:   1. Ambulatory: Able to walk to loading area without physical assistance and without likelihood of resulting in harm or injury. This group should be denoted with green wristbands and escorted in a one to five staff to patient ratio and can be transported in a large group. 2. Wheelchair: Alert but unable to walk due to physical or medical condition. These patients are clinically stable and have a low likelihood of resulting in harm due to prolonged sitting and do not require equipment beyond oxygen or intravenous fluids. This group should be denoted with yellow wristbands and can be safely managed by a single nonclinical staff member. 3. Nonambulatory: Clinically unable to be moved in seated position and may require ventilators and/or cardiac monitors. These patients require transport by bed, gurney, or stretcher and may be transferred to evacuation sleds, backboards, or rescue dragged on their mattress. The group should be denoted with red wristbands and will require ambulance transport to the destination facility.   After the patients have been triaged, they are moved from their patient room to a patient holding area, by a horizontal movement team. A vertical movement team then moves the patient down to the ground floor or patient loading area. Vertical movement can be exhausting, therefore teams should be augmented by public safety, security, plant operations, and other nonclinical personnel. Preestablished loading zones should exist for each level of patient triaged. Ambulatory patients should be loaded at a main entrance accustomed to patient drop off and pick up. Wheelchair patient loading will require an entrance that can accommodate several transport vehicles, such as buses and vans. Finally, the nonambulatory patients require an ambulance, so the emergency department is the most logical loading zone. These are the most critical patients and usually moved out of the facility last. Patient movement sequencing will be such that the greatest numbers of patients move out the fastest way possible.

EMERGENCY PREPAREDNESS EXERCISE DESIGN AND CONDUCT Emergency preparedness exercises are designed to evaluate the EOP/ERP’s appropriateness, adequacy, and the effectiveness of logistics, human resources, training, policies, procedures, and protocols.14 The exercise should stress the limits of the plan to support assessment of the organization’s preparedness and performance. The design of the exercise should reflect a likely disaster, and test the organization’s ability to respond to the effects of this emergency and its capabilities to provide care, treatment, and services. Individual exercises should be part of an exercise and evaluation cycle. Hospitals participate in a range of exercises including discussion-based, such as tabletops, and operations-based such as drills, functional and full-scale exercises. These exercises can be isolated within the hospital or be part of a larger community, coalition or statewide exercise, such as an airport mass casualty exercise. When planning an exercise, the organization should review past training and exercises for types, objectives, partners and areas for improvement. Community exercises should be assessed for possible involvement and collaboration, to meet facility exercise requirements. The hazard

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vulnerability analysis should be reviewed for potential needs and to ensure consistency with the overall emergency preparedness strategy. Exercise design and development begins with establishing a planning team. This team determines potential exercise objectives that test each of the critical areas of emergency management: Communications, Resources and Assets, Safety and Security, Staff Responsibilities, Utilities Management, and Patient Clinical and Support activities. The team may also identify appropriate target capabilities such as medical surge, mass fatality management or volunteer management to be evaluated during the exercise. After conducting the exercise, an exercise debriefing or “hot-wash” should be conducted, to identify deficiencies and opportunities for improvement. These deficiencies are communicated to the EM Committee for improvement monitoring and EOP/ERP modification. Subsequent exercises should include objectives written to evaluate the effectiveness of plan improvements.

REFERENCES 1. Rubin JN. Recurring pitfalls in hospital preparedness and response. Journal of Homeland Security 2004, January. Retrieved August 2, 2006, from http://www.homelandsecurity.org/newjournal/articles/rubin.html. 2. PricewaterhouseCoopers’ Health Research Institute. Closing the seams: Developing an integrated approach to health system disaster preparedness. 2007. Retrieved November 2, 2007, from http://www.pwc.com/ extweb/pwcpublications.nsf/docid/9CEC1E9BDCAC478525737F005C80A9. 3. National Fire Protection Association. NFPA 1600 standard on disaster/emergency management and business continuity programs. 2007. Quincy, MA. 4. The Joint Commission. Comprehensive accreditation manual for hospitals: The official handbook. Oakbrook Terrace, IL: Joint Commission Resources; 2014. 5. Accreditation Canada, Qmentum Program. Standards: Leadership, Section 14. 2014. 6. Canadian Standards Association. Z1600–08: Emergency Management and Business Continuity Programs. 2008. Available from http://www.driecentral.org/2008-Z1600.pdf. 7. American College of Health Executives. Policy Statement: Healthcare Executives’ Role in Emergency Preparedness. Healthcare Executive Sep/Oct 2010. 8. U.S. General Accountability Office. Catastrophic disasters: Enhanced leadership, capabilities, and accountability controls will improve the effectiveness of the nation’s preparedness, response, and recovery system. 2006, September. Retrieved September 10, 2006, from www.gao.gov/cgi-bin/getrpt?GAO-06-. 9. Trust for America’s Health. Ready or not? Protecting the public’s health from diseases, disasters, and bioterrorism. 2007. Retrieved December 18, 2007, from http://healthyamericans.org/reports/bioterror07/Bio TerrorReport2007.pdf. 10. The Joint Commission. Health care at the crossroads: Strategies for creating and sustaining community-wide emergency preparedness strategies 2003. Retrieved December 12, 2007, from http://www. usaprepare.com/ep3-12-03.pdf. 11. Planning for emergencies in healthcare facilities. 2010. Retrieved February 3, 2014 from http://www.public. health.wa.gov.au/3/1370/2/planning_for_emergencies_in_health_care_facilities.pm. 12. U. S. Department of Labor. Occupational Safety and Health Administration. Best practices for hospital based first receivers of patients from mass casualty incidents involving hazardous substances. 29 C.F.R.1910 120. 2006. Washington, DC. 13. Agency for Healthcare Research and Quality. Altered Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc; 2005. Online at http://www.ahrq.gov/research/altstand/. 14. Krisberg K. Public health preparedness drills reap benefits, concerns. The Nation’s Health 2003;33. Retrieved August 2, 2006, from http://www.medscape.com/viewarticle/46327.