Make your disaster drills effective

Drills can help your ED prepare for disaster. "The scenario you choose should be based on reality" says Robert Knies, RN, MSN, CEN, clinical nurse specialist. "In today's world, almost anything is possible anywhere-mass shootings in small towns, bombings of churches in any size community. You must also consider highway and railway incidents in terms of what is transported through your town."

It's impossible to be prepared for every possible situation, but drills have another purpose. "You can't possibly predict what the actual situation will be. The goal is to encourage staff to think on their feet and be creative with solutions," says Dunmire.

Here are some ways to make disaster drills more effective:

Know your objectives. Decide what your goals are for the drill, and then plan accordingly, says Jessie Moore, RN, MSN, CEN, ED Clinical Nurse Specialist at Veteran's Memorial Medical Center in Meriden, CT. "For example, if you want to use the drill to educate staff about their roles, your activities in planning and carrying out the drill will be different than if your objective is to "test the system," she explains.

Disaster drills can be used as either training exercises or to test the effectiveness of a drill. "The former is a good tool as a final part of a training program," says Auf der Heide. "The latter should be designed to test the plan to identify potential weaknesses, and should be a prelude to revising the plan."

Schedule drills at all times. Disaster drills are typically held on the day shift, but a disaster can happen at any time. "Drills should be scheduled on all shifts and on both weekdays and weekends if possible," recommends Moore. Change of shift is a good time for a drill, since there tends to be confusion during that time, she adds.

Constraints in scheduling times for drills may include availability of victims, limitation of community resources, staffing patterns, and willingness to interrupt normal activities, Moore notes.

Key staff members should be given an opportunity to experience the role they will take during an actual disaster. "Have different people who may be in key roles practice at that role," says Knies. "If you have several supervisors, have them each take their role at different drills."

Meet JCAHO requirements. JCAHO requires at least two exercises be conducted each year, held no closer than four months, and no further than six months apart, notes Moore. "They do not consider tabletop exercises sufficient to meet the requirement," she says. "You must enact the procedures in your plan, and preferably have real victims. They also look favorably on using both internal and external scenarios, and in our recent visit, showed a great interest in Hazmat Disasters."

Performance during the drill must be evaluated. "This is a new item on the JCAHO assessment," notes Moore. "At my institution, we critique each drill performance by having named observers objectively assess performance in key areas using a predetermined checklist."

The checklist is designed to be quantitatively scored, so that overall performance and improvement in subsequent drills can be tracked. "Each drill critique also brings to light problems not previously anticipated," says Moore. "These are placed on an ongoing Issues List, and tracked monthly until they are resolved, and then reassessed with the next drill performance."

"Real" victims need to be used at least part of the time, to satisfy JCAHO requirements. "Use of real people moulaged as victims helps significantly to promote realism," says Moore.

At the University of Pittsburgh, real victims are used during drills, such as a recent airplane accident drill. "The participating hospitals used upwards of 100 blunt trauma victims who were all moulaged. We also involved other people to act as family members hysterical attempt to access the facility," says Susan Dunmire, MD, FACEP, assistant professor of emergency medicine at the University of Pittsburgh School of Medicine. "Reporters" attempted to access the ED, to determine if security was able to stop that access, she adds.

High school students are generally recruited for this task. "As part of their health class, students are allowed to take a few hours for a field trip, and usually do quite well with this," says Dunmire.

Involve non-ED staff. Staff should be involved in planning and carrying out the drill. "Staff members from departments outside the ED are extremely important, as the ED staff frequently has a good understanding of what disaster response is and should be, but other units in the hospital are not as well prepared," says Moore. "One way to do this is to have the internal drill be on different units, and involve staff from that unit in the planning. That way, they have an investment in helping the drill to carry out the desired objectives."

In past years, Veteran's Memorial found that their drills needed to involve other departments. "We found we weren't carrying out the drill far enough to allow ancillary services to see the victims and determine their resources and needs," says Moore. "Now, we have specific objectives for each drill that state to what extent the drill will be enacted."

Take your time. "Most drills tend to be conducted too swiftly, often due to constraints on victims or resource availability," says Moore. "More realism is present if staging of victim transport/arrival is carried out as it would be in a real scenario situation."

Involve local community. At Veteran's Memorial, the fire department personnel are involved at both the external and internal disaster scenarios, says Moore. "Seeing the fire department in full gear come into your department lends a sense of realism," she explains. "At our last drill, several parents saw the fire trucks and ambulances and came rushing in a panic state, so I guess we hit the realism button.'

Consider acts of terrorism. This scenario is commonly overlooked in EDs, which is a mistake, says Colonel Edward Eitzen, MD. "The threat of biological or chemical terrorism is here now and is increasing in likelihood, and lack of preparation will mean that more people will die who might have been saved," he adds.

When preparing for a biological or chemical disaster, protecting the ED from contamination is a major concern. "It's necessary to separate people who were truly exposed from hysterical individuals or those who just believe they were exposed," says Eitzen. Protection of health care providers, barrier precautions with transmissible infectious agents, and stockpiling of antibiotics, antitoxins, and antidotes, are other concerns, he notes.

Mass chemical or biological casualties can overwhelm the capacities of any ED, says Eitzen. "A biological attack with anthrax in a large city could kill or incapacitate hundreds of thousands of people, overwhelming numbers and demands on healthcare resources," he stresses. "Disaster drills should be coordinated between local, state, and federal agencies."

Consider internal victims. At University of Pittsburgh, a drill was held that simulated a structural collapse, with 25 victims, requiring some of the ED staff to go to another floor. "When the disaster is within the hospital itself, it's extremely stressful on staff. They tend to get disoriented when they are up on a floor not used to, and may forget about the ABCs of trauma," says Dunmire.

A response team in case of internal disaster includes the administrator on duty and several ED nurses and physicians. "We split up the staff. Thirty percent go to the site and are replaced by incoming nurses," says Dunmire. "The response team is just a temporary measure until paramedics get there, but it's important for staff to organize what equipment they need to take with them."

Address radiation exposure. If your facility does radiation therapy, the ED should go beyond the regulatory requirements for drills, says Knies. "If a fire or boiler explosion occurs where the isotopes are stored, the rest of the facility needs to be able to deal with that," he explains.

During University of Pittsburgh's radiation drill, one patient was a blunt trauma victim with radiation exposure. "That presented an interesting dilemma for us, because our decontamination room is not our trauma room and doesn't have the equipment," Dunmire explains. "So, we had to decide on the spot to keep the patient in decontamination and move equipment in as necessary." As a result, the ED created a mini-response cart to use if that situation came up again, she says.

Tailor scenarios for your ED. Go beyond standard scenarios, such as plane crashes or schoolbus accidents, and tailor drills to specific scenarios for your ED, suggests Knies. "The scenarios should be as specific as possible, in relation to internal and external site and community potentials," he says.

Make drills realistic

To be effective, drills should be as realistic as possible. "One of the biggest obstacles to carrying out a realistic drill is the attitudes of staff on duty," says Moore. "Disaster drills are often seen as a bother that interferes with `real' patient care. Care of the real patients should never be compromised, but we should take the stance that emergency preparedness is vitally important, and use the opportunity to educate those patients and families in the ED that we take this community responsibility very seriously."

If drills are not realistic, they will not be as effective, emphasizes Moore. "Simulations need to be carried out to the degree that you can assess the resources needed, including beds, staff, and all ancillary services," she says.

Be as realistic as possible. Disaster scenarios should be chosen that reflect potential real scenarios specific to your setting, says Moore. "They should include both natural catastrophes and other types, such as explosions and mass transit mishaps, which can happen anywhere," she notes. "To be most realistic, involve community public safety agencies and industry representatives."

Problems to simulate in a drill include overloading of the hospital closest to the disaster site, overloaded phone circuits, large numbers of phone calls inquiring about the missing (or those thought to be missing) or asking for advice, the presence of large numbers of news reporters, loss of municipal power/water, and back-up generator failure, says Erik Auf der Heide, MD, MPH, FACEP, assistant professor in the department of emergency medicine at Emory University School of Medicine in Atlanta.

Assess staffing needs during the drill. A realistic assessment of the normal activities of the affected hospital departments is necessary. In some instances, extra staff may need to be scheduled to prevent the drill from interfering with patient care.

"This will enable the staff `enacting' the care of drill patients to do so with less stress and feelings that they are abandoning the patients who `really need care'," says Moore. "This coverage needs to be carefully considered, as the real disaster will often strike when no extra coverage is on."

But don't allow the drill to interfere with care of actual patients. For major drills, it may be necessary to give advance notice in order to staff adequately. For an airplane crash drill, area hospitals were notified of the drill in advance. "Each got from 10 to 20 victims, but that number can still be overwhelming when you are having a busy day in ED," says Dunmire. "If you know about the drill ahead of time, you can cordon off a particular area to deal with disaster victims so they don't interfere with patient flow."

Include enough victims. "In many drills, there are only five or 10 victims, and, in real situations, most facilities can handle that many, so a disaster might not be called," says Knies. "The problem is getting enough volunteers to play victims. We have done `paper drills,' where we put the patient information on a stretcher, a disaster chart is generated, and the stretcher proceeds through to the necessary areas, such as the OR, CAT scan, or the morgue."