Mock Drills in Hospitals- How to conduct mock drills?

Internal disaster management in hospitals is very critical. Hospitals need to prepared to handle emergencies and conduct regular mock drills to check the protocols, awareness of staff and also the equipment.

1. CAHO MASTERCLASS SERIES Mock Drills How to Conduct a Mock Drill? Dr. Lallu Joseph Quality Manager, Associate GS, CMC Vellore Secretary General, CAHO

2. Learning Objectives 2 Workplace Emergency Phases of emergency management Steps to emergency preparedness Mock drills and types How to conduct mock drills Mock drill calendar Mock drill as a safety indicator

3. What is a workplace emergency? A workplace emergency is an unforeseen situation that threatens your employees, patients or the public, disrupts or shuts down your operations or causes physical or environmental damage. 3

4. Emergency in a Hospital 4 Risk to Health and life. Property. Environment. Causes Fire and explosion. Toxic/ Flammable gas leaks. Structural collapse. Natural and man-made disasters . Consequence Escalates to crisis. Risk to business continuity.

5. Four Phases of Emergency Management 5 To protect people and property in the wake of an emergency, disaster or crisis. To rebuild after a disaster and return back to normal. To  take actions ahead of time  to be ready for an emergency. To  prevent  emergencies and take steps to minimize their effects. Phase 1: Mitigation Phase 2: Preparedness Phase 3: Response Phase 4: Recovery

6. Five Steps to Emergency Preparedness 6 1. Know the risks. 2. Build the team. 3. Prepare the plans. 4. Test the plans. 5 Update everyone.

7. 1. Know the Risks 7 Fire Bomb threat Failure of utilities Flood Earthquake Structural collapse Medical emergency

8. Risk Quantification Matrix 8

9. Risk Score 9 Threat Likelihood (L) Consequence/ Severity of Impact (S) Risk Fire 4 4 16 Floods 2 3 6 Infant abduction 2 4 8 Bomb threat 1 5 5 Risk Cut-off Values 1 - 5 Low risk 6 - 12 Medium risk 15 - 25 High risk

10. 2. Build the Team 10 Every individual may have a role as a first responder. Subject matter experts from different departments should help in overall span of the plan, including the four phases of emergency management cycle: Mitigation: Preventing emergencies and minimizing the effects if an event occurs. Preparedness: Identifying efforts to prepare for the event. Response: Planning efforts to respond safely to the event. Recovery: Identifying actions needed to return the facility to normal operations. Representatives from safety, security, HR, PR, facilities, operations and top management should be involved from the start.

11. 3. Prepare the Plans 11 Common mistake - We often think that the bigger the document, the better it is! And it is often conducted ( in vacuum), with no input from the end users. Emergency plans should be the product of an inclusive team instead of an individual or group.  It should be concise as to the threat, risks and the mitigation steps. It should have an outline of each emergency: Whom to call, their contact number and what should an individual do to ensure their own safety and safety of others.  It should have a description of the specific tasks of all individuals. Note: If the plans are already in place, then the team would form a good review committee.

12. 4. Test the Plans 12 Will the plan work? How do you know? Two methods to test the plan Lecture and response sessions. Tabletops. Lectures and response sessions allow stakeholders to ask questions, find solutions to bridge the gaps in the plans. Tabletops allows participants to simulate the response and not to actually physically perform the actions needed. And discussion about everyone’s responsibilities during the tabletop help in understanding who is responsible and what they do. The most important element is identifying weak links or action items. Note: Drills should be performed after validating the results of the lecture and tabletop sessions. 

13. 5. Update all Staff 13 First responder - All staff. Communication - All staff. Codes - All staff (Code Red, Pink, Violet, Blue, Black). Specific and focus training to different groups: Handling hydrants - Fire and security teams. Evacuating sick patients - Nurses, doctors and technologists.

14. Mock Drills and Types

15. Culture of Drills can Save Lives One of the most gripping stories of disaster drill planning is the story of Rick Rescorla. Rescorla safely led 2,687 Morgan Stanley employees out of the World Trade Center’s South Tower on Sept. 11, 2001. As Morgan Stanley’s security chief, he was one of the few who saw the vulnerability of the towers. After surviving the 1993 terrorist attack on the Twin Towers, Rescorla was certain they would eventually be attacked again. He made Morgan Stanley employees practice orderly and swift evacuation drills once in every three months. Rescorla’s foresight and leadership saved lives. 15

16. What is a mock drill? 16 Mock drill  is a  practice  to save life/ lives in real time situation of any kind of danger or calamity that occurs suddenly with no time or very little time to react.

17. Why mock drills? To review the emergency preparedness plan of the organisation . To evaluate standard operating procedure. To check the understanding of the staff on their roles and responsibilities.  To enhance coordination among the emergency support functions and various departments. To check the workability of the systems and installations for mitigating the risk. For example: Fire alarms and detectors. To understand gaps in the system to remove deficiencies and to execute further improvement plan to avoid life and property loss. To enhance the ability to respond faster. 17

18. Importance of Mock Drills in Hospitals 18 Patients are weak and require external help to evacuate.  Presence of many relatives and visitors. Less staffing and different categories of staff. Presence of equipment that adds to vulnerability.

19. Classification of Mock Drills 19 ‘In-house’ mock drill: It is conducted within the organisation without involving outside agencies for any sort of response, apart from being observers. ‘Out-house’ mock drill: It involves external stakeholders like local, district or State jurisdiction, in order to assess the response mechanism and to update the SOPs of the organisation. Depending on Stakeholders Involved

20. Classification of Mock Drills 20 Pre-announced drills It is conducted after informing staff about the drill. It involves: Establishing new protocols. Performing a drill for the first time in the area/ department. Performing a drill in sensitive/ vulnerable areas. Unannounced drills It is conducted after the staff are clear about the mock drills and have attained a certain level of proficiency. Based on the Level of Preparedness

21. Categories of Drills and Exercises 21 Tabletop exercise Functional drill Full scale drill

22. Three Basic Types of Drills 22 Tabletop Exercise (TTE) Facilitated analysis of an emergency situation in an informal and stress-free environment. Simplest Functional Drill Simulates an emergency in the most realistic manner possible, short of moving real people and equipment to an actual site. Medium complexity Full Scale Drill As close as possible to the real event, it takes place on location using equipment and personnel that would be called upon in a real event. Complex

23. Table Top Exercise (TTEx) It is a very useful training tool. It is a precursor to mock exercise. It is largely a discussion guided by a facilitator (or sometimes two facilitators who share responsibilities). Is like a problem-solving or brainstorming session. Unlike a functional exercise, problems are tackled one at a time and talked through without stress. It is an excellent tool for understanding the awareness of staff. 23

24. Table Top Exercise (TTEx)- Virtual Instead of physical TTEx Very easy to conduct Can have many participants Excellent tool for simulating the situation Can be a great tool to evaluate understanding and response Can be hybrid- mix of both physical drill and interview 24

25. How to Conduct Mock Drills?

26. Pre-requisites for an Effective Programme Regardless of the size, complexity and risk involved in the drill, an effective drill/exercise should include the following essential elements: Adequately trained team personnel/equipment required/logistics supported. Well-defined process for drill design/conduct. Definite criteria for evaluation. Qualified evaluators. 26

27. Purpose of Coordinating Conference 27 To delineate: Objectives of mock exercise. Scope of exercise. Selecting the type of emergency/ crisis for mock exercise. Selecting the coordinator/lead. Deciding the date and venue for tabletop/ mock exercise. To identify involvement of p articipants: Players in a drill/exercise. Departments. Number of participants. To invite media for coverage (If required).

28. Steps to Conduct Mock Drill 28 Pre-drill briefing - Scenario narrative. Positioning of independent observers. Drill initiation. Drill activity. Drill termination. Drill critiquing. Drill evaluation: Observations and recommendations. Feedback from the participants. Evaluation. Drill evaluation report.

29. Pre-drill Briefing 29 Announced drill Pre-drill briefing with the participants to explain the scene and the ground rules for executing the drill. Review of operational procedures and safety precautions with the participants. Briefing of the drill procedure. It involves briefing by the coordinator to the drill team and the observers.

30. Positioning of Independent Observers 30 Independent observers should be trained and conversant with the protocol. Independent observers should be deployed at key locations of the mock drill. Observers should be provided with checklist/ evaluation format of the response expected which is drawn from the protocol. Response mechanism during the drill should be closely observed. C onformances and gaps identified should be documented.

31. Drill Initiation The drill should be initiated by the lead/ coordinator in accordance with the planned drill scenario. The scenario narrative should describe the events leading up to the time the exercise begins. It should set the scene for later events and capture the attention of the participants. It could include answers to questions such as: How was the information relayed? What damages have been reported? What was the sequence of the events? Was there any advance warning issued and how long before the event? What factors influenced emergency procedures? 34

32. Drill Activity After the drill initiation, every activity and response should be carried out according to the scenario and SOPs. During the drill, independent observers should document all activities based on the criteria of the drill scenario. Each drill should have specified areas of evaluation so that all actions required are observed and evaluated. 35

33. Observations d uring the Mock Drill

34. Observations d uring the Mock Drill

35. Deviation Checklist

36. Drill Termination 39 The drill scenario should be allowed to continue till completion of the stated objectives. The drill should be terminated by the lead/ coordinator in accordance with the plan.

37. Critiquing Drills 40 Following the drill, the lead/ coordinator should hold a session to critique the drill along with the observers and drill team. It should be two-way communication between the drill team and the participants. The process should first involve self-evaluation by the participants, then a discussion of the evaluation notes, checklists, actions taken and the overall drill performance. The critical analysis should highlight the successes, shortcomings of the drill scenario, personnel’s actions and equipment accessibility. The critique should include an analysis of the expected versus the actual operating actions. The incident commander should determine whether the drill objective was met or not.

38. Drill Evaluation Report 41 It i s the act of observing and recording mock drill activity, by comparing the performed actions against the drill objectives. Evaluation should broadly have the: Details of the drill and gaps in conducting the drill with limitations. Observations and recommendations: Report the gaps identified with suggestive actions to improve the preparedness. Feedback from the participants.

39. Example   Expected Actual Did the staff shout for help Y Y Did the staff 1 try to put the fire with nearest fire extinguisher Y Y Did the staff 2 inform the fire office Y Y Did the fire team arrive on time Y Y Did the Electrical team arrive on time Y N Did the AC team arrive on time Y N Did the Medical Gas team arrive on time Y N Did the STSG arrive on time Y Y Did the Fire officer announce level 2 Y Y Did the Charge nurse assign staff for the patients Y Y Did the security clear the way for the fire team to arrive Y Y Total opportunities 11 Deviation 3 Variation in mock drill (In %) 27%

40. Template for Evaluation of Mock Drills 43 Introduction Scope and objectives Drill/exercise scope Participants/participating agencies Mock drill objectives Scenario summary Initial conditions Sequence of events Critique Scope of evaluation Notification and communications Operations and field responses Equipment and facilities Standard operating procedures Drill-related problems Other observations Outcomes Significant findings/successes Loopholes/deficiencies/omissions Opportunities for improvement Plan of action for corrective actions

41. Follow-up Activity 44 Reviewing the performance. Assigning responsibility to close the gaps. Documenting closures and presenting to committee. Ensuring timelines for closures.

42. Mock Drills Calendar 45 Emergency drills and exercises should be conducted regularly in a hospital to test the plan and to develop the capacity of staff to respond to an emergency/ disaster/crisis. Drills offer the opportunity to identify training needs, establish new reflexes and to teach through action, repetition and to update/change the plan.

43. Mock Drill Calendar - Example 46

44. Mock Drill Calendar - Example 47

45. Mock Drill as a Safety Indicator 48 Month Number of steps to be followed* Number of violations in protocol % of violation Jan 2017 54 24 44% May 2017 60 22 37% October 2017 59 15 25% Mar 2018 57 9 16% Aug 2018 57 8 14% *Number of steps to be followed need not be constant as it will vary according to the inclusion/deletion of protocols from the previous drill.

46. References Vivian C. McAlister, MB. Drills and exercises: the way to disaster preparedness, Can J Surg. 2011 Feb; 54(1): 7–8. Hospital and Health Facility Emergency Exercises Guidance Materials. World Health Organization (WHO) Regional Office for the Western Pacific with support from the European Commission Humanitarian Aid department (ECHO), 2010 https://blog.pocketstop.com/steps-to-conduct-a-fire-drill-at-work SOP on “Conduct of Mock Exercises”. National Disaster Response Force. Government of India. Ali, M., & Williams, M. D. (2019). No-Notice Mystery Patient Drills to Assess Emergency Preparedness for Infectious Diseases at Community Health Centers in New York City, 2015-2016. Journal of community health, 44(2), 387–394. Chou, W. K., Lin, C. H., Cheng, M. T., Chen, Y. C., & Shih, F. Y. (2019). The Value of Functional Exercise in Pediatric Mass- Casualty Incident Training.  Journal of acute medicine ,  9 (3), 118–127. Guidelines for Hospital Emergencies Preparedness Planning. Guidelines for Hospital Emergencies Preparedness Planning. 2002 5 steps to emergency preparedness for any disaster, Robert Lang, https://www.facilitiesnet.com/emergencypreparedness/article/5-Steps-To-Emergency-Preparedness-For-Any-Disaster--17186 49

47. Thank You!