Hurricane Scenario: Lessons Learned - The 2012 Integrated ...

Patient Movement Lessons Learned

AGENDA
Welcome
Introduction - The Continuum of Patient Movement
Block 1 - Pre-Incident Planning
Block 2 - Patient Movement Response
Block 3 - Post Landfall
Block 4 - Lessons Learned Discussion
Patient Movement Track – Lessons Learned

INTRODUCTION
• Panel Members:
• Texas Dept of State Health Services: Rick Bays
• LA Dept of Health and Hospitals: Dr. Roseanne
Prats and Dr. Jimmy Guidry
• Air National Guard: Col Jackie Nave
• VA FCC: William Bossert
• USNORTHCOM: Bill Macchi
• USTRANSCOM: CAPT Corley Pucket
• HHS: Joe Lamana
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective
2008 Public Health
Emergencies
• Yearning for Zion Ranch
• National Salmonella Outbreak
• 1 Tropical Storm (Edouard)
• 3 Hurricanes (Dolly, Gustav, Ike
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Successes
• Pre-deployable Teams
• FEMA Ambulance Contract
• Contracted Medical Staff
• Federal & State Integration
– DMAT
– DMORT
– FMS w/staff
– IRCT
– NDMS
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Successes
• EPAP & Pharmacy Contracts
• Contracted EMS (Ambulances & Staff)
• Nursing Homes as Shelters
• Contracted Shelter Support
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Challenges
• Evacuation
– Enhanced Patient/Evacuee Tracking
– Priority of Patient Evacuee Movement
– Air Ops – NDMS & TMF Link
– Definition of Patient in NDMS
– Transportation Asset Management
– Education & Training
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Challenges
• Sheltering
– Acuity of Evacuees in Shelters
– Using Nursing Homes as Shelters
– FMS Not Equipped for Acuity
– FMS Wrap-around
Services
– Renal Dialysis
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Challenges
• Repatriation
– Patient/Evacuee Tracking
– Short Term -vs- Long Term Sheltering
– Patient Assessment
– Standard of Care
– Transportation and Medical Oversight
– Public Health and Medical Infrastructure
Patient Movement Track – Lessons Learned

Hurricane Response Lessons Learned
Texas Perspective Challenges
• Command & Coordination
– Staff Readiness
– Staff Fatigue, Multiple Emergencies
– Continuity of Operations
• Policies/Procedures/Processes
• Communications
Patient Movement Track – Lessons Learned

Medical Institution
Evacuation Plan
Lessons Learned
Dr. Jimmy Guidry, MD
Dr. Rosanne Prats, MHA, ScD
Patient Movement Track – Lessons Learned

MIEP: Catastrophic Planning
• Relocation of entire hospitals
• Concurrent evacuation of multiple hospitals
• Realistic Expectation: blend of both SIP and
EVAC
Patient Movement Track – Lessons Learned

What is the potential throughput?
Number of Parishes: 12
Number of Hospitals: 60+
Regions 4,5: 624 patients
Regions 3,4:
343 patients
Anticipated Planning Range: low - high
Regions 1,3,9: 1063 patients
343 - 1063 (reasonable “worst case” planning scenarios)
Patient Movement Track – Lessons Learned

Patient Evacuation via NDMS
LOCAL
HOSP
MSN
PMR
M
S
N
Regional
Coordinator/
AE Liaison
Ambulances dispatched
to hospitals and return
to the APOE
State EOC/JPMT
P
M
R
MSN
PMR
Mission
Built
APOE/AMP
Ambulance
Control/Staging
TRANSCOM
CRE
GPMRC
P
M
R
AMC
(TACC)
M
S
N
Airfield
Incident
Commander/
AE CDR Element
Crews
Alerted
Mission Specifics
(MSN #, Times, Etc.)
AELT
MASF
CCATT
NDMS
HOSPITALS
Patient Movement Track – Lessons Learned
APOD/FCC

Patient Movement Track – Lessons Learned
GUSTAV & IKE RESPONSE

Evacuation and Sheltering
– Mandatory Evacuations Orders
• Gustav: 17 parishes
• Ike: 3 parishes
– Number of People Sheltered (numbers are
approximate and sourced from GOHSEP rolling sitreps)
Gustav
Ike
Gen Pop 25,000 2,841
CTNS 37,375 1,620
MSNS/FMS 7,637 329
Patient Movement Track – Lessons Learned

Gustav/Ike: Hospital Evacuations
Hurricane Gustav* Pre Storm Post Storm Total
Full Evacuation 38 7 45
Partial Evacuation 25 3 28
Total 63 10 73
Approximately 1000 patients evacuated pre-storm; 223 patients were evacuated post storm.
Hurricane Ike Pre Storm Post Storm Total
Full Evacuation 2 0 2
Partial Evacuation 3 0 3
Total 5 0 5
Approximately 30 patients were evacuated pre-storm; 0 patients were evacuated post storm
Patient Movement Track – Lessons Learned

Gustav/Ike: Nursing Home Evacuations
Hurricane Gustav Pre Storm Post Storm Total
Full Evacuation 94 2 96
Partial Evacuation 0 0 0
Total 94 2 96
8,401 residents evacuated pre-storm; 160 residents evacuated post-storm
Hurricane Ike Pre Storm Post Storm Total
Full Evacuation 2 1 3
Partial Evacuation 2 0 2
Total 4 1 5
210 residents evacuated pre-storm; 116 residents evacuated post-storm
Patient Movement Track – Lessons Learned

GUSTAV Medical Institution Evacuation:
August 31, 2008
State/ hospitals waited for almost two days before C-130s and AE
crews showed up at Region 5 AMP and Region 1 AMP.
Region 5 AMP
Chennault Airport
124 NDMS patients Regions 4
Acadiana Airport
34 Homebound patients
Patient Movement Track – Lessons Learned
Regions 3
Moved by ground/air
ambulances the NDMS
patients and homebound
patients to Region 1
Regions 1 AMP
Lakefront Airport
302 NDMS patients
81 Homebound patients

IKE (Modified) Medical Institution Evacuation:
September 11, 2008
Ike was an extremely large storm that clipped
southwestern part of the state. Landfall was in Texas
on September 13, 2008.
Region 5
Chennault Airport
6 patients flown out;
absorbed by
In-state hospitals
Patient Movement Track – Lessons Learned

Repatriation of NDMS patients and Medical
Special Needs patients
State
Number
of
Patients
Total
Number
Received
Total
Patients
Deceased
Total Patients
Left to be
Received
Total Patients in
CareFlite Que
Alabama 9 9 0 0 0
Arkansas 325 304 21 0 0
Kentucky 3 3 0 0 0
Mississippi 98 98 0 0 0
North Carolina 1 1 0 0 0
Oklahoma 30 29 1 0 0
Tennessee 8 8 0 0 0
Texas 86 84 2 0 0
Total 560 536 24 0 0
Source: DHH Repatriation Cell, October 2, 2008 (Kathy Kliebert)
Patient Movement Track – Lessons Learned

Patient Movement Track – Lessons Learned
LESSONS LEARNED

Lesson Learned: Interface Points are potential
areas for communication challenges
LOCAL
HOSP
MSN
PMR
M
S
N
Regional
Coordinator/
AE Liaison
Ambulances dispatched
to hospitals and return
to the APOE
State EOC/JPMT
P
M
R
MSN
PMR
Mission
Built
APOE/AMP
Ambulance
Control/Staging
TRANSCOM
CRE
GPMRC
P
M
R
AMC
(TACC)
M
S
N
Airfield
Incident
Commander/
AE CDR Element
Crews
Alerted
Mission Specifics
(MSN #, Times, Etc.)
AELT
MASF
CCATT
NDMS
HOSPITALS
Patient Movement Track – Lessons Learned
APOD/FCC

Extensive and Intensive planning required.
Conduct your planning meetings NOW.
Disaster Occurs
Emergency
Response Team
Advance
Element
(ERT-A)
DHS Regional Operations Center
(ROC)
Joint Preliminary Damage and Needs Assessment
Local
First
Responders
Alert
Mayor/County
Executive
Activates Local
Work with EOC
Volunteer
Organizations
Requests
Aid from
Governor
Activates State
EOC
Informs
Governor
Declares
State
Emergency/
Disaster
DHS
Regional
Director
Reports
To
DHS
Director
Contacts
Disaster Field Operations
Local State Federal
Emergency Support Functions
#1. Transportation
#2. Communications
#3. Public Works & Engineering
#4. Firefighting
#5. Emergency Management
#6. Mass Care, Emergency Assistance, Housing and Human Services
#7. Resource Support
#8. Health & Medical Services
#9. Search & Rescue
#10. Oil and Hazardous Materials Response
#11. Agriculture and Natural Resources
#12.Energy
#13 Public Safety and Security
#14 Long Term Community Recovery
Patient Movement Track – Lessons Learned
#15 External Affairs
Provides
Requests Emergency
Major Disaster
Declaration
Principal
Federal
Official
Joint
Field Office
Sets Up
Federal
Coordinating
Officer
Joins
Declares
Emergency/
Major
Disaster
Appoints
State
Coordinating
Officer
President
of the
United States

Lesson Learned: Multiple layers increases
opportunity for Data Corruption
Aeromedical Marshalling Point (AMP) C2 Structure
AMP Incident
Commander
Ground OPS
EMS
Air OPS
FACC/TALCE
Hospitals
DRC Designee
Patient Care
CASF/DMAT
Logistics
Airport/DHS-
FEMA
Ambulances
Hangar/Fuel/
Food/Water
Patient Movement Track – Lessons Learned

Lesson Learned: Understanding of
patients that can/ cannot be evacuated
• Patient groups that should be closely
evaluated for potential evacuation:
– Neonatal ICU
– Critical Care
– Dialysis
– Psychiatric
Patient Movement Track – Lessons Learned

Communication Challenges
• …The AMP has a MOG of 4…
• The tail will have lift-off at
• What do you mean by hyperbaric patient?
• GPMRC
• FCC
• CASF, MASF
Patient Movement Track – Lessons Learned

Lesson Learned: Identify, Quantify, and Qualify
critical assets
Critical Assets
AMP Incident Command
Ambulances
Medically Configured Military Craft
AE Crew
MASF
NDMS/DMAT
CCATT
Primary Entity
State and Federal footprint
Surge ambulances via contracts
Supporting Pre-deployed Equipment
Grant funds have been directed to each region to
purchase the grocery list of AMP package.
Patient Movement Track – Lessons Learned

Lesson Learned: Importance of Clearly
Articulated (yet brief) Processes
• Manifest Process
• Repatriation Process
Patient Movement Track – Lessons Learned

Thanks!
A Copy of the Plan and Forms can be found at:
www.lhaonline.org
Emergency Response Plan
Annex 3 – Sheltering/ Evac of Hospitals
Patient Movement Track – Lessons Learned

AIR NATIONAL GUARD Lesson Learned
ANG
AE CAPABILITY AND
RESPONSE
Col Jacqueline Nave
HQ NGB/A3O
Patient Movement Track – Lessons Learned 31

ANG Lessons Learned
• Early release or pre-positioning of T-10 WRM
equipment is essential to timely response from ANG
AE forces
• MASF on rolling stock enhances capability for
mission requirements
• MASF equipment set is not adequate for support of
medical special needs patients
• MASF augmentation team needed for 24 hour OPS
and large patient numbers
• Large amounts of cargo and pets decreased patient
on-load capabilities
Patient Movement Track – Lessons Learned

ANG LESSONS LEARNED
• Funding issues
• AELT embedded with State JOC and LNOs
was essential to effective communication
and patient tracking
• CRE must arrive prior to AE assets
• Resupply
• Communication with civilian authorities
Patient Movement Track – Lessons Learned

VA FEDERAL COORDINATION CENTER
NDMS Patient Reception-FCC
Dallas
Comparison
Katrina/Rita –Gustav/Ike
William Bossert
Patient Movement Track – Lessons Learned

Katrina/Rita
reception in a semi-vacuum
• Patient Reception team (VA staff; TX DMAT;
Fire Dept; DoD) recently exercised on C-130
hulk but never used
• Reception team prepared site not knowing
what number of patients and acuity were to
be received
Patient Movement Track – Lessons Learned

The HULK
Patient Movement Track – Lessons Learned

Katina – set up
Patient Movement Track – Lessons Learned

Katrina - Reception
Patient Movement Track – Lessons Learned

Katrina/Rita – reception site
• Reception site for Katrina – JRB,
Carswell Field, Fort Worth with City of
Fort Worth for transport support
• Reception site for Rita – Love Field,
Dallas, with City of Dallas for transport
support
Patient Movement Track – Lessons Learned

JRB Carswell
Patient Movement Track – Lessons Learned

Dallas – Love Field
Patient Movement Track – Lessons Learned

Katrina/Rita - equipment
• VA/DoD reception equipment used to set
up site (litters, litter stanchions, blankets,
pillows, chairs, tables, computers,
printers, fax machine)
Patient Movement Track – Lessons Learned

Gustav/Ike – a seasoned reception team
• Patient Reception Team – VA staff; TX
DMAT/NY DMAT; DFW airport concentric
circle Fire Dept support; DFW Emergency
Mgmt support; American Airlines; Red
Cross
• Reception team prepared site based on
experience from Katrina/Rita
Patient Movement Track – Lessons Learned

A United Nations of Responders
Patient Movement Track – Lessons Learned

Katrina/Rita – reception site
• American Airlines maintenance hanger – huge
space (enough for aircraft unloading inside a
hanger)
• DFW airport Office of Emergency Management
(well trained in mass casualty response); and
concentric circles for transport (ambulances,
fire fighters and paramedics)
• Bring ambulances in to hanger for close
transport of patients
Patient Movement Track – Lessons Learned

Huge Space
Ambulances in place in American Airlines hanger, out of
potential weather
Patient Movement Track – Lessons Learned

Gustav/Ike - equipment
• VA/DoD reception equipment +
– OWL (Over weight litters)
– Pediatric response equipment
– Pharmacy cache
– Communications equipment
– Airline transport equipment
Patient Movement Track – Lessons Learned

Pharmacy Cache
Site was “safety inspected” to include MSDS
Patient Movement Track – Lessons Learned

Ground Transport
Patients + equipment were too heavy to carry
Patient Movement Track – Lessons Learned

Issues
• Technology – use of Web-EOC
• MRSA
• Type of Patient
• Banding
• Where’s the plane???
Patient Movement Track – Lessons Learned

Just in time – infection control
Just in case
Patient Movement Track – Lessons Learned

Lots of Medical Equipment
CCATT team with patient + equipment
Patient Movement Track – Lessons Learned

Banding
Although arm banding not used for NDMS we were ready
Patient Movement Track – Lessons Learned

How do you keep 100 people engaged?
Patient Movement Track – Lessons Learned

USNORTHCOM
Mr. Bill Macchi
NORAD-USNORTHCOM Surgeon Directorate
SG Director of Operations
CDR Brian Tolbert, MSC, USN
NORAD-USNORTHCOM Surgeon Directorate
Chief, Medical Plans and Operations Division
250 Vandenberg Street, STE B-018
Peterson AFB, CO 80914-3800
Medical Operations Cell Phone: 719-554-0565
Patient Movement Track – Lessons Learned

USNORTHCOM
• Identified Issues of Constraint to AE Process
– The National Disaster Medical System (NDMS) is designed for
steady-state ops, not time-constrained crisis
• “In-Extremis AE”
– Cost will be “out of pocket” unless a signed and funded
Mission Assignment is provided
• Delays decision to move patients - Who Pays and When
– System defines DoD role to cover only APOE to APOD
movements
• Locals and States responsible to move patients from NDMS
facility to APOE
• FCC’s responsible to move patients from APOD to NDMS
facility
Patient Movement Track – Lessons Learned

USNORTHCOM
• Identified Issues of Constraint to AE Process
– Non-NDMS patients are put into the system for movement both
from or to a Non-NDMS facility
• Nursing Home patients, Special Needs Patients
• Non-NDMS facilities have no FCC affiliation for patient
regulation
– USTRANSCOM Force Structure for AE
• Active Duty force account for ~20% of overall capability
– limits throughput of patients- sources one APOE
without augmentation
• ~80% force requirement is Reserve and Guard personnel
– Need long lead time to mobilize Reservists for mission –
cost associated with mobilization is not there
• Alternative sourcing solutions needed
– Coordinated Title 32 and Title 10 AE
• Who is supported and who is supporting - How does the C2
work
Patient Movement Track – Lessons Learned

DoD Lessons Learned
CAPT Corley E. Puckett, MSC, USN
Deputy Command Surgeon
U.S. Transportation Command
Patient Movement Track – Lessons Learned
OPR: TCSG

2008 DoD Lessons Learned
• Most significant lessons learned
– Use of TRAC2ES Web
– Patient Reporting Requirements
– Medical Special Needs Patients
– APOE Support Requirements
– DHHS DMAT Strike Teams
– ANG Aeromedical Evacuation Unit
Patient Movement Track – Lessons Learned

2008 DoD Lessons Learned
• Use of TRAC2ES Web
• Using TRAC2ES Mobile GPMRC was unable to handle the large number of
PMRs
• GPMRC revised business processes to use TRAC2ES-Web
• GPMRC processed large number of PMRs for Hurricane Ike using TRAC2ES
Web
• Patient Reporting Requirements (TRAC2ES, GDSS, JPRT)
• Very difficult to obtain consistent info on patients evacuated
• DirMob4-Air assigned responsibility for patient reporting
• Contingency Response Element deployed to each APOE for Hurricane Ike
• Joint Patient Reporting Team (JPRT) deployed to each APOE for Hurricane Ike
• N-NC/TRANSCOM Patient Reporting CONOPS (pending approval)
• Medical Special Needs Patients
• DOD evacuated a large number of medical special needs patients in 2008
• Unique support requirements (OSL, medical supplies, adult diapers, etc)
Patient Movement Track – Lessons Learned

2008 DoD Lessons Learned
• APOE Support Requirements
• Contingency Response Element
• Flight Surgeon required to augment the MASF
• Additional trained medical personnel required to support the MASF
• Litter bearers
• DHHS DMAT Strike Teams
• DMAT personnel successfully integrated into MASFs for Hurricanes Gustav &
Ike
• USAF School of Aerospace Medicine to train 72 DMAT personnel for this
mission at the NDMS training summit in April 2009
• AMC/SG to provide required CCATT equipment for 2009 hurricane season
• ANG AE Units
• TX requested ANG AE units support their State coordinated evacuations
• ANG AE units operated APOE at Beaumont TX for Hurricanes Gustav & Ike
• Unity of effort required (Title 10 & Title 32 forces)
• Title 10 forces supported patient evacuation from Beaumont TX for Hurricane Ike
Patient Movement Track – Lessons Learned

HHS
THE CONTINUUM OF CARE
Joe Lamana
Department of Health & Human Services
Office of Preparedness and Emergency
Operations
Joseph.lamana@hhs.gov
202.260.7196
Patient Movement Track – Lessons Learned

Origination /
Disaster
Area
Origination /
Disaster
Area
Local
Federal ESF#8
Patient Movement Schematic
“The Continuum of Patient Movement”
Federal ESF#8
Patient
Transport
Begins APOE APOD
* Initial JPAT Entry /
EMR Encounter
* Notional / Desired Entry of Pt Info
NGB – EMAC / Title 32
FEMA Ambulance Contract
(Ambulances and Care Flight)
Ground / Air Transport
Hand-Off to Final
Destination Facility
State
DoD Mil Air
NDMS
Enters
TRAC 2 ES
APOD
Air Transport
Air Transport
NoTRAC 2 ES
NDMS
FCC
Exits
TRAC 2 ES
APOE
FCC
DoD Mil Air
NDMS
Destination
Site
Hospital / FMS
Traditional
EMR Encounter
Destination
Site
Patient Reentry
Transport Begins
NGB – EMAC / Title 32
FEMA Ambulance Contract
(Ambulances and Care Flight)
JPAT / EMR

Department of Health & Human Services
• Conducted After Action Review Conference
– Oct 08; Nashville, TN
– Over 100 participants from local, State and Federal
– Developed 5 work groups
• Patient Movement
• Fatality Management
• Command and Control
• Patient Care
• Veterinary Care
– Work will lead to ESF #8 CONOPS
• Planning not in synch with common operating picture
– Playbooks – share with operational teams
– Pre-scripted MAs – facilitate more rapid response
– Gap Analysis – validated with State/local; need to do better for
patient movement
• Modular design of NDMS assets
Patient Movement Track – Lessons Learned

1. Movement of Patient from Point of
Origin to First Receiver
Local
State
2. Hold/Care at Originating Facility
Support
Origination /
3. Disaster Movement Ground and Care / Air to Transport Medical
AreaSpecial Needs Shelters
Origination /
Disaster
Area
NGB – EMAC / Title 32
FEMA Ambulance Contract
(Ambulances and Care Flight)
DoD Mil Air
NDMS
Federal ESF#8
Patient Movement Schematic
“The Continuum of Patient Movement”
Air Transport
Federal ESF#8
Patient
Transport
BeginsPatient Evacuation Support
APOE APOD
* Initial JPAT Entry /
EMR Encounter
Medical Regulating
* Notional / Desired Entry of Pt Info
Enters
TRAC 2 ES
Air Transport
NDMS
FCC
Exits
TRAC 2 ES
7. Movement from
Reception Area to
Definitive Care or
Healthcare Facility
8. Hold, Care at Definitive
Care SiteDestination
Site
Hospital / FMS
Traditional
EMR Encounter
Destination
Site
Patient Reentry
APOD
Transport Begins
9. Movement from Healthcare Facility to Final Disposition APOE – Home of Record
Hand-Off to Final
Destination Facility
4. Reception, Hold,
Care at POE or AE
Marshalling Point
Area
5. Movement and In-
Transit Medical Care
from Point of
Embarkation to Point of
Debarkation
Patient Tracking
Patient NoTRAC Tracking
2 ES
6. Reception, Hold, Care at
POD Area
FCC
DoD Mil Air
NDMS
Patient Evacuation
Support
NGB – EMAC / Title 32
FEMA Ambulance Contract
(Ambulances and Care Flight)
Medical Regulating
JPAT / EMR