The importance of critical thinking skills in disaster management.

The adverse circumstances occasioned by disasters rarely remain static but rather continue to evolve, temporally and spatially, rendering preplanned response operations uncertain, at best, and ineffectual, at worst. As such, disaster management professionals need to think critically to implement response strategies best suited to the circumstances at hand, with the best available information. This paper provides an overview of critical thinking, and its importance in helping leaders provide order to the chaos often associated with disaster response and recovery efforts. Critical thinking skills include the ability to identify and define a problem, recognise assumptions, evaluate arguments, and apply inductive and deductive reasoning to draw conclusions from the available information. Understanding and improving a leader's critical thinking skills helps to provide a sense of confidence, trust and authority during a community-wide crisis. As such, emergency management professionals must continually enhance their critical thinking skills.

Enhancing resiliency for elderly populations : Shelter-in-place planning and training at facilities serving elderly populations through the Rhode Island Senior Resiliency Project.

Elderly populations are disproportionately affected by disasters. In part, this is true because for many older adults, special assistance is needed to mitigate the consequences of disasters on their health and wellbeing. In addition, many older adults may reside in diverse living complexes such as long-term care facilities, assisted living facilities and independent-living senior housing complexes. Planning for each type of facility is different and the unique features of these facilities must be considered to develop readiness to deal with disasters. Based on this, the Rhode Island Department of Health established the Senior Resiliency Project to bolster the level of resiliency for the types of living facilities housing older adults. The project involves performing onsite assessments of energy resources, developing site-specific sheltering-inplace and energy resiliency plans, and educating and training facility employees and residents on these plans and steps they can take to be better prepared. Based on the feasibility of conducting these activities within a variety of facilities housing older adults, the project is segmented into three phases. This paper describes survey findings, outcomes of interventions, challenges and recommendations for bridging gaps observed in phases 1 and 2 of the project.

Inter-organisational response to disasters.

Inter-organisational communication failures during times of real-world disasters impede the collaborative response of agencies responsible for ensuring the public's health and safety. In the best of circumstances, communications across jurisdictional boundaries are ineffective. In times of crisis, when communities are grappling with the impact of a disaster, communications become critically important and more complex. Important factors for improving inter-organisational communications are critical thinking and problem-solving skills; inter-organisational relationships; as well as strategic, tactical and operational communications. Improving communication, critical thinking, problem-solving and decision-making requires a review of leadership skills. This discussion begins with an analysis of the existing disaster management research and moves to an examination of the importance of inter-organisational working relationships. Before a successful resolution of a disaster by multiple levels of first responders, the group of organisations must have a foundation of trust, collegiality, flexibility, expertise, openness, relational networking and effective communications. Leaders must also be prepared to improve leadership skills through continual development in each of these foundational areas.

Clinical guidelines for responding to chemical, biological, radiological, nuclear and trauma/burn mass casualty incidents: Quick reference guides for emergency department staff.

The word 'DISASTER' may be used as a mnemonic for listing the critical elements of emergency response. The National Disaster Life Support Education Foundation's (NDLSEC) DISASTER paradigm emphasises out-of-hospital emergency response and includes the following elements: (1) detect; (2) incident command system; (3) security and safety; (4) assessment; (5) support; (6) triage and treatment; (7) evacuate; and (8) recovery. This paper describes how the DISASTER paradigm was used to create a series of clinical guidelines to assist the preparedness effort of hospitals for mitigating chemical, biological, radiological, nuclear incidents or explosive devices resulting in trauma/burn mass casualty incidents (MCIs) and their initial response to these events. Descriptive information was obtained from observations and records associated with this project. The information contributed by a group of subject matter experts in disaster medicine, at the Yale New Haven Health System Center for Emergency Preparedness and Disaster Response was used to author the clinical guidelines. Akin to the paradigm developed by the NDLSEC for conducting on-scene activities, the clinical guidelines use the letters in the word 'disaster' as a mnemonic for recalling the main elements required for mitigating MCIs in the hospital emergency department.

Disaster and exercise performance information collection tool: capturing observations in four minutes or less.

The objectives of the work described in this paper were to: (a) identify existing gaps in data collection, processing and dissemination across all types of emergencies; (b) build a tool that permits documentation, manipulation and propagation of relevant observations in emergency preparedness exercises or real-world incidents to inform critical decision makers in real time and to facilitate the elaboration of lessons learned, best practices and pioneering strategies for the management of future disasters; (c) validate the efficacy of the tool for collecting, processing and disseminating disaster-related information, through its integration in a series of exercises. The disaster and exercise performance information collection tool (DEPICT) was developed to address needs identified via the analysis of survey responses provided by representatives of military and civilian organisations with disaster response experience. Consensus discussions were held to identify criteria and operational parameters for the tool. As the development of DEPICT progressed, feedback and recommendations for improvements were provided to the developers, who incorporated the recommendations in successive iterations, resulting in increased refinements of the tool. DEPICT was subsequently tested for feasibility through operations-based exercises centred on catastrophic earthquakes in three diverse geographic locations of the USA. Feedback regarding DEPICT's functional performance during the exercises was used to inform further refinements to the program. The authors developed the DEPICT software on a PHP platform to accomplish two goals: (1) offer a core that supports user interaction and data management requirements (eg data capture, transmission and storage); (2) present a user-friendly interface with a shallow learning curve to facilitate a better user experience. DEPICT is a user-friendly, web-based application that is accessible through various mobile web-enabled devices. The application allows responders, emergency planners and exercise evaluators to capture written and photographic field observations, on average, in four minutes or less per observation. These observations may be further processed or formatted offsite by analysts, prior to their submission for final exercise performance evaluation. Ultimately, the data form the basis of after-action reports, which, in turn, underpin future decision making and improved disaster response practices.

Integrating public health and medical intelligence gathering into homeland security fusion centres.

Homeland security fusion centres serve to gather, analyse and share threat-related information among all levels of governments and law enforcement agencies. In order to function effectively, fusion centres must employ people with the necessary competencies to understand the nature of the threat facing a community, discriminate between important information and irrelevant or merely interesting facts and apply domain knowledge to interpret the results to obviate or reduce the existing danger. Public health and medical sector personnel routinely gather, analyse and relay health-related inform-ation, including health security risks, associated with the detection of suspicious biological or chemical agents within a community to law enforcement agencies. This paper provides a rationale for the integration of public health and medical personnel in fusion centres and describes their role in assisting law enforcement agencies, public health organisations and the medical sector to respond to natural or intentional threats against local communities, states or the nation as a whole.

Resource allocation: an approach for enhancing hospital resiliency.

The objective of the work described in this paper was to develop the Hospital Emergency Support Function (HESF) model, which could be used by hospitals to augment medical surge capacity based on the reallocation of internal hospital personnel, in the wake of a catastrophic natural or manmade disaster. A group of subject matter experts, including clinicians with disaster response experience, hospital emergency coordinators and business continuity planners, was assembled to conceptualise the basic framework of the HESF model. The model was validated via feedback from a panel of decision makers at Yale-New Haven Hospital and development of a consensus among the panel, using a modified Delphi method. Hospital personnel and departments were reviewed, evaluated and stratified according to their latent contributions to medical surge capacity. Those pivotal to medical surge capacity were deemed HESFs, whereas those ancillary to medical surge capacity were considered non-critical or ancillary functions. Based on this classification, personnel assigned to non-critical hospital departments were identified as potentially divertible to HESFs, ie available to enhance medical surge capacity during a catastrophic emergency. The activation of the HESF model provides an alternative to utilising external resources for enhancing staffing during a medical surge event. The HESF model is based on the National Response Framework Emergency Support Functions and relies solely on internal hospital personnel to augment medical surge capacity in the event of a medical and public health crisis.

Collective response to public health emergencies and large-scale disasters: putting hospitals at the core of community resilience.

Healthcare organisations are a critical part of a community's resilience and play a prominent role as the backbone of medical response to natural and manmade disasters. The importance of healthcare organisations, in particular hospitals, to remain operational extends beyond the necessity to sustain uninterrupted medical services for the community, in the aftermath of a large-scale disaster. Hospitals are viewed as safe havens where affected individuals go for shelter, food, water and psychosocial assistance, as well as to obtain information about missing family members or learn of impending dangers related to the incident. The ability of hospitals to respond effectively to high-consequence incidents producing a massive arrival of patients that disrupt daily operations requires surge capacity and capability. The activation of hospital emergency support functions provides an approach by which hospitals manage a short-term shortfall of hospital personnel through the reallocation of hospital employees, thereby obviating the reliance on external qualified volunteers for surge capacity and capability. Recent revisions to the Joint Commission's hospital emergency preparedness standard have impelled healthcare facilities to participate actively in community-wide planning, rather than confining planning exclusively to a single healthcare facility, in order to harmonise disaster management strategies and effectively coordinate the allocation of community resources and expertise across all local response agencies.

Fostering disaster resilient communities across the globe through the incorporation of safe and resilient hospitals for community-integrated disaster responses.

The impact of catastrophic events on hospitals and communities is huge and continues to hinder progress in developing nations and industrialized countries alike. Over the last 10 years, the UN/ISDR has sponsored a series of global conferences to increase awareness of the importance of risk and vulnerability reduction and the need to build disaster resilient communities. In recognition that hospitals contribute to the health and resiliency of a community, ISDR has adopted the PAHO and WHO "Safe and Resilient Hospital" initiative. The primary focus of the initiative is to ensure the physical and functional integrity of hospitals during a disaster. Hospital resiliency also must encompass the ability to fully integrate hospital facilities and their services into an overall community response to prevent hospitals from becoming isolated from other responding organizations. In order to help promote the "safe and resilient hospital" initiative, during the 15WCDEM, three strategic objectives were identified for hospitals that meet SEARO Benchmark #5. These are: (1) establish tiers of standards (criteria) that define "safe and resilient" hospitals in diverse regions of the world; (2) develop a tool to assess the extent to which hospitals, meet the criteria for "safe and resilient" hospitals; and (3) apply the evidence derived from use of this tool to promote the concept of "safe and resilient" hospitals as an integral part of emergency preparedness, responses, and recovery, and maximize the political commitment from decision-makers within and outside the healthcare sector to support, protect, and integrate the initiative into a community-wide disaster response. Ultimately, attaining these objectives will protect the lives of patients and healthcare workers, ensure that hospitals are able to provide urgently needed and everyday medical care to the community they serve and minimize risk and vulnerabilities of patients, healthcare workers and other individuals within the community.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.