BB question

ORIGINAL RESEARCH
Education and Training of Hospital Workers:
Who Are Essential Personnel during a
Disaster?
Michael Reilly, MPH, NREMT-P;1 David S. Markenson, MD, EMT-P2
Abstract
Hospital plans often vary when it comes to the specific functional roles that are
included in emergency and incident management positions. Bioterrorism coordinators and emergency managers for 31 hospitals in a seven-county region
outside of a major metropolitan area, with urban, suburban, and rural demographics were surveyed to determine which specific functional roles were considered “essential” to their hospital’s emergency operations plans. Furthermore,
they were asked to estimate the percentage of their “essential” staff trained to
perform the functional roles delineated in the hospital’s plan. Responses were
entered into a database and descriptive statistical computations were performed.
Only three categories of hospital personnel were reported to be “essential” by all
hospitals to their emergency preparedness plans: emergency department physicians, nurse, and support staff. Training for overall “essential” staff ranged by
Correspondence:
hospital 73.6-83.3%. Some hospitals reported that these staff members have
Michael J. Reilly, M P H , NREMT-P
received no training in their anticipated role based on the hospital emergency
New York Medical College, School of
response plan. Allied health professionals and emergency medical techniPublic Health
rd
cians/paramedics (that are employed by hospitals) had the least amount of
SPH Bldg. 3 , Suite 100
training on their role in the hospital preparedness and response plan, 33.3%
Valhalla, New York 10595 USA
and 22.2% respectively. Without improved guidance on benchmarks for preE-mail: michael_reilly@nymc.edu
paredness from regulators and professional organizations, hospitals will continue to
lack the capacity to effectively respond to disasters and public health emergencies.
This manuscript and the data collection activities were
1. Assistant Director, Center for Disaster
Medicine, Assistant Professor of Public
Health Practice, New York Medical
College School of Public Health, Valhalla,
New York USA
2. Director, Center for Disaster Medicine,
Associate Professor of Public Health
Practice, New York Medical College,
School of Public Health, Valhalla, New
York USA
partially supported with fundingfrom the New York
State Department ofHealth through Health Research Reilly M, Markenson DS: Education and training of hospital workers: Who are
Inc., and the Health Resources and Services
essential personnel during a disaster? PrebospitalDisastM?rf2009;24(3):239-245.
Administration (HRSA), Bioterrorism—Hospital
Preparedness Program Cooperative Agreement
Introduction
(HRSA Grant #15-0282-04) to the Westchester Acute care hospitals and medical centers are a vital component of healthcare
County Health Care Corporation, Regional Resourceinfrastructure. Each day these facilities are relied upon to provide acute, rouCenter, and a contract (CMC-6385) with New York tine, and primary health care to millions of Americans. In times of public
Medical College.
health crisis, the acute care hospital will be expected to render a prompt and
Keywords: disasters; functional roles; hospital
preparedness; personnel; training
Abbreviations:
EMS = emergency medical services
E M T = emergency medical technician
FEMA = Federal Emergency Management
Agency
HICS = hospital incident command system
HRSA = Health Resources and Services
Administration
ICS = incident command system
NIMS = [US] National Incident
Management System
OSHA = [US] Occupational Safety and
Health Administration
PPE = personal protective equipment
May-June 2009
competent response to assist in minimizing morbidity and mortality.
In spite of the obvious roles and responsibilities of acute care hospitals during
a major health or medical crisis in the United States, numerous deficiencies have
been described concerning the lack of preparedness among the nation’s hospitals
and trauma centers.1″7 In response to these deficiencies, several governmental
agencies and professional organizations have required and/or recommended standards for hospitals that are related to education, training, and preparedness for disasters and public health emergencies.8″11
Although some guidelines exist, there is no universal standard that describes
which roles or job functions within a hospital are essential to the hospital’s ability to respond to and recover from a disaster or public health emergency. The
current federal guidance, including that from the National Incident
Management System (NIMS) Integration Center as well as the Occupational
Received: 08 July 2008
Accepted: 31 July 2008
http://pdm.medicine.wisc.edu
Web publication: 22 June 2009
Prehospital and Disaster Medicine
240
Education and Training of Hospital Workers
1. Of the following staff roles in your facility, what percentage have been trained in each of the following categories?
Staff Roles
Training Categories
ED Director
ICS/HEICS
ED Support Staff
NIMS
ED Physician
PPE (for contaminated and highly infectious patients)
ED Nurse
Decontamination
Staff Nurse
Medical Management of CBRNE Patients
Staff Physician
Functional Role in Emergency/Disaster
Allied Health (PT, OT, etc.)
Nursing Assistants/Aides
Hospital Administrators
Security
Facilities/Janitorial
Housekeeping
EMTs/Paramedics
Clerical/Admissions
2. Of the following staff roles in your facility, which would you consider essential to your hospital preparedness plan in an
emergency or disaster? Of these essential staff, what percentage have received training related to their intended role during
a disaster or emergency?
Staff Roles
ED Director
ED Support Staff
ED Physician
ED Nurse
Staff Nurse
Staff Physician
Allied Health (PT, OT, etc.)
Nursing Assistants/Aides
Hospital Administrators
Security
Facilities/Janitorial
Housekeeping
EMTs/Paramedics
Clerical/Admissions
3. Of the following staff roles outside, but affiliated with your facility, what percentage have received training to be a part of
your facility’s surge plan?
Outpatient Nurse
Outpatient Physician
Outpatient Allied Health
Outpatient Nursing Aide
Outpatient Clerical
Outpatient Administrators
Community Nurse
Community Physician
Community Medical Assistant
Community Allied Health
Visiting/Home Health Nurse
Visiting/Home Health Aide
Visiting/Home Allied Health
4. List the specific preparedness-related training programs offered to your hospital staff in the past 36 months.
5. Please explain how appropriate courses are identified to train your hospital staff? What steps are taken to assure that
course content is reliable and credible?
6. Have you identified any specific areas where training is needed but not currently available? If so, what type of training and
in what area(s)?
Reilly © 2009 Prehospital and Disaster Medicine
Figure 1—Survey instrument (CBRNE = chemical, biological, radiological, nuclear, or explosive; ED = emergency
department; EMT = emergency medical technician; HEICS = Hospital Emergency Incident Command System;
ICS = incident command system; NIMS = National Incident Management System; OT = occupational therapy;
PPE = personal protective equipment; PT = physical therapy)
Safety and Health Administration (OSHA), has been
unclear regarding, specifically, who should be educated and
trained to perform key functional roles at a hospital during
disasters or public health emergencies. This extends from the
boardroom, in simply staffing the hospital’s emergency operations center (EOC), to the workers performing emergency
patient decontamination in the emergency department. As
such, there is considerable institutional variability among
Prehospital and Disaster Medicine
hospital preparedness plans as to the specific functional roles
that are expected to be called upon or utilized in times of disasters or major incidents.
The purpose of this study was to determine the compliance of hospitals with recommended hospital staff training
and to determine which hospital workers are viewed by
healthcare emergency planners as “essential” to their hospital’s emergency operations plans.
http://pdm.medicine.wisc.edu
Vol. 24, No. 3
Reilly, Markenson
241
ICS/HEICS
%
NIMS
%
PPE (for
contaminated and
highly infectious
patients)
%
Decontamination
%
Medical
Management of
CBRNE Patients
%
ED Director
80
45
85
70
78
ED Support Staff
35
2
66
55
42
ED Physician
37
10
67
53
60
ED Nurse
46
12
70
63
55
Staff Nurse
33
3
58
27
30
Staff Physician
23
5
60
22
34
Allied Health (PT, OT,
etc.)
25
6
55
22
20
Nursing
Assistants/Aides
30
6
62
28
23
Hospital
Administrators
69
28
54
26
34
Security
61
26
67
51
38
Facilities/Janitorial
37
9
60
39
29
Housekeeping
29
5
48
27
20
EMTs/Paramedics
29
18
70
41
51
Clerical/Admissions
29
3
39
17
16
40.3
12.7
61.5
38.7
37.8
Reilly © 2009 Prehospital and Disaster Medicine
Table 1—Percentages of hospital staff trained in specific knowledge areas (CBRNE = chemical, biological, radiological,
nuclear, explosive; ED = emergency department; EMT = emergency medical technician; ICS/HEICS = incident command
system/Hospital Emergency Incident Command System; NIMS = National Incident Management System;
OT = occupational therapist; PPE = personal protective equipment; PT = physical therapist)
Methods
Bioterrorism coordinators and emergency managers for 31
hospitals in a seven-county region immediately north of a
major metropolitan area, with urban, suburban, and rural
demographics were surveyed to determine which specific
job functions were “essential” to their hospital’s emergency
and disaster plan, and what percentage of the personnel in
these roles had received training in their anticipated emergency
duties according to the hospital’s emergency operations plan.
Standardized, six-item telephone surveys were designed
by the investigators with input from the regional hospital
preparedness coordinating body, as assigned by the State
Public Health Department. The survey initially was
assessed by members of this group to determine its usability. The goals of the State Public Health Department were
used to assess a component of the hospitals systems’ emergency preparedness planning. Fourteen common, regionally
accepted, hospital job functions were selected for analysis in
this survey. Survey items 1 and 2 focused on these specific
functional roles. Item 3 assessed 14 hospital-affiliated, outpatient or community job areas that have a clear counterpart within the hospital. Items 4-6 were qualitative items
designed to indicate the education and training needs of each
specific hospital for regional planning purposes (Figure 1).
Interviewers were trained by the authors and provided
with contact information (e-mail, telephone numbers, addresses) for each hospital’s Bioterrorism Coordinator/Emergency
Manager. Interviewers contacted each hospital representative
May-June 2009
by telephone to complete the survey. Non-respondents subsequently were contacted via telephone, e-mail, and standard mail to complete the survey. Responses were recorded
by the interviewers and entered into a database. All
responses were pooled and basic summary statistical processing was performed on the aggregate data to assist in
depicting regional trends. Microsoft Excel Standard
Edition 2003 (Microsoft, Inc., Redmond, WA) was utilized
to perform basic descriptive statistical calculations.
Initially, the project was conducted under the authority
of the Public Health Department to assess the ability of
hospitals to respond to disasters as part of their oversight of
the hospital system. Following this, a database of the results
with all hospital and other identifying data removed was
created for further analysis. As an existing database with no
identifying data was evaluated, this project was considered
exempt research.
Summary statistics were calculated using pooled, aggregate response data to generalize the survey results throughout
the region. Individual hospital’s responses are not reported.
Results
Surveys were completed during a five-week period. The
response rate of the hospitals in the region was 24/31
(77.4%) at the completion of the survey.
Table 1 is a list of a topic-specific types of training by
job function. The training topics included are common by
required or suggested training programs by regulatory
http://pdm.medicine.wisc.edu
Prehospital and Disaster Medicine
Education and Training of Hospital Workers
242
Essential
%
Training in Role
%
95.0
89.3
ED Support Staff
100.0
73.8
ED Physician
100.0
81.0
ED Nurse
100.0
83.3
Staff Nurse
79.2
66.5
ED Director
Staff Physician
70.8
54.8
Allied Health
(PT, OT, etc)
33.3
26.1
Nursing
Assistants/Aides
54.2
46.7
Hospital
Administrators
83.3
75.8
Security
79.2
69.7
Facilities/Janitorial
62.5
52.4
Housekeeping
50.0
48.8
EMTs/Paramedics
22.2
23.2
Clerical/Admissions
62.5
55.2
Reilly © 2009 Hrehospital and Disaster Medicine
Table 2—Percentage of hospitals who indicated each
function was “essential” to their disaster plan and the
amount of functional role training that has been provided to these personnel. (ED = emergency department;
EMT = emergency medical technician;
OT = occupational therapist; PT = physical therapist)
agencies, professional associations, or scientific bodies.
These topics include incident command system/National
Incident Management System (ICS/NIMS); personal protective equipment (PPE); decontamination; medical management of patients exposed to chemical, biological, radiological,
nuclear, or explosive (CBRNE) materials; and functional
roles during emergencies or disasters.
The emergency department directors had the highest
percentages of training in all of the content areas including
training related to their role in the hospital response plan
(89.25%). Emergency medical technicians (EMTs) and
paramedics employed by hospitals had the least amount of
training in functional roles (23.2%), and clerical and
administrative staff had the overall lowest percentages of
training in all categories (Tables 1 and 2).
Staff physicians received the least amount of training in
ICS/HICS (23%) and ED support staff received the least
amount of training in NIMS (2%). In all other categories,
emergency department directors had the highest percentages of training and clerical and administrative personnel
had the lowest percentages (Table 1).
The percentage of hospitals that indicated that specific
staff were “essential” to their disaster plan, and the amount
of training they have received to perform their functional
roles are listed in Table 2. Overall, about 60.5% of hospital
staff had received some training on their individual functional roles as described in the hospital Emergency
Operations Plan (EOP).
Prehospital and Disaster Medicine
Only three categories of hospital personnel were reported
to be “essential” to all hospitals’ internal emergency preparedness plans: emergency department physicians, emergency
department support staff, and emergency department nurses. Allied health professionals (physical therapy, occupational therapy, etc.), emergency medical technicians and
paramedics were most infrequently described as “essential”
to the hospital preparedness/disaster response plan, 33.3%
and 22.2% respectively (Table 2).
Training for the staff described by hospitals as “essential” ranged from (73.6-83.3%). Furthermore, as these are
aggregate data, it is noted that some of the hospitals reported that these “essential” staff members have received no
training in their anticipated functional role described in the
hospital’s emergency and disaster response plan.
Hospital staff also responded regarding the inclusion of
non-inpatient and hospital-affiliated providers in disaster
and emergency-related training. These include physicians
on staff at the hospital and their office staff, outpatient
departments, and community-based healthcare providers.
The highest percentage of affiliated staff who received
training to provide emergency surge capacity to the hospital in a disaster or emergency were outpatient nurses
(34.7%). In contrast, community-based and visiting/home
care allied health professionals received the least amount of
training (7.8-8.4%). Overall, only about 19.2% of non-hospital based staff had been trained to provide any surge
capacity to the hospital in times of public health emergencies or disasters (Table 3).
In the qualitative items, responses varied widely in the
perceived needs of each hospital. Thirteen (54.2%) hospitals reported that the most frequent training program they
offer to hospital staff is ICS training. Interestingly, 20/24
(83.3%) of hospitals surveyed reported that they use no formal process or procedure to identify appropriate training
courses for hospital staff to assure that course content is
reliable and credible. Despite the apparent deficiencies in
training among “essential” staff, 11/24 (45.8%) of hospitals
reported that there are no content areas for which training
is needed but currendy is not available to them (Figure 2).
This was confirmed by investigators through the State
Health Department and the regional hospital resource centers that confirmed that training is available to each of the
hospitals, in each content area, free of charge, at their location, at any time they request it.
Discussion
There are no clear definitions on who are considered essential
hospital staff during a disaster or public health emergency.
Although there have been attempts at creating common roles
and responsibilities through systems like HICS, OSHA’s
Hospital First Receiver Program, and Federal Emergency
Management Agency’s (FEMA) Hospital Emergency
Response Training program, the lack of adherence to these
models shows that frequendy the hospital administration
decide who it thinks is important or “essential” to their
internal hospital operations during an emergency.
Overall the respondents reported that the emergency
department staff was the most “essential” to their hospital
emergency response plans, although, out of all personnel in
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Vol. 24, No. 3
Reilly, Markenson
243
%
Preparedness-related training programs offered to hospital
staff in the past 36 months
Outpatient Nurse
34.7
Outpatient Physician
27.0
ICS
13
Outpatient Allied Health
11.6
Decontamination
11
Outpatient Nursing Aide
27.0
NIMS
4
Outpatient Clerical
27.0
HAZMAT
4
Outpatient Administrators
27.0
Evacuation
3
Community Nurse
18.3
POD Training
4
Community Physician
15.5
Emergency Management
3
Community Medical Assist.
15.5
CBRNE Management
3
PPE
1
Community Allied Health
7.8
Community Clerical
15.5
Mental Health in Disasters
1
Visiting/Home Health Nurse
16.8
General disaster training
1
Visiting/Home Health Aide
16.8
Staff functional roles
1
Visiting/Home Allied Health
8.4
Process or procedure for identification of reliable, credible,
and appropriate courses to train hospital staff
19.2
Reilly © 2009 Prehospital and Disaster Medicine
Table 3—Percentages of affiliated hospital staff who are
trained to provide surge staffing by job role
Formal Process
3
Informal Process
1
the hospital, emergency department support staff had the
lowest training compliance with current NIMS guidelines.
Furthermore, emergency department directors had the
highest percentage of training in all areas; however, the
emergency department directors only represent a single
individual in the hospital.
Although emergency department staff have a clear role
in disasters, it is important for hospital emergency planners
not to undervalue staff in other functional areas. For example, not all patients entering or exiting a hospital during a
disaster or emergency will be admitted through the emergency department. A small fire or a need to evacuate a single patient floor may not affect or involve emergency
department personnel. Also, patients who are the victims of
a disaster in a nearby jurisdiction and who are being transferred to a hospital in outlying areas due to bed shortages
may be admitted directly to a patient floor and bypass the
emergency department. These scenarios also would require
non-emergency department staff to have an understanding
and practical knowledge of their role during a disaster or
public health emergency. Furthermore, all hospital staff
should have the knowledge, skills, and abilities to assist in
other capacities during a disaster or public health emergency in order for the hospital to have a greater surge
capacity. Hospital emergency planners could achieve this
through building disaster education and training upon
more traditional and commonly practiced emergency procedures such as fire drills, which may assist staff in becoming more comfortable with evacuation procedures.
Emergency medical technicians/paramedics and allied
health personnel (physical therapists, occupational therapists, etc.) were considered least essential by hospitals, but
may be invaluable during certain emergencies or disasters
since they have the capacity to augment the in-hospital
No Process
May-June 2009
20
Specifically identified areas where training is needed but
not currently available
11
None
ICS/NIMS/HEICS
6
Functional Role Training
3
Decontamination/HAZMAT
5
1
Communications
Reilly © 2009 Prehospital and Disaster Medicine
Figure 2—Summary of qualitative responses
(CBRNE = chemical, biological, radiological, nuclear,
or explosive; HAZMAT = hazardous materials;
HEICS = Hospital Emergency Incident Command
System; ICS = incident command system;
NIMS = National Incident Management System;
PPE = personal protective equipment)
clinical workforce and increase available staffing levels during/following an event. It is important to note that not all
hospitals surveyed employ emergency medical technicians
or paramedics. However, all hospitals reported relying on
emergency medical services (EMS) personnel and equipment in their disaster plans for the purposes of mass patient
transfers, evacuation, and surge decompression of hospital
beds. Including the prehospital personnel in this survey is
important to show that hospitals, who rely upon these personnel to perform essential functions during disasters and
emergencies, do not often provide them with the education
and training to perform these roles according to their hospital’s emergency operations plans.
Hospitals that employ EMTs and paramedics also may
be overlooking a valuable asset that can assist in creating
surge capacity during a disaster or public health emergency.
http://pdm.medicine.wisc.edu
Prehospital and Disaster Medicine
Education and Training of Hospital Workers
244
100
80
60
40
20
HomeRN
Community RN Outpatient RN
Staff RN
EDRN
Type of Nurse
Reilly © 2009 Prehospital and Disaster Medicine
Figure 3—Percentage of nurses trained by nursing specialty (RN = registered nurse)
Not all public health emergencies require increased 9-1-1
responses. Waves of patients presenting with minor medical
syndromes or flu-like symptoms may not require EMS personnel to be over-utilized. However, these presentations
may fill emergency departments and hospital beds, and
EMTs and paramedics as hospital employees may have an
added role. Paramedics specifically have the education and
training, clinical experience, and scope of practice (under
medical direction) to perform critical patient care functions, including but not limited to triage, clinical examination, advanced airway management, intravenous access,
advanced cardiac life support, medication administration,
phlebotomy, and electrocardiography. Medical directors at
these hospitals should explore with emergency planners
how using prehospital personnel in this manner may assist
the hospital during a major incident or staff shortage.
Emergency department nurses were described by all
hospitals to be essential in their facility’s emergency plans.
However nurses in general had varying levels of training,
which decreased as nurses began practicing outside of the
hospital (Figure 3). Although specific procedures and technical aspects of nursing care may vary from unit to unit,
principles of disaster nursing and nurses’ roles and responsibilities according to the hospital plan should be taught to
every nurse employed by the hospital or health system. This
practice will make it easier for nurses to “float” to different
clinical areas during disasters and assist with increasing the
surge capacity of the hospital.
Hospitals require guidance on how to evaluate available
training programs and determine if they meet the specific
content or competency requirements in a particular topic
area. Additionally, hospital administrators lack the ability to
easily determine which agency or organization’s standardized course fulfills the regulatory requirements or guidelines.
Prehospital and Disaster Medicine
Development of a standardized and validated evaluation
tool, metric, or set of guidelines that could assist hospital
emergency planners in identifying appropriate training programs to fulfill the educational/training requirements could
assist in increasing hospital preparedness. Future efforts
should develop such a tool.
The few areas that influenced hospital administrators
when deciding what training programs to offer were the
NIMS Compliance Guidelines published through Department
of Homeland Security/FEMA, the HRSA Hospital
Preparedness Grant Program deliverables administered
through the State Department of Health, and guidelines
from accreditation bodies; however, it was largely up to the
hospital administrators to ultimately prioritize their training needs. Although some training mandates have been
given to the hospitals, they reported low percentages of
training compliance in certain areas of training such as ICS,
NIMS, and decontamination. Furthermore, any preparedness-related education/training that was required or recommended to hospitals (in this survey) was made available to
each of the hospitals in each topic, free-of-charge, at their
location, at any time they requested it through statewide,
funded, regional resource centers. This makes the findings
more significant since it truly was up to each hospital
administration to determine who was trained and what
training they received based on how they were deemed
“essential” by the hospital administrators.
In spite of training in all required content areas being
available through a State Health Department Regional
Resource Center, which was designed to provide hospitals
with planning and training resources for emergency preparedness topics, the Regional Resource Center reported
that there had been a “very low” utilization rate. They further informed the study authors that this suggested that the
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Vol. 24, No. 3
Reilly, Markenson
245
overall cost and availability of training may not be the limiting factor in low compliance, but it was necessary to
explore other contributing factors to low compliance with
hospital staff preparedness training mandates.
When asked by interviewers about barriers to preparedness training, virtually all of the hospital administrators
voiced difficulty in coordinating and conducting a comprehensive preparedness education and training program for all
hospital workers. Specifically, hospital representatives reported that either they lacked the internal expertise or credentials
necessary to conduct education and training in areas such as
ICS, decontamination, PPE, or CBRNE management and
were forced to contract with outside vendors to provide these
courses. Additionally, hospitals stated that even with internal
subject matter expertise to conduct the required or necessary
programs, often it was difficult to get staff to attend trainings
due to the time required away from their daily job duties, collective bargaining agreements, which specified overtime pay
or other types of compensation for educational activities,
inadequate staffing to allow staff to attend the courses, or
lack of institutional support or internal mandate requiring
compliance with the requirements.
Regulatory agencies and professional bodies should
develop compliance benchmarks for preparedness education/training, including criteria for acceptable courses and
model curricula that clinical and professional educators can
utilize to design adequate and effective programs for hospital workers. Additionally, workgroups comprised of hospital emergency managers and preparedness professionals
should be created within these professional organizations
and work with hospitals and medical centers to identify
solutions to barriers in hospital preparedness in order to
enab

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