Orlando Health’s journey toward effective disaster preparedness began more than 20 years ago. As the Level One Trauma Center at Orlando Health Orlando Regional Medical Center (ORMC) grew and developed into the busiest in Florida, we recognized our likely role as the primary referral center in the event of a major disaster in Central Florida. In 1996, our hospital disaster plan was only five pages and did not even include the words “surgery” or “trauma.” The plan addressed the intake of victims into our emergency department, but not the multiple details necessary for what would today be considered a comprehensive hospital disaster plan. Recognizing the inadequacy of our disaster preparations, we convened a multi-disciplinary committee of surgeons, emergency medicine physicians, anesthesiologists, intensivists, nurses, respiratory therapists and administrators to begin the process of defining how we would respond to an influx of multiple casualties. Over the past 20 years, that initial disaster plan has grown and evolved into a strategic plan that is now hundreds of pages long, and influenced by our real-world disaster responses, our frequent disaster exercises / drills and the changing world in which we live. Our hope in this chapter is to provide you with an overview of our journey so that you can begin or augment your own preparations for disaster incidents.
In creating a comprehensive hospital disaster plan, our initial concern was for natural disasters. This was stimulated by the memory of Hurricane Andrew in 1982, a series of tornadoes that struck Central Florida in 1998 and three major hurricanes that struck Central Florida during a six-week period in 2004. With the tragic events of September 11, 2001, we, along with the entire United States, found ourselves faced with the growing threat of international terrorism. Bombings in London and Madrid, the threat of biological attacks following the Anthrax scares in both Washington, D.C., and Florida, the worldwide threat of infectious agents such as Middle Eastern Respiratory Syndrome (MERS) and Ebola, and concerns for terror-related chemical weapons and nuclear “dirty bombs” expanded our focus to the vast multitude of potential disaster threats. Given the proximity of our hospitals to high-profile amusement parks and sports stadiums in Orlando, we began to perform threat analyses, identifying public and private venues that could become potential targets in our community. As we considered each of these potential mass casualty situations, we modified our disaster plan accordingly and practiced the skills necessary to respond to such incidents in our disaster exercises. This included purchasing specialized equipment for decontamination of victims injured in a biologic, chemical or radioactive disaster as well as personal protective equipment for our hospital staff. We also determined how we would rapidly increase our patient bed capacity (“surge” capacity) to accommodate a sudden inflow of 100 or more casualties. Most importantly, we created an Office of Emergency Preparedness with experienced, full-time staff devoted to ensuring that each of our hospitals and clinics is prepared to respond appropriately to any mass casualty event.
Following the mass shootings in Columbine, Colorado (1999); Blacksburg, Virginia, at Virginia Tech (2007); Fort Hood, Texas (2009); Aurora, Colorado (2012); Sandy Hook, Connecticut (2012); and San Bernardino, California (2015), many of our disaster exercises have focused on active shooter scenarios, an increasingly common cause of mass casualties. In fact, in March 2016, three months before the Pulse nightclub tragedy, we participated in a three-county, 15-hospital, annual disaster exercise where the scenario was an active shooter on a local university campus. More than 500 volunteer victims participated in this exercise. The lessons we learned from this and previous exercises allowed us to continuously refine and improve our disaster preparedness and response capabilities, ultimately culminating in our response on the morning of June 12, 2016.
Exercises (Drills) and Training
Benjamin Franklin once said, “If you fail to plan, then you are planning to fail.” There are thus three “Ps” to successful disaster response: planning, preparation and practice. While a disaster plan may look great on paper, it can fall apart rapidly in its execution if the team members involved have not practiced its implementation. Successful disaster planning requires both table-top AND live exercises. We are frequently told by team members from other hospitals that their administrators are reluctant to hold live exercises as they are costly and interrupt normal patient care. Such thinking is penny-wise and pound-foolish. It would be a tragedy for patients of a disaster incident to succumb to their injuries because a hospital had not appropriately planned and prepared to provide for their care. At Orlando Health, our hospital administrators have been supportive and actively participate in our disaster exercises, recognizing the value of such planning in advance of a catastrophic event.
Our training exercises over the years have ranged from natural disasters to biologic / chemical / radioactive attacks to large-scale bombings and mass shooting incidents. Our choice of training scenarios has been guided by our threat analyses, developed in conjunction with local, state and federal law enforcement agencies. We perform a minimum of one full-scale, multi-county drill and two hospital-wide disaster exercises each year (one of which is typically a table-top exercise). We notify the hospital staff of the date of a disaster exercise, but keep the details of the scenario confidential so that they become known only as the scenario unfolds, just as a true disaster incident would occur. While we tend to hold disaster exercises at times of the day and on patient units that are least disruptive to normal patient care, some exercises are held without warning and may occur at night and on weekends. As the Pulse nightclub tragedy demonstrated, disasters and mass casualty events do not respect the normal 9:00 am to 5:00 pm workweek. All team members and shifts should have experience in practicing disaster response and becoming familiar with the hospital disaster plan.
In each of these exercises, we drill to fail to both test multiple aspects of our disaster response plan and uncover areas for potential failure. As an example, one scenario began with a tornado on a local interstate highway causing a semi-tractor truck carrying chlorine cylinders to overturn. A leaking 1-ton chlorine cylinder threatened to engulf both the hospital and a school bus carrying children that was involved in a nearby accident. This scenario allowed numerous aspects of our disaster plan to be tested, including multiple traumatic patient injuries, chemical exposure, hospital evacuation and involvement of both our pediatric and adult hospital facilities. Only through the use of complex disaster exercises such as this can a hospital truly begin to test its capabilities and staff, and identify where the hospital’s current disaster plan could fail. While our initial disaster exercises were limited to just our hospital, in recent years the full-scale community exercises in Central Florida have included hospitals from across five counties and numerous law enforcement and governmental agencies. For example, spurred by memory of the Pulse nightclub tragedy, our most recent community exercise included 2,000 participants, 85 agencies, 27 hospitals and 1,100 volunteer victims. (Examples of disaster exercise scenarios we have utilized are listed in Table 1.)
Recognizing the need to create an alternate treatment facility in the event of a catastrophic event or hospital failure, Orlando Health also has developed the capacity to deploy a field hospital if needed. Each year, our staff takes part in the annual Alternate Medical Treatment Site (AMTS) / Alternate Care Site (ACS) day-long event. Team members meet at our Emergency Preparedness warehouse, receive a safety briefing, set up and equip the AMTS/ACS tents, and participate in a training exercise. The team then demobilizes and packs the AMTS/ACS away for subsequent use as part of their training.
Over the years, we have learned the importance of developing relationships with local, state and federal agencies in disaster response. A real-world disaster event is not the time to be introducing yourself to law enforcement and government representatives for the first time. As a result, we have invited our local police, sheriff, fire, emergency medical services (EMS), Federal Bureau of Investigation (FBI) and Secret Service, among others, to participate in our disaster exercises to develop relationships with these agencies. We also have trained with the Florida National Guard to share capabilities, practice patient hand-offs and jointly become familiar with response efforts and equipment.
Real-World Incidents
Over the years, Orlando Health’s hospital disaster response plan has been tested in several real-world incidents. These events have included suspicious packages, electronic medical record downtimes / failures, multiple hurricanes, a suspicious white powder contained within a threatening letter to staff, and the Pulse nightclub tragedy. For most of these events, we have activated our Hospital Incident Command System (HICS) to direct the hospital’s response. These real-world incidents provide an opportunity to test our disaster plan under real-world conditions, train our hospital staff on their respective roles and gain valuable insight into our disaster plan’s successes and failures. We learn from these failures and revise our plan accordingly to account for these deficits in future events. We also have a low threshold for activating HICS and implementing our disaster response plan when our hospital bed capacity is severely stretched and patient safety is at risk. These opportunities allow our HICS staff to practice and maintain their disaster response skills so they are ready when a real-world event occurs.
Creating a Hospital Disaster Plan
In the 18 months following the Pulse nightclub tragedy, Orlando Health team members have had the opportunity to speak about disaster planning and response to more than 300 groups worldwide. We have learned tremendously from our discussions with other hospitals that have experienced similar mass casualty incidents. We also have been surprised by the considerable number of hospitals that have admitted they do not have a disaster response plan. Some have stated their plan is to immediately transfer victims to another larger hospital. This is never an appropriate plan. As the aftermath of Hurricane Katrina in New Orleans (2005) and Hurricane Irma in Miami (2017) demonstrated, all hospitals and skilled nursing facilities must plan to be self-sufficient until aid can be reasonably expected to arrive. This may take several days. In the interim, plans must be in place to provide food, water, power, sanitation and ongoing medical care to both existing inpatients and new victims of the disaster event. Failure to do so places the lives of patients and hospital staff at risk.
Emergency Preparedness Staff
As our corporate disaster response plan developed, we recognized the need for dedicated emergency preparedness staff. Two roles were created: Corporate Manager, Department of Emergency Preparedness and Emergency Preparedness Specialist. These individuals are responsible for all emergency response activities at Orlando Health.
Emergency Operations Plans
Orlando Health, like many hospitals or hospital systems, has numerous policies and procedures (P&Ps). Effective emergency preparedness is no different and also requires numerous P&Ps. These P&Ps are also known as Emergency Operations Plans (EOPs). Each EOP is created to address separate and distinct emergency situations. A hospital’s response to mass casualties from a natural disaster is different from that of an active shooter event or a bioterrorism attack. To date, our Office of Emergency Preparedness has created 33 separate, detailed P&Ps. These P&Ps each must be updated on a regular basis so that they remain both current and relevant. This requires a process for updating the P&Ps as needed.
Comprehensive Emergency Management Plan
The Comprehensive Emergency Management Plan (CEMP) is an overview document that summarizes how an organization intends to handle an emergency situation. It includes the basics of a disaster response that do not change from event to event. The P&Ps mentioned above are annexes to the CEMP, describe the response to specific situations and are included as addendums to the CEMP. This document is required not only by The Joint Commission, but also by our State Agency for Healthcare Administration. The CEMP should be updated at least annually and whenever major changes to the hospital’s disaster plan are deemed necessary. During the three hurricanes we experienced during a six-week period in 2004, we updated our fledging CEMP every two weeks as we learned new lessons about what did and did not work in our response to each hurricane’s arrival.
The CEMP is a document that should be developed in collaboration with local law enforcement and governmental agencies so that all are familiar with their expected roles and responsibilities in a disaster situation. Hospitals should check with their state agency’s health department to see if there are any requirements for CEMPs, and whether they are to be submitted annually to their authority having jurisdiction (AHJ). In Florida, the Agency for Healthcare Administration has an annual requirement for a CEMP to be updated and submitted to the AHJ.
After Action Report and Improvement Plans
After each disaster exercise or real-world event, the Office of Emergency Preparedness drafts an after action report (AAR) detailing the hospital’s response and any lessons learned. These lessons, and any identified changes to the hospital disaster plan, are outlined in an improvement plan (IP). Both documents are required by The Joint Commission. More importantly, they help equip a hospital for future disaster events. The size of these documents is less important than the content. Following the Pulse nightclub tragedy, multiple meetings were held to create the AAR/IP for the event. The resulting document was 51 pages and identified 66 areas for improvement. The Corporate Emergency Preparedness team places this information into an IP matrix for each hospital so that all improvement items from each of the individual AAR/IP documents can be implemented effectively.
Equipment and Supplies
Emergency equipment and supplies are essential commodities in disaster response. The Corporate Emergency Preparedness team is responsible for inventorying and maintaining all disaster supplies at Orlando Health. ORMC has supplies that are color-coded according to triage category and pre-positioned as necessary. Additional supplies are stockpiled in the Corporate Emergency Preparedness warehouse for distribution as required during a disaster event. These assets are inventoried at least once a year and the team continues to build out supplies and resources to ensure that the organization is ready to respond to an emergency.
Summary
Over the past two decades, we have diligently worked to ensure that Orlando Health is prepared to respond to the worst that nature or man can cause. This has not been easy and has required significant collaboration, coordination and support from both those internal and external to the organization. We have recognized that disaster preparation is both continuous and additive. A single disaster exercise does not adequately prepare a hospital to respond. Each exercise identifies both strengths and weaknesses. Correction of these weaknesses makes subsequent disaster responses better, but new weaknesses always will be discovered as no two events are ever alike. Successful disaster response takes people, processes, resources, equipment, time and money to adequately prepare for and respond.
