Public Health Emergency Preparedness

Introduction

The attacks against the United States in 2001 and the Severe Acute Respiratory Syndrome (SARS) epidemic of 2003 emphasized the need for and importance of preparedness for both natural and manmade mass casualty incidents (MCIs) that may cause sudden and unexplained demand on services. Disaster preparedness is required of Federal and State governments, local and regional public health infrastructure, law enforcement agencies, emergency response services, and health care systems. Within health care systems, hospitals will be called upon in the event of incidents to provide care to large numbers of ill, injured, exposed, and concerned individuals. Thus, hospital planning for disaster response is of the utmost importance. In addition, hospitals are required to perform drills as a component of their emergency management plan according to regulations set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).¹

One of the foci of hospital disaster planning has been the use of drills to train employees in and to test aspects of hospital response. Several types of hospital drills have been used, including computer simulation, tabletop exercises, and operationalized drills involving specific victim scenarios.^2-22 The latter have been carried out with either mock (volunteer) victims or paper-based clinical descriptions of victim status. Drills can be costly and complex to organize; to maximize the value of such endeavors, evaluation plans must be included. Disaster drill evaluations then can help hospitals to further their level of disaster preparedness.

Evaluation is based on accurate observation, which requires careful documentation of events before, during, and after a drill. Using a standardized observation and evaluation approach allows for a consistent record each time a drill occurs within an institution. A standardized approach helps to capture the specific strengths and weaknesses of hospital responses during the drill. Using a standardized evaluation also allows comparison from one drill to the next to determine improvements in areas where weaknesses have been identified.

Drawing from the published literature on disaster drills as well as input from a variety of experts in the field, the Johns Hopkins University Evidence-based Practice Center (JHU EPC) developed a set of evaluation modules and addenda for operationalized hospital disaster drills. These modules are designed to enhance the learning opportunities presented through a disaster drill in the hospital setting. This document describes the principles behind the approach used to develop the evaluation modules and addenda, the associated learning objectives, and recommendations for the use of the modules and addenda, including the identification and training of observers.

Purpose

As a part of the emergency management plan, every hospital is required to have a structure in place to respond to emergencies. This structure is routinely tested during drills. The evaluation modules for hospital disaster drills are designed to be a part of that testing. The attached modules are intended to assess the impact of the drill as hospital disaster response progresses and develops. Viewed in this way, hospital disaster drill evaluations can provide a learning opportunity for all who participate in a planned drill. The disaster drill evaluation modules present topics for evaluation in a systematic manner. They should be used to identify strengths and weaknesses in hospital disaster drills, and the results gained from evaluation should be applied to further training and drill planning. Although the evaluation modules can be used to identify improvement in repeated drills, they are not intended to be used to make final or complete judgments about whether a hospital passes or fails in its planning and training endeavors. The value of this approach is to identify specific weaknesses that can be targeted for improvement and to promote continuing efforts to strengthen hospital disaster preparedness. Systematized and standardized observations can be very useful to assess overall process improvement and require focused attention and education prior to the planned hospital disaster drill.

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Development of the Evaluation Modules

Background

The JHU EPC used sources from both the literature and current practice when designing the evaluation modules. From a systematic review of published reports on the effectiveness of hospital disaster drills,²³ the JHU EPC identified topics that should be addressed in a comprehensive evaluation of a drill. In addition, the JHU EPC derived some items for the evaluation modules by referring to information about the Hospital Emergency Incident Command System (HEICS), an emergency management system that outlines a management structure and incident command system (ICS) with defined responsibilities, clear reporting channels, and a common nomenclature.²⁴ The HEICS model, developed in California to combat natural disasters including fast moving fires, has since become a prototype for disaster incident management and is a popular model among hospitals. The JHU EPC also used the JCAHO regulations standard for Environment of Care, Emergency Management Planning as a resource.²⁵

Expert Input

The evaluation modules were developed by a multi-disciplinary team of experts at the JHU EPC who recently completed a systematic review of the literature on training of clinicians for public health events relevant to bioterrorism preparedness²⁶ and a systematic review of published reports on hospital disaster drills.²³ The team included clinical specialists in emergency medicine and infectious diseases, individuals with extensive experience conducting and evaluating disaster drills, and experts in form and questionnaire design. The team obtained input from other internal and external experts in hospital disaster preparedness representing a broad range of disciplines and perspectives. External experts included representatives of Federal, State, and local agencies (for example, the Health Resources and Services Administration [HRSA], the Agency for Healthcare Research and Quality [AHRQ], the Maryland Institute for Emergency Services System [MIEMSS], and the New York City Department of Health and Human Services), professional organizations (for example, the American Hospital Association [AHA] and JCAHO), and several academic medical institutions.

On the basis of the review of the literature on disaster drills and input from a range of experts with hospital disaster drill experience, the team outlined the action zones within the hospital that should be evaluated during drill activities. The team then identified principles that would guide the scope and detail of the evaluation. With periodic review and comment from internal and external experts, the team developed the specific items that are included on the evaluation modules for hospital disaster drills. Items included were reviewed internally by all members of the team for relevance, specificity, and clarity. The JHU EPC then piloted the modules in two multi-hospital regional disaster drills in the summer of 2003. Participating hospitals provided feedback on the use of the evaluation package. Subsequently, peer review by external experts provided additional comments on the organization and content of the forms. The evaluation modules for hospital disaster drills reflect all input received from these steps.

Guiding Principles in Developing the Evaluation Modules

Need for observing multiple hospital zones. Because evaluation of a disaster drill requires an understanding of drill activities in all areas of the hospital, the JHU EPC developed an approach that allows evaluation of disaster response activity through documentation by trained observers in identifiable functional and geographic zones. To assist the hospitals in planning a drill, the JHU EPC designed a Pre-drill Module to identify the active zones for the drill. The four zones identified in this approach are Incident Command, Decontamination, Triage, and Treatment.

Each of these zones has a separate evaluation module. Each of these modules contains both items common to all zones and items unique to a particular zone. This format allows for observation and collection of information in each zone as well as subsequent integration of data across zones during evaluation. In addition, for exercises that include biological or radiation scenarios, a Biological Incident Addendum or a Radiation Incident Addendum is to be attached to each of the zone-specific forms. Each zone module should be completed by at least one observer who is dedicated to the zone throughout the entire drill. Table 1 illustrates the use of the modules and addenda for different scenarios.

Need for documentation of time points. Recording time points of drill activities is a widely accepted method of evaluating drill activities. The JHU EPC recognizes the value of this; however, extensive documentation of time points by a single observer can detract from the primary goal of the evaluation, which is to document the many simultaneous activities in the zone as a whole. Documenting the range of activities is a labor-intensive activity. The JHU EPC addressed this issue of recording time points by designing the modules to document limited, specific time points. These are listed in the first section of each zone module. This approach will help to capture and understand the flow of the drill, particularly when comparing activities between zones. In some situations, to fulfill specific drill purposes, it may be valuable to collect and analyze additional time points. If a hospital wants to record additional time points, the General Observation and Documentation Addendum can be used. When the General Observation and Documentation Addendum is used, a second observer, who is assigned the specific task of time point documentation, should be stationed in each zone. The particular time points to be collected and the value of collecting these should be discussed in advance of the drill.

Documenting clinical care outcomes. The zone evaluation modules track the volume of victims in each zone and the adequacy of the provisions made for them, including space, staff, supplies, and other issues. The modules are not designed to collect individual victim level data. Information on victim flow is limited to the Decontamination, Triage, and Treatment Zone Modules. Collecting outcomes of triage and treatment for each individual victim was deemed beyond the scope of this evaluation approach. The modules monitor the zone and the outcome for the zone as a whole, not for each victim.

If information about clinical decisionmaking and individual victim outcomes is desired to meet specific educational objectives, then the hospital should develop guidelines for appropriate care and documentation in emergency situations. The hospital also should identify and train observers with a medical background who are capable of making such assessments and should consider using smart victims (persons with medical training who are able to assess their own care). For hospitals that choose to monitor selected patient-level clinical care data, we have included the Victim Tracking Addendum.

Need for debriefing (after-action review). In addition to real-time observations, a comprehensive evaluation must include methods to obtain feedback from participants, including organizers, staff, and victims, at the end of the drill. This allows for discussion of issues that span more than one zone, for example, the effectiveness of communication between the incident command center and patient treatment areas. Thus, the JHU EPC designed not only zone-specific modules that focus on issues that can be ascertained by an observer during the drill, but also a debriefing module that can be used to evaluate and integrate cross-zone issues at a post-drill debriefing session. The magnitude of a problem may become more evident when evaluating across zones.

Ease and flexibility of use. The evaluation modules are designed to be readily understood, easy to use, and applicable to many different drill scenarios. The latter is important because hospitals may use different scenarios to evaluate disaster preparedness. The items included on the forms are ordered by subject, and this order is the same across all modules to aid the observers as well as to facilitate the subsequent analysis. Comment boxes are included at the end of each section for recording information not otherwise captured.

Safety and security. Conducting a hospital disaster drill may create a number of safety issues that should be considered. These include:

• Advance consideration of the planned drill activities, including planned movements with unfamiliar equipment, to identify any safety related issues.
• Protection for actual patients who are on the premises.
• Safety of drill victims and participating health care workers (e.g., consideration of how the weather on the day of a drill might affect drill victims and health care workers).
• Special considerations for any children who may be involved.
• Contingency plans, including identifying and circulating the code word to stop the drill in case of an actual emergency.

These issues may require focused attention and education before the planned hospital disaster drill, and hospitals should consider designating a safety officer to monitor the drill and its participants as the drill evolves.

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Evaluation Modules and Addenda

Internal Structure of Modules

For consistency, the zone forms for Incident Command, Decontamination, Triage, and Treatment have the same structure and subject headers, which appear in the same order:

• Time Points.
• Zone Description.
• Personnel.
• Zone Operations.
• Communications.
• Information Flow.
• Security.
• Victim Documentation and Tracking.
• Victim Flow.
• Personal Protective Equipment (PPE) and Safety.
• Equipment and Supplies.
• Rotation of Staff.
• Zone Disruption.

Numbering of questions on the forms. Questions under each subject header include some items that are consistent from zone to zone and some that are unique for the zone. Questions common to several zones have been identified with a "C" before the question number. Questions that are zone-specific are identified by a unique letter code before the question number. Those codes are listed in Table 2. The common items appear first under each subject header, and the zone-specific items follow. In some cases, a "C" item, although applicable to several different zones, was deemed not applicable to a specific zone. In this case, the item was deleted; however, item numbering was held constant. Therefore, in the case where a "C" item has been deleted from the sequence, the numbering will skip. For example, the order of items might be "C1," "C2," "C3," "C5." This only occurs with "C" items. Figure 1 illustrates a typical page from a module and the numbering issues discussed.

Coding on the forms and use of comment boxes. Each item requires a response, and the answer sets are designed so that a logical response to each question is available. For an item where there are multiple response choices, these choices are listed alphabetically in most cases. (For an example, go to Figure 1, Item C14.)

Each question on each form has a specific set of responses relevant to that item. The standard answer set is "Yes," abbreviated by "Y," "No," abbreviated by "N," and "Unclear," abbreviated by "U." This appears on the forms as "Y/N/U." For some items, "Not Applicable," abbreviated by "NA," is added. We have used NA to avoid excessive skip patterns that could be confusing. Observers should be instructed to select NA only in cases where the item does not in any way apply. NA is not a substitute for missing information, negative information, or to avoid writing a comment in the comment box.

Comment boxes are at the end of each subject area to allow for additional observations made during the drill. In the case where a comment relates to a specific item, the observer is to identify the specific item. Figure 1 illustrates a typical page from a module and the coding issues discussed.

Color coding for the modules and addenda. The JHU EPC recommends that each form be printed on a different color of paper to assist in organizing and tracking the modules and addenda before and after a drill. This approach allows for quick identification of a specific module and worked well when tested in field trials. Colors used previously are identified in Table 2. Maintaining the same colors in future drills will aid in making comparisons over time.

Description of Modules and Their Objectives

The complete hospital drill evaluation is designed in a set of modules and addenda. Drill organizers may print and copy the modules and addenda from the electronic version of this document. The modules are designed to be flexible to meet specific needs during a variety of drills. Each module and specifics for its use are described below. The Decontamination Zone Module is needed for radiation and chemical drills, but currently is not recommended for use in a biological drill. Table 1 indicates the use of the different modules for a number of common disaster drill scenarios. If the drill is targeted at a particular clinical area (e.g., decontamination), other modules can be omitted. For example, omit the Triage Zone Module when there is no victim influx.

Personal protective equipment (PPE) is needed in different areas at different times. The list of PPE for the modules and addenda was developed through consultation with experts, and includes different items on the different forms. These lists may need to be updated as new knowledge emerges regarding the most appropriate PPE for different types of exposures.

Pre-drill module. The evaluation starts at the planning stage of the drill. This is essential in maximizing the learning opportunities. The Pre-drill Module should be completed by the hospital during the planning stages of the drill, preferably by the planning team as a group. This module should be used in all disaster drills. This form is designed to collect the following:

• Goals and objectives for the scope of the evaluation.
• Sufficient background information to facilitate the drill planning.
• Information on specific areas that the hospital wishes to evaluate.
• Resources required.

Incident command center zone module. The Incident Command Center Zone Module is designed to ascertain information about the basic operation of the incident command system that can be reliably recorded by an observer. This zone module should be used in all disaster drills whenever the drill objective includes evaluation of the incident command structure. This form is designed to assess the following:

• Command structure in the zone.
• Adequacy of staffing in the Incident Command Center.
• Communication and information flow from hospital areas to the Incident Command Center.
• Communication with outside agencies.
• Adequacy of the security, safety provisions, and physical space.

Decontamination zone module. The Decontamination Zone Module is designed to collect information about the functioning of the decontamination area. This zone module should be used in all disaster drills in which radiation or chemical exposure is in the scenario and decontamination must be conducted. This form is designed to assess the following:

• Command structure in the zone.
• Communication and information flow in the zone.
• Security and victim and staff safety in the zone.
• Adequacy of staffing and physical space in the zone.
• Practicality and appropriateness of decontamination equipment and PPE.
• Decontamination zone operations, including use of equipment.
• Victim flow in the zone.

Triage zone module. The Triage Zone Module is designed to collect information about the functioning of the triage area(s) in a disaster drill. It can be used in primary or secondary triage areas. This zone module should be used in all disaster drills involving mock or paper victims. This form is designed to assess the following:

• Command structure in the zone.
• Communication and information flow in the zone.
• Security and victim and staff safety in the zone.
• Adequacy of staffing and physical space in the zone.
• Relation of the physical characteristics of the zone to triage activities.
• Efficiency and appropriateness of victim-oriented triage activities.
• Triage operations.
• Victim flow in the zone.

Treatment zone module. The Treatment Zone Module is designed to collect information about the functioning of the treatment area(s) in a disaster drill. This module should be used whenever the drill objectives include evaluation of patient care activities beyond the triage area. The items are appropriate for use in emergency department-based treatment areas or in other clinical care areas (for example, the radiology department or medical or surgical inpatient floors). This form is designed to assess the following:

• Command structure in the zone.
• Communication and information flow in the zone.
• Security and victim and staff safety in the zone.
• Relation of the physical characteristics of the zone to treatment activities.
• Efficacy of treatment operations.
• Adequacy of materials and supplies in the zone.
• Victim flow in the zone.

Group debriefing module. The Group Debriefing Module is described in the section on Debriefing (After-Action Review).

Description of Addenda

Four addenda are part of the hospital disaster drill evaluation. Addenda are to be used to supplement the zone forms. For example, for a hospital-wide radiation exposure drill the Radiation Incident Addendum must be added to the Incident Command Center, Decontamination, Triage, and Treatment Zone Modules. In the case of a biological scenario drill, the Biological Incident Addendum must be added to the Incident Command Center, Triage, and Treatment Zone Modules. As shown in Table 1, the Biological Incident Addendum should only be used for drills involving a biological scenario, and the Radiation Incident Addendum should only be used for drills involving a radiation scenario. The addenda have specialized purposes as described below.

Biological incident addendum. The Biological Incident Addendum is designed to collect additional information during drills that address the response to a biological incident. This addendum should be added to the end of each of the Incident Command, Triage, and Treatment Zone Modules. This addendum should be used in all disaster drills that address a biological incident. Because of the complexity of assessing the level of exposure for different biological incidents, an expert in the field should be involved when planning and assessing the drill. This form is designed to assess the following:

• Awareness that a biological agent was the cause of illness.
• Whether appropriate expert monitoring personnel were contacted.
• Whether health and safety needs of staff were met.
• Whether health and safety needs of existing patients were met.
• Whether health and safety needs of victims were met.
• Availability of special medications and supplies.

Radiation incident addendum. The Radiation Incident Addendum is designed to gather additional information in drills that address the response to a radiation-related incident. This addendum should be added to the end of each of the zone modules, including Incident Command, Decontamination, Triage, and Treatment. This addendum should be used in all disaster drills that address radiation exposure. Because of the complexity of assessing the level of exposure for different radiation incidents, an expert in the field should be involved when planning and assessing the drill. This form is designed to assess the following:

• Awareness that radiation exposure was the cause of illness.
• Whether appropriate expert monitoring personnel were contacted.
• Whether health and safety needs of staff were met.
• Whether health and safety needs of existing patients were met.
• Whether health and safety needs of victims were met.
• Availability of special supplies.

General observation and documentation addendum. The General Observation and Documentation Addendum is designed for use by an additional dedicated observer to document detailed activities in a single unit. For example, during a chemical drill, an additional dedicated observer could be assigned in the area where personnel don their PPE to document in detail the time required for personnel to dress, appropriateness of dress, and other issues. The Addendum has a front page and a continuation page. The continuation page may be copied as necessary, and sequential numbers must then be inserted at the bottom right, depending on the number of pages needed.

Victim tracking addendum. The Victim Tracking Addendum is designed for use by an additional dedicated observer to track the progress of individual victims as each progresses through the drill. This can be used within one zone for a large group of victims, or the observer can follow a small group of victims across zones from the beginning to the end of drill participation. The purpose could be to assess the length of time within each zone or to assess the disposition of the victims from the medical perspective. The latter is only useful with clear victim descriptions and understanding of the emergency medical procedures at an individual hospital. The Addendum has a front page and a continuation page. The continuation page may be copied as necessary, and sequential numbers must then be inserted at the bottom right, depending on the number of pages needed.

Modifying the Modules or Addenda

The modules are designed to be flexible and yet include basic information relevant to evaluating a hospital's ability to respond to different types of disasters. In some settings, hospitals may develop drills more precisely targeted at a particular system (for example, communications) or type of skill development. Drill coordinators may elect to modify the forms. In this case, care should be taken to preserve a numbering system that allows for comparisons between and across zones, and the "footer" on the bottom left should be changed to indicate the date and the group that edited the form.

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Evaluation Planning and Execution

To evaluate a hospital disaster drill, hospitals must give attention to numerous issues before, during, and after the drill. This document is intended to help hospitals with the evaluation of a disaster drill, but it is not intended to provide direction on how to design the drill itself. Drill organizers should therefore have training in how to design and conduct a disaster drill before planning the evaluation of a drill. Such training is available through the Federal Emergency Management Agency (see Disaster Drill Resources).

Preparation Before the Drill

Hospital disaster drills are resource-intensive, complex exercises that demand substantial preparation. The Pre-drill Module must be completed by drill organizers who are fully aware of the hospital's specific objectives for, and ability to commit resources to, the drill. Ideally, the group planning the drill should meet to complete the Pre-drill Module. In addition, a thorough review of the sections and items in each of the other modules and addenda will be useful to develop an overall knowledge base helpful to planning the drill. If this is to be a multi-hospital or regional drill, each hospital involved must work closely with the overall drill coordinators. A lead observer at each hospital should be designated to coordinate with the regional drill planners and be the contact person during the drill. Drill organizers may want to recruit observers from within the hospital or from other organizations if the hospital does not have enough people with appropriate expertise.

Observers

Role of the observers. The value of the learning opportunity, and the success of the drill, depend on the observers. Serving as an observer is a demanding role requiring skills in observing, understanding and recording. Observer selection is therefore critically important, and observers must receive training in how to use the evaluation modules. This training will be most effective if the modules are given to observers far enough in advance to allow them to review each module in detail. Documentation by the trained observers provides information to evaluate the drill. Observers may record personal statements about their observations in the comment boxes, but in this case should note that these are opinions. Observers should be educated about the types of victims they may encounter, including smart victims (i.e., those with medical training who are able to assess their own care) and moulaged victims (i.e., healthy volunteers with realistic-looking injuries). Observers also should be instructed on how to record the care given or not given to victims.

Background knowledge required. Observers observe the activities during the drill and record their observations. Observers require general knowledge of the operations of the zone that they are evaluating; however, specific medical knowledge is not required. It is acceptable for an individual who normally works in the zone to function as an observer for the zone, with the clear understanding that during the drill he or she is not available to assist with any drill activities. Observers must not have any role other than that of evaluating the drill; they also must not respond to questions from drill participants about the drill. To qualify as observers, volunteers drawn from outside the hospital must have knowledge of hospital functions.

Number of observers needed in each zone. At least one observer should be present in each zone continuously during a drill. Zone modules are to be completed by the designated zone observers. All should be familiar with the zone modules, including the ordering of the sections and the content and meaning of each question. In some cases, additional zone-based observers may be needed for specific activities that require observation of numerous staff or victims. To capture such information, the additional observers should use the Victim Tracking Addendum or the General Observation and Documentation Addendum. If the drill organizer requests extensive time point data collection, an additional observer in each zone should be assigned to this task. Specific time points and the reasons for collecting them should be outlined before the drill starts.

Shift changes for extended drills. If a drill is expected to last for an extended period, drill organizers should set a time period for each observer to serve, and should plan for rotating in fresh observers. Each observer should start a new zone module when rotating in.

Collection of information on victim outcomes. If drill organizers want to collect victim clinical process or outcome data, additional observers will be needed in each zone. In such cases, standards for clinical care in an emergency setting must be available, and observers must have sufficient clinical knowledge to report on clinical decisionmaking.

Training sessions. Training sessions for observers must occur before the drill takes place. During these sessions, the observers should receive their zone assignments, and the relevant zone modules must be reviewed in detail. Observers will be documenting complex tasks, and complete familiarity with the content of the evaluation modules and addenda, as well as the zone configuration and equipment, is essential. All questions and response sets should be explained. Questions about the forms should be addressed at the training sessions. Observers should be given instructions about how to be an effective observer. The following points should be emphasized:

• All observations made during the drill are confidential.
• All observers must be completely familiar with the content of the forms they are completing, including the meaning and intent of the form contents and the points to describe in the comment sections.
• Observers should position themselves so that they are not obstructing the flow of the drill but are able to see drill activities.
• Observers may ask questions of drill participants to clarify the actions they have taken or to clarify observations and discussions. Questions should be asked in an unobtrusive manner. Observers should refrain from asking leading questions that may alter the actions of participants.
• Observers must not participate in drill activities. If asked a question by a drill participant about a drill issue, they should state that they are evaluating and are unable to answer the question.
• Each question on each module should have a response. The response NA should be indicated only when the question does not apply.

Activities of the Evaluation Coordinator

Responsibilities of the Evaluation Coordinator at the hospital include:

Before the Drill

• Recruiting and selecting observers.
• Organizing training sessions.
• Assigning observers to zones.
• Distributing relevant modules for review prior to drill.
• Color coding the modules and addenda to facilitate identification, distribution and collection.
• Distributing evaluation modules to the observers.
• Interacting with the coordinators of a regional drill when the drill involves more than one hospital.

During the Drill

• Assuring that all participants know the code word needed to stop the drill in case of a real emergency.
• Acting as a point of contact for observers during the drill.
• Monitoring performance of the observers in the various zones during the drill.
• Rotating in new observers as appropriate.
• Identifying the end of the drill and notifying observers.
• Collecting forms at the end of the drill.
• Reviewing the forms briefly with the observers to assure completeness and legibility.
• Supplying evaluation information for the specific hospital to the evaluation coordinator for the entire drill when the drill involves more than one hospital.

After the Drill

• Coordinating after-drill activities, including debriefing sessions, and informing the observers, including those who may have changed shifts.
• Encouraging all participants to attend debriefing sessions.
• Ensuring that all observers attend the debriefing sessions, and when there are multiple debriefing sessions, assigning observers to specific sessions.
• Collecting information from the post-drill debriefing session.
• When the drill involves more than one hospital, supplying evaluation information for a specific hospital to the evaluation coordinator for the entire drill.

Debriefing (After-Action Review)

Debriefing is an integral part of the drill process. A debriefing should occur in all disaster drills to obtain feedback from participants and observers on performance during the drill. There are different approaches to debriefing. One method is to conduct one large debriefing session with all participants and observers present and to ask a series of general questions about the drill. The Group Debriefing Module is designed to accommodate this approach. Another method is to rely on a designated person in each zone participating in the drill to conduct a group debriefing session with the participants from that zone.

Group debriefing module. The Group Debriefing Module contains a series of open-ended questions that are designed to elicit valuable information and facilitate discussion during a group debriefing session after completion of a drill. Depending on the specifics of the drill and the needs of the hospital, questions may be added or deleted from this list. This module is designed to cover all issues raised during the drill, including incident command structure, communications, security, decontamination, triage, treatment, and other areas. The main objective of the debriefing is to identify issues experienced during the drill that may not be captured by the evaluation modules. Facilitators should create an open, non-judgmental atmosphere and welcome all comments. This exercise is vital to fulfill the learning objectives of the drill.

Documenting the debriefing. A scribe should be assigned to record the responses of the group. Videotaping and/or audiotaping the debriefing session may help to capture all comments. The leader of the debriefing should make a general announcement that the purpose of audiotaping and/or videotaping will be restricted to evaluating the exercise more completely and should not hinder open exchange.

Post-drill Information Management and Review

The evaluation information should be collected by the Evaluation Coordinator, reviewed with the drill organizers, and presented to senior hospital management as soon as possible after the drill. For multi-hospital drills, these activities need to be coordinated with the overall drill coordinator. To facilitate organization of the evaluation information so that it can be distributed to appropriate personnel within the hospital, the electronic version of this document includes a template of a spreadsheet (see Appendix A in the electronic version of this document). The Evaluation Coordinator should arrange for the evaluation information to be entered into a master spreadsheet. This requires entry of data by hand and should be supervised carefully. Once the data are entered, the spreadsheet can be used to create summary tables and compare items within and across zones. Questions that are common to all zone forms are numbered the same way on each zone form to facilitate qualitative comparisons across zones. The intention of this qualitative comparison is to identify common strengths and weaknesses within a particular hospital's many zones, not to compare the performance of individual zones. Depending on the drill objectives, some specific zone modules or questions may be of greater interest than others.

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Additional Issues

Type of Hospital Drill

This drill evaluation approach focuses on hospital-based operationalized drills. The basic issues covered in the modules and addenda may be used for planning and developing operationalized drills, as well as evaluating them. Many of the issues addressed in the modules also will apply to other types of training in hospital disaster response, such as drills involving computerized simulation or tabletop exercises. However, the evaluation modules for hospital disaster drills were not designed for evaluation of computerized simulations or tabletop exercises.

Disaster Drill Resources

Information regarding biological, chemical, and radiation threats can be found on the Centers for Disease Control and Prevention (CDC) Web site at http://www.bt.cdc.gov.

Information regarding emergency management can be found at the Federal Emergency Management Agency (FEMA) Web site at http://www.fema.gov. This Web site also contains information on opportunities for training in disaster preparedness.

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