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DISASTER EXERCISE

GUIDEBOOK
Preparing, Conducting and Evaluating an Emergency
Preparedness Exercise

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

2006

DISASTER EXERCISE GUIDEBOOK


Preparing, Conducting and Evaluating an Emergency Preparedness Exercise

TABLE OF CONTENTS
INTRODUCTION

EXERCISE PREPARATIONS

SCENARIO

LOGISTICS

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CONDUCTING THE EXERCISE

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APPENDICES

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A. VOLUNTEER VICTIM CONSENT FORM


B. VOLUNTEER VICTIM BRIEFING SHEET
C. PATIENT SCENARIOS
D. PATIENT SCENARIO MATERIALS
E. INJECTS
F. DISASTER EXERCISE EVALUATION FORM
G. ADDITIONAL EVALUATION MATERIAL
H. LESSONS LEARNED WORKSHEET

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FORMS
HEICS: SECTION PERSONNEL TIME SHEET
HEICS: EMERGENCY INCIDENT MESSAGE FORM
HEICS: ACTIVITY LOG
HEICS: PROCUREMENT SUMMARY REPORT
HEICS: RESOURCE ACCOUNTING RECORD
POST EXERCISE CRITIQUE FORM

ABOUT MCHC
METROPOLITAN CHICAGO HEALTHCARE COUNCIL

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2006

INTRODUCTION
The purpose of this guidebook is to assist hospitals in implementing an emergency preparedness
exercise involving an outbreak of influenza. It contains suggestions for implementation of the exercise
in order to meet accreditation and regulatory requirements.

EXERCISE PREPARATIONS
Announced vs. Unannounced
A decision must be made whether the exercise will be announced or unannounced. There are pros
and cons to either approach. An announced exercise will provide the opportunity for staff to review
and familiarize themselves with the emergency preparedness plan; an unannounced exercise allows
the organization to test the facilitys strengths and weaknesses in a more realistic manner.
Real Patients vs. Paper Patients
A determination whether to use real or paper patients must be made. Using real patients
requires the recruitment and education of volunteers to serve as patients. Consents must also be
obtained from the volunteers (Appendix A). If paper patients are used, the paper must be treated as
though it is a real patient and must be physically moved through the system.

SCENARIO
General Patient Population
The scenario for this exercise is an outbreak of influenza. If real patients are used, the volunteers
must be instructed (using the Briefing Sheet {Appendix B} and Patient Scenarios {Appendix C}) on
how they are to act and how they are to answer questions posed to them by hospital staff. When
distributing Briefing Sheet and Patient Scenarios to volunteers, instruct them as whether material is to
be memorized or referenced. It is also important that the staff talk with the volunteer victims during
the exercise. Failure to communicate with victims regarding history, physical exam, testing
and procedures ordered and other relevant information including discharge instructions (e.g.,
if a prescription is ordered) will limit the information available to direct diagnosis and
treatment. More importantly, it will limit the value of conducting the exercise.
Patient Scenarios are located in Appendix C. Included are scenarios for a sick patient, a worried
well individual and a person that arrives as a worried well individual but becomes sick while at the
hospital. These scenarios can be duplicated to provide the correct number of individuals the facility
needs to adequately conduct the exercise. Some volunteer victims should be instructed to complain
of severe symptoms (that may necessitate admission) and others should be briefed that they do not
have severe symptoms. For example, the facility may want 35 total patients including 15 sick
patients, 5 of whom are severely ill, 10 worried well individuals and 5 people that get sick while at
the hospital.
In order to test the hospitals response to non-English speaking populations, volunteers that speak
foreign languages fluently can be instructed to only speak foreign languages.

Special Needs Populations


To make the exercise more realistic and to test the hospitals response to special needs populations,
scenarios are available for (Appendix C):

Adult female person of size


Adult hearing impaired person
Infant with a tracheostomy
Infant with a gastrostomy tube
Infant on home oxygen therapy

If the facility opts to incorporate special needs populations in the exercise, the volunteers acting as
real patients should be briefed and provided with the appropriate special needs scenario. In order to
make the patients with special needs more realistic, the following props can be used:
Adult female person of size
Inflatable Sumo wrestler suit - available at costume shops or on-line
Housecoat/Mu-mu/duster or a light weight bathrobe to wear over the inflatable suit (it must be
lightweight and very large so the suit is not compressed)

FAN
FAN

Infant with a tracheostomy

Life size baby doll available at discount stores or


resale shops
Insert an infant-size tracheostomy tube (use either a
power drill with the appropriate size bit for a hard-neck
doll, or a seam ripper for soft-neck dolls)

Infant with a gastrostomy tube


Life size baby doll available at discount
stores or resale shops
Insert an infant size gastrostomy tube (use
either a power driver with the appropriate size
bit for a hard-type doll, razor knife or seam
ripper for a soft doll)

Infant on home oxygen therapy


Life size baby doll available at discount stores or resale shops
Secure an infant size nasal cannula to the doll with medical tape
Empty and clean a green two liter soft drink bottle with the cap intact
Drill a hole in the bottle cap using a drill bit just smaller than the end of the oxygen tubing;
insert the end of the tubing into the cap
Label the soda bottle OXYGEN

In order to maximize the impact of the props, it is important to make sure hospital staff
knows to take the props seriously.
Patient Scenario Materials
In order to add realism to the patient scenarios, additional materials/props should be provided to the
volunteer victims. This includes a mock nasopharyngeal swab and results, blood test results, and
results of a chest x-ray. The envelopes described below should be attached to the appropriate
scenarios (e.g., worried well are given only the envelope with worried well test results). Volunteer
victims should be instructed to give the appropriate envelopes to hospital staff ONLY if the
particular test they have an envelope for is ordered. Appendix D contains printable text for all of
the patient scenario material. (The text is formatted to print on 2 inch by 4 inch shipping labels.)

Nasopharyngeal Swab For Patients with the Flu (or get sick at the hospital):
1. Print and place a label with the following text on a #10 (9.5 inches x 4 inches) envelope:
NOTE TO HOSPITAL STAFF: Follow your hospitals normal procedures for
specimens.

NASOPHARYNGEAL SPECIMEN
NOTE TO PATIENT: Give this to the hospital staff if a swab of your nose is done.

2. Place 2 Q-Tips or applicators in the #10 envelope.


3. For Patients with the Flu (or get sick at the hospital), print the following text on labels and
place the labels on 2 index cards (one label only on each card):
Rapid Antigen Test for Influenza

All Other Tests for Influenza

Positive

Positive

4. For Worried Well Patients, print the following text on labels and place the labels on 2 index
cards (one label only on each card):
Rapid Antigen Test for Influenza

All Other Tests for Influenza

Negative

Negative

5. Place the index cards in a # 6 envelope (3.5 inches x 6.5 inches) with a label printed and
placed on the envelope that reads:
NOTE TO HOSPITAL STAFF: Transport the Nasopharyngeal specimen in this
envelope to the lab.
To be opened by the Lab ONLY.
TEST RESULTS FOR:
NASOPHARYNGEAL SPECIMEN
NOTE TO LAB STAFF: Report results in usual manner i.e., once normal test
run time has elapsed.

6. Place the # 6 envelope inside of the #10 envelope with the Q-tips or applicators.
Blood Specimens For Patients with the Flu (or get sick at the hospital)
1. Print and place a label with the following text on a #10 (9.5 inches x 4 inches) envelope:
NOTE TO HOSPITAL STAFF: You must provide your own appropriate empty Blood
Specimen tube. Follow normal procedures.
BLOOD SPECIMEN
NOTE TO PATIENT: Give this to the hospital staff if they pretend to do Blood Tests.

2. For not-so-sick patients: Print the following text on labels and place the labels on 2 index
cards (one label only on each card):
CBC

All Other Tests

Results: WNL

Results: WNL

3. For really sick patients: Print the following text on labels and place the lables on 2 index
cards (one label only on each card):
CBC

All Other Tests

Results:
WBC: 12.2
All else: WNL

Results: WNL

4. Place the index cards in a # 6 envelope (3.5 inches x 6.5 inches) with a label printed and
placed on the envelope that reads:
NOTE TO HOSPITAL STAFF: Transport this envelope to the lab with the mock blood specimen
(empty tube). To be opened by lab only!

Blood Test Results


NOTE TO LAB STAFF: Report the results in the usual manner using the appropriate time frame.

5. Place the # 6 envelope inside of the #10 envelope.


X-Ray Results For Patients with the Flu (or get sick at the hospital)
1. Print and place a label with the following text on a #10 (9.5 inches x 4 inches) envelope:
X-RAY
NOTE TO PATIENT: Give this to the hospital staff if they take you to X-Ray.

2. Print the following text on labels and place the labels on separate index cards (vary the results
given to patients):
Chest X-RAY

Chest X-RAY

Chest X-RAY

Results:
WNL

Results:
Right lower lobe infiltrate

Results:
Left lower lobe infiltrate

3. For really sick patients: Print the following text on labels and place the labels on index cards:
Chest X-RAY
Results:
Bilateral Left lower lobe infiltrate

4. Place one of the index cards in a # 6 envelope (3.5 inches x 6.5 inches) (vary the cards)
with a label printed and placed on the envelope that reads:
NOTE TO HOSPITAL STAFF: Transport this envelope to X-Ray with the patient.
To be opened by X-Ray only.

X-RAY RESULTS
NOTE TO X-RAY DEPT: Report the results in the usual manner using the
appropriate time frame.

5. Place the # 6 envelope inside of the #10 envelope.


Pharmaceuticals For Patients Requiring a Prescription
1. Print and place a label with the following text on a #10 (9.5 inches x 4 inches) envelope:

NOTE TO HOSPITAL STAFF: If a prescription is ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION
(Blank Form)
NOTE TO PATIENT: Give this to the hospital staff if you are told you will be getting a prescription or medication.

2. Print the following text on a label and place on an index card:


PHYSICIAN: Write the prescription here

3. Place the index card in the #10 Envelope.


4. Place 10 candies, e.g., M&Ms, Skittles,etc. (all the same color is recommended) in a # 6
envelope (3.5 inches x 6.5 inches) with a label printed and placed on the envelope that reads:
NOTE TO PATIENT: Transport this envelope to the Pharmacy with the prescription.

PRESCRIPTION
NOTE TO PHARMACIST: Dispense this candy as the prescribed medication. Follow
normal procedures using your true inventory. If you do not have the medication currently
in your stock, you cannot dispense anything.

5. Place the # 6 envelope inside of the #10 envelope.

Injects
A series of injects has been developed for the exercise in order to more fully challenge the facility and
to assure that all areas of the hospital participate in the exercise. The facility can use the provided
injects or create their own. Hospitals may elect to create their own to test new system or suspected
weaknesses or areas of recent training focus. The injects include:
#

Situation

Departments That
May Be Involved:
Nursing
Housekeeping

40% of the nursing staff and 30% of the housekeeping staff for the next
shift have called in sick.

Eight family members have arrived looking for their loved one. They tell
the receptionist that they heard their loved one was not feeling well; they
demand to see their sick family member. Two of the family members are
coughing and sneezing incessantly.

Social Services
Pastoral Care

President Bush is giving a commencement speech in the area. There


are massive traffic jams in the area and family members that are coming
to pick up patients that have been discharged cannot get to the hospital.
The patients awaiting discharge are complaining they are hungry.

Admitting
Food Service

A city garbage truck has blown a transmission while on a trash run


across from the hospital ED entrance. The truck crew parked the truck
and was picked up by another city crew. A large pool of transmission
fluid has formed and is flowing downhill towards the ED doors.
The local long term care facility contacts the hospital and indicates they
are unable to accept any transfers of discharged patients.

Security
Facilities
Housekeeping

Nursing
Admitting
Social Services

6A Twenty-five kindergarten children and two teachers from a nearby


elementary school arrive in the ED seeking treatment. They are
complaining of not feeling well. Some of the children have been
vomiting. Many children do not speak English.

Social Services
Pastoral Care

6B Twelve of the children from the elementary school require admission due
to dehydration. You are unable to transfer the children to a pediatric
tertiary care center due to unavailability of inpatient beds.

Admitting
Nursing

Staff is refusing to go home at the end of their shift. They are worried
that they might bring whatever these patients have home to their
families. Some of them have indicated that they are prepared to stay for
a week or longer.

Housekeeping
Facilities

After learning that the ED is experiencing a significant number of ill


patients, pastoral care reports they have 25 faith leaders in the hospital
that were at a hospital-sponsored luncheon ready to provide spiritual and
psychosocial support to patients, visitors and staff.

Pastoral Care
Social Services

A local news station is reporting that the area is in the middle of an


outbreak of pertussis (whooping cough). You have not received any
official communication from the local public health department.

Public Affairs
Infection Control

In addition, a minimum of five patients should require admission in order to test the facilitys surge
capacity. Injects for this scenario should be: THIS PATIENT NEEDS TO BE ADMITTED.
The exercise controller should make the determination which of the messages/events the facility
should inject. The injects should be printed on cards and handed one at a time to the appropriate
staff member. It would be to the hospitals advantage to use as many of the injects as possible. See
Appendix E for the injects in a printable form.

LOGISTICS
CONTROLLERS
It is recommended that an individual be assigned to act as an exercise controller. This individual
should provide assistance in making the exercise as real as possible. Some of the tasks the
controller should be responsible for include:

Creating a roster of volunteers


Distributing briefing sheets, scenarios and props to volunteers
Instructing volunteers; confirming consent
Meeting and instructing the volunteers as to where and how they should enter the facility (e.g.,
in the E.D., in the lobby)
Keeping track of the volunteers to make sure no one gets lost
Expediting the movement of the volunteers
Assuring that the exercise injects are handled appropriately (e.g., making sure the correct
individual and/or department gets the message)
Overall coordination of the volunteer victims through the system

EVALUATORS
A Disaster Exercise Evaluation Form (Appendix F) should be completed for the facility to document
performance during the exercise. A staff member should be assigned the task of completing the form
during the drill. A copy should be kept on file at the hospital and one forwarded to MCHC. In addition,
HRSA requires that additional evaluation forms be completed (see Appendix G). These forms should
also be returned to MCHC.

HOSPITAL FEEDBACK - POST-EXERCISE DEBRIEFING


A post exercise debriefing should be held shortly after the drill to review the hospitals response during
the exercise. Individuals should be encouraged to share positive experiences as well as discuss
areas where improvements can be made. Open communication and dialogue should be encouraged
amongst all areas of the facility.

CONDUCTING THE EXERCISE


HANDLING ARRIVING PATIENTS/VOLUNTEERS
To ensure that the victims come into/arrive at the hospital in a realistic manner, the facility should:

Assign the controller to meet the victims to provide detailed instruction, including how to enter the
hospital and via which entrance.

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Consider sending volunteer victims:


Directly to the emergency department
To the main door/lobby/reception area
From private physician offices as referrals
From the floors, i.e., as a sick visitor
Provide a card with the controllers name and information on how to reach that person to each
volunteer victim (in the event a volunteer has a true emergency or complaint/concern following the
event).
Make the controller available if the volunteer victims have questions or need clarification.
PLEASE MAKE SURE THAT STAFF IS AWARE THAT ABSOLUTELY NO INVASIVE
PROCEDURES ARE TO BE PERFORMED ON THE PATIENTS/VOLUNTEERS AND
THAT THEY TAKE THE PROPS SERIOUSLY.

OPERATIONAL POINTS
Due to the nature of the scenario, there will not be an official start time at which the drill is called.
Rather, the scenario will evolve. Hospitals will need to take this into account as the exercise
progresses. For example, the facility may experience an influx of patients with similar
symptomatology. More and more patients may arrive necessitating the hospital to go on virtual
bypass. When making the determination if bypass would be required, make sure to take into account
real patients and drill patients/volunteers. At some point, facilities may find it necessary to contact the
local health authorities, implement their peak census policy, or activate the hospitals disaster plan. It
is very important that hospitals follow their established policies and procedures.
Note! Any communication or reporting to outside agencies, must be
preceded by the statement, THIS IS A DRILL, THIS IS A DRILL. This
must be repeated twice.

In preparing for the exercise, you may wish to review the following:
Hospital Emergency Incident Command System (HEICS)

Implementation of HEICS

Hospital Bed Capacity

Surge plan
Capacity management plan
Procedures to request ambulance diversion/bypass
Off-site options/assistance
Patient discharges & transfers

Isolation Capacity

Isolation plan
Negative pressure capability
Use of appropriate personal protective equipment
Plan for fit testing of respirators
Traffic flow

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Healthcare Personnel

Activation & deployment of Regional Emergency Medical Emergency Response Team


(RMERT) members
Plan for bringing in additional staff

Credentialing

Plan for granting disaster privileges


Memorandum of Understanding (MOU) with other facilities

Pharmaceutical Caches

Timely distribution of prophylaxis to staff/family and others as appropriate


Procedures to request the Strategic National Stockpile (SNS)

Decontamination

Plan for decontamination of victims


Use of appropriate personal protective equipment (PPE)
Disposal of runoff

Mental Health

Surge capacity
Plan for psychosocial interventions
Mental health services (including family issues for patients and staff)
Family/visitor centers
Spiritual care

Communications and Information Technology

Redundant communication system


Access to the appropriate Health Alert Network

Laboratory

Communication with the laboratory including internal alerts regarding suspected organisms
Integration of laboratory services in the facilitys disaster plan including rapid & effective lab
services
Capacity to identify threat agents
Protocols for referral of clinical samples to the Laboratory Response Network (LRN) nodes
that have analytical capabilities (the Illinois Department of Public Health Laboratory)
Process for specimen collection, processing, shipping & handling

Contagious Disease Protocols

Protocols for patients presenting with febrile rash illness


Protocols for patients presenting with fever and respiratory illness

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Surveillance

Process for identification of potential outbreaks


Laboratory procedures & notification
Notification of local health authorities
Reporting

Mortuary

Storage capacity including surge


Identification of the deceased

Pediatrics

Capacity to care for children in the ED & on inpatient units

Special Needs Populations

Capacity to care for the elderly


Capacity to care for the disabled
Translation Services
Capacity to care for the disabled with service animals
Persons with other special needs

Finance

Procedures for documentation of expenses & supply use

Staff Issues

Immunizations
Fatigue
Family responsibilities
Sheltering in place
Day care
Pet care
Elder care
Process for communicating situation updates to keep all aware & informed

Other

Red Cross patient locater system

CONTROLLING OVERLY ENTHUSIASTIC VOLUNTEER VICTIM ACTING


In the event that a particular volunteer victims acting is jeopardizing the care of actual patients, a
mechanism should be developed in the facility where the exercise controller uses the command,
FREEZE to stop play of the individual volunteer victim. The controller should instruct the staff to
contact them in the event that actual patient care is being compromised. The volunteer victims should
be instructed during their briefing to immediately cease play acting when they hear the word
FREEZE.

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COMMUNICATION TO ACTUAL PATIENTS AND VISITORS


In order to alleviate any anxiety experienced by actual patients and/or visitors during the exercise,
consider developing signage and/or cards or flyers explaining the hospital is conducting an
emergency preparedness exercise.
LOOKING AHEAD: 2006 LESSONS
In order to build upon the experiences gained during this years exercise, please complete the
Lessons Learned (Appendix H) work sheet after the drill and return it to the Metropolitan Chicago
Healthcare Council, 222 S. Riverside Plaza, 19th Floor, Chicago, IL 60606. Our goal to is to compile a
list of suggestions that may be helpful for all hospitals going forward. Rememberthe drill has not
been successful if nothing is learned!

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APPENDICES

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

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2006

APPENDIX A
Volunteer Victim Consent Form

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

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2006

CONSENT AND RELEASE


1.

I, ________________, consent to allow _____________________ to participate in a "mock"


Participant or parent/guardian of minor

name of participant

disaster drill conducted by ___________________________________.


Name of organization sponsoring drill

2.

I understand that the "mock" disaster drill is required of hospitals by law as to enable hospitals
and other health care institutions to meet their responsibilities for the care of emergency victims
in the event of any disaster.

2.

I understand that as a participant in the "mock" disaster drill, ________________ will have
name of participant

make-up applied to so as to look like a "disaster victim"; may have his/her clothing soiled or torn;
and will be transported by stretcher, wheelchair or some other method. In addition, it will be
necessary for _________________ to travel from the "disaster site" to a hospital by
name of participant

whatever method is deemed necessary by the Disaster Committee members or participating


hospitals, including car, ambulance, etc.
3.

_________________ does not have any medical condition which would preclude
name of participant

participation in the "mock" disaster drill.


4.

In consideration for being given the opportunity to participate, I voluntarily agree to release
participating hospitals, _____________________________, their officers, agents, employees,
Name of organization sponsoring drill

and all other personnel for myself, my heirs, dependents, and assigns from any and all liability for
any participation in and observation of the "mock" disaster drill. I recognize and agree to assume
any and all risks.
6.

I further consent to the talking of photographs and videotapes of the disaster drill which may
include pictures. I understand that these photographs or videotapes may be retouched and that
no one will be identified by name. I further understand that the photographs and videotapes will
only be used for the purposes of education, knowledge, and research.

__________________________________

___________________________________

SIGNATURE OF PARTICIPANT

SIGNATURE OF PARENT IF A MINOR

__________________________________

___________________________________

ADDRESS

TELEPHONE

__________________________________

___________________________________

BIRTH DATE OF PARTICIPANT

DATE

__________________________________
WITNESS SIGNATURE

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APPENDIX B
Volunteer Victim Briefing Sheet

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

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2006

VOLUNTEER VICTIM BRIEFING SHEET


PURPOSE:
Thanks for being here today. We are conducting a disaster drill to test the emergency plans at area
hospitals. Each of you will be role-playing the part of an ill individual who has gone/been taken to an area
hospital in order to be treated for signs and symptoms of an illness.
ITINERARY:

Receive information, instructions and script handouts


Participate in group orientation session; ask questions
Receive scenario materials, props, and envelopes containing test results and lab samples
Play role of victim

THINGS TO KNOW:
You will be role-playing at real hospitals in real emergency departments and being cared for by real
hospital personnel. For some organizations, this drill may be a surprise.
Expect some confusion as personnel may not know you are acting, particularly if you are one of
the first to arrive.
If at any point you are asked to stop acting, i.e., the drill is called short due to a real emergency,
please do so.
If at any point the drill begins to jeopardize real patient care, you will be instructed to FREEZE.
This means you should immediately stop acting to allow staff to appropriately care for real
patients.
INVASIVE PROCEDURES ARE STRICTLY PROHIBITED! If at any point, someone tries to
perform an invasive procedure (i.e., start an I.V., take x-rays or draw blood) stop them. Make it
clear that you are a Volunteer and ask the caregiver to speak to the charge nurse for clarification.
The charge nurse is the nursing supervisor.
If at any point during the drill you need to contact anyone in charge of the exercise, i.e., you
become ill or seem to have lost your group, ask for the charge nurse or drillcontroller.
If any aspect of the drill makes you uncomfortable or seems unreasonable, please ask for the
charge nurse.
Regarding role playing:

Study your script.


It is critical that you stick to your script as specified. In particular, do not change or embellish any
aspect of your medical condition. Use your script as a cheat sheet even if doing so forces you to
break out of character. It is more important that you give accurate information than that you are a
good actor.
You can ad lib when asked questions not related to your medical condition or your script, for
example, who is your primary care doctor, do you have an emergency contact, what is the name of
your college, do you have roommates, do you have pets, and do you have allergies. Try to stick to
the truth to make your character more realistic.
If you are not sure how to respond to a question say, Im not certain.
Do not offer information unless asked. However, be forthcoming if asked questions related to the
information you have available.
Do not share your script with any hospital personnel prior to or during the exercise.
In some cases, you may be taken to areas of the hospital outside of the E.D. to have tests
conducted (i.e., x-ray or lab). This is part of the exercise. However, remember no invasive
procedures or x-rays should be taken and ask for a charge nurse if anything seems amiss.
You may receive envelopes with your script that instructs you to give them to the hospital staff if
they order any tests. The envelopes have instructions on them for you to follow.

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APPENDIX C
Patient Scenarios

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

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2006

PATIENT SCENARIO:
FLU VICTIM
Thank you for participating as a victim for our disaster drills. We appreciate your willingness to
assist us by playing the part of an ill person presenting to a hospital emergency department for
emergency medical care.
The following information will help you in your role playing. If any portion of these instructions is
unclear, please ask for assistance from a hospital staff member prior to the drill. You may keep this
document with you to use as a cheat sheet, but under no circumstances give it to the hospital
staff.
Your Role:
You have the flu but do not tell the hospital staff you have the flu. They will need to figure it out.
Remember the symptoms of the flu (given below) so that you can tell the hospital staff why you have
come to the hospital. You can use your real name and provide other information (such as whether
you have allergies) when you are questioned at the hospital.
You MAY receive envelopes or message cards on the day of the drill with instruction on them. Please
make sure to follow the directions.
At the hospital, you will need to complain of flu symptoms. If you are given a card that says you must
be admitted to the hospital, your symptoms need to be severe.
General Symptoms of Flu: (NOTE: Symptoms come on suddenly and all at once)

Fever (101 104 degrees F)


Headache in the front, temples, or top of your head
Extreme Tiredness (cant get out of bed, tired after taking a shower, walking to the bathroom,
being out of bed for a short period of time, etc.)
Weakness (like a dishrag, wet spaghetti, legs cant support you)
Dry Cough
Sore Throat
Runny Or Stuffy Nose
Muscle/Body Aches (even hair and fingernails hurt)

Stomach symptoms, such as nausea, vomiting, and diarrhea, also can occur but are more common in
children than adults
Complications of flu can include bacterial pneumonia, dehydration, and worsening of chronic medical
conditions, such as congestive heart failure, asthma, or diabetes. Children may get sinus problems
and ear infections.
Here are some Questions & Answers on the flu:
What is influenza (flu)?
Influenza, commonly called "the flu," is caused by the influenza virus, which infects the respiratory
tract (nose, throat, lungs). Unlike many other viral respiratory infections, such as the common cold,
the flu causes severe illness and life-threatening complications in many people.
What is the difference between a cold and the flu?
The flu and the common cold are both respiratory illnesses but they are caused by different viruses.
In general, the flu is worse than the common cold, and symptoms such as fever, body aches, extreme
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tiredness, and dry cough are more common and intense. Colds are usually milder than the flu.
People with colds are more likely to have a runny or stuffy nose. Colds generally do not result in
serious health problems, such as pneumonia, bacterial infections, or hospitalizations.
How do I find out if I have the flu?
Because these two types of illnesses have similar flu-like symptoms, it can be difficult (or even
impossible) to tell the difference between them based on symptoms alone. A test can confirm that an
illness is influenza if the patient is tested within the first two to three days after symptoms begin. In
addition, a doctor's examination may be needed to determine whether a person has another infection
that is a complication of influenza.
How do Flu viruses spread?
Flu viruses spread in respiratory droplets caused by coughing and sneezing. They usually spread
from person to person, though sometimes people become infected by touching something with flu
viruses on it and then touching their mouth or nose.
For how long is the Flu contagious?
Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to
5 days after becoming sick. Some young children and people with weakened immune systems may
be contagious for longer than a week. That means that you can pass on the flu to someone else
before you know you are sick, as well as while you are sick.
How soon will I get sick if I am exposed to the flu?
The time from when a person is exposed to flu virus to when symptoms begin is about one to four
days, with an average of about two days.
How long is someone sick with the flu?
Typically the flu resolves after 3--7days, but can persist for more than 2 weeks. Among certain
persons, the flu can make underlying medical conditions worse and can lead to pneumonia.
Complications of the flu can include pneumonia as well as other conditions.
How many people get sick or die from the flu every year?
Each flu season is unique, but it is estimated that, on average, approximately 5% to 20% of U.S.
residents get the flu, and more than 200,000 persons are hospitalized for flu-related complications
each year. About 36,000 Americans die on average per year from the complications

22

PATIENT SCENARIO:
WORRIED WELL PERSON WITH FLU ONSET AT HOSPITAL
Thank you for participating as a volunteer for our disaster drills. We appreciate your willingness to
assist us by playing the following part: You are quite convinced and worried that you are ill, but you
are not really physically ill at the time you get to a hospital emergency department for help. However,
once you get to the hospital, and while you are being examined, you actually do get physically sick
and this happens rapidly.
The following information will help you in your role playing. If any portion of these instructions is
unclear, please ask for assistance from a hospital staff member prior to the drill. You may keep this
document with you to use as a cheat sheet, but under no circumstances give it to the hospital
staff.
Your Role:
You enter the Emergency Department convinced you are sick, but, at that time, you really are just
worried. Once you begin to be examined, you develop a rapid onset of flu symptoms. Do not tell
the hospital staff that you have the flu.
Follow the Script Below:
1) When you are initially admitted in the Emergency Department:
You are very anxious and worried about getting sick. You should describe ONLY VAGUE
symptoms to the hospital staff do not mention a specific disease, ONLY the vague,
nonspecific symptoms. You can use your real name and provide other information (such as
whether you have allergies) when you are questioned at the hospital.
At the hospital, you will say that you came to the hospital because you are sick like other people at
your work. When asked how long you have been sick, answer, For a little while, maybe a day or
so. You complain of the following symptoms and display the following behaviors:

Symptoms
Complain that you are feeling restless, nervous and very worried about your health
Complain about the following symptoms but be vague.
Very tired
Muscle tension
Trouble sleeping
Heart is racing
The nurse in the emergency room may ask if you have other specific symptoms. If the nurse
asks specifically about other symptoms, answer kind of or sort of - you will be very, very
vague in admitting to whatever symptoms the nurse mentions For example, if asked,
Have you had a fever? Reply, I think so. Do not say that you took your temperature. If
asked, Do you have pain anywhere specifically? Reply, Kind of everywhere.

Behavior
Act significantly distressed but do not interfere with regular functioning of the
emergency room staff. Do not be disruptive! When you are being attended to, act very
upset, nervous crying, trembling, wringing your hands, rocking back and forth. Repeatedly
state such things as Im so sick and Im just getting worse here, or I really need help
because I know Im really sick.

2) While you are being evaluated/examined in the Emergency Room:

23

You develop actual flu symptoms. Flu symptoms come on quite rapidly. Do not tell the
hospital staff you have the flu. They will need to figure it out. While you are being examined, state,
in a frightened voice, Oh! My head just started to hurt very badly! Complain of all of a sudden feeling
extremely weak (and act extremely weak). Remember any of the other
symptoms of the flu (listed below) so that you can tell the hospital staff.

Symptoms
Fever (101 104 degrees F)
Headache in the front, temples, or top of your head
Extreme Tiredness
Weakness (like a dishrag, wet spaghetti, legs cant support you)
Dry cough
Sore throat
Runny or Stuffy Nose
Muscle/Body Aches (even hair and fingernails hurt)
Stomach symptoms, such as nausea, vomiting, and diarrhea, also can occur but are more
common in children than adults.

24

PATIENT SCENARIO:
WORRIED WELL PERSON
Thank you for participating as a volunteer for our disaster drills. We appreciate your willingness to
assist us by playing the part of someone who is quite convinced and worried that he/she is sick (but
he/she is really not physically sick) and comes to a hospital emergency department for help.
The following information will help you in your playacting roll. If any portion of these instructions is
unclear, please ask for assistance from a hospital staff member prior to the drill. You may keep this
document with you to use as a cheat sheet, but under no circumstances give it to the hospital
staff.
Your Role:
You are very anxious and worried about some physical symptoms you are experiencing. You
should describe ONLY VAGUE symptoms to the hospital staff do not mention a specific
disease, ONLY the symptoms. You can use your real name and provide other information (such as
whether you have allergies) when you are questioned at the hospital.
At the hospital, you will say that you came to the hospital because you are sick like other people at
your work. When asked how long you have been sick, answer, For a little while, maybe a day or
two. You complain of the following symptoms and display the following behaviors:
Symptoms:
Complain that you are feeling restless, nervous and very worried about your health.
Complain about the following symptoms but be vague.
Very tired
Muscle tension
Trouble sleeping
Heart is racing
The nurse in the emergency room may ask if you have other specific symptoms. If the nurse asks
specifically about other symptoms, answer kind of or sort of - you will admit to having whatever
symptoms the nurse mentions however, be very, very vague in your response. For example,
if asked, Have you had a fever? Reply, I think so. Do not say that you took your temperature. If
asked, Do you have pain anywhere specifically? Reply, Kind of everywhere. Continue to be
inexplicit.
Behavior:
Act significantly distressed but do not interfere with regular functioning of the emergency
room staff. When you are being attended to, do not be disruptive but act very upset, nervous
crying, trembling, wringing your hands, rocking back and forth. Repeatedly state such things as Im
so sick and Im just getting worse here, or I really need help because I know Im really sick.

25

PATIENT SCENARIO:
ADULT FEMALE PERSON OF SIZE
Background
You are part of the special needs population as a person of size, weighing 575 pounds.
Instructions
You will be provided with an inflatable Sumo costume and house dress to wear while at the hospital.
The suit comes with a fan that is inserted into a pocket on the right hand side at about waist level.
Turn the fan on just before you enter the hospital in order to inflate the suit. Make sure the pocket
zipper is closed so that the fan doesnt fall out.
When you are examined by the hospital personnel, tell them that you weigh 575 pounds. Make sure
you act as though you are really large; for example, if the staff asks you to get into a wheelchair,
tell them that you will not fit and that you need a larger one.
Ask to use the bathroom. Go to the bathroom, and when you come out tell a staff member that
when you sat on the toilet it came off the wall (if it is wall-mounted) or broke (if it is attached to
the floor) and water is going all over the floor. The staff should then call housekeeping and
the engineer.

PLEASE NOTE
Please do not laugh and joke about what you being asked to do; there are people that really are
large. They require special accommodations at the hospital, and that is what we are testing during
the drill. While the use of the Sumo suit may be amusing, props such as this make the drill
experience more realistic for the drill participants.

26

PATIENT SCENARIO:
ADULT HEARING IMPAIRED PERSON
Background
You are part of the special needs population as a hearing impaired person and are unable to hear
anything.
Instructions
When you are examined by the hospital personnel, tell them that you are unable to hear anything. If
they write questions on paper for you, you may answer them either verbally or by writing a response.
If the staff provides you with a sign language interpreter, let the interpreter know that you really dont
sign, but that you will pretend to sign. Ask the interpreter to verbalize the words they are signing. You
may then pretend to sign.

PLEASE NOTE
Please do not laugh and joke about what you being asked to do

27

PATIENT SCENARIO:
SPECIAL NEEDS INFANTS: INFANT WITH TRACHEOSTOMY

History
You have a 6 month old infant with a tracheostomy (a surgical opening that creates an airway in the
neck in order to bypass the upper airway due to inability to ventilate normally). A tracheostomy tube
is inserted into the stoma (opening) to maintain the airway patency (unblocked airway). The
tracheostomy was performed due to congenital tracheal stenosis, which is a narrowing of the lumen
(diameter) of the trachea. Your child is able to breathe on his/her own without a respirator. You
provide the tracheostomy care at home for your child which includes care of the tracheostomy tube
and suctioning as needed to remove accumulated secretions.
Instructions
Please inform the hospital staff that your child needs to be suctioned. Hospital staff should obtain
supplies to perform this (appropriate size suction catheter, normal saline, gloves, suction, bag valve
mask with O2). Once the child is suctioned, he/she is fine.

28

PATIENT SCENARIO:
SPECIAL NEEDS INFANTS: GASTROSTOMY TUBE (G-TUBE)

Gastrostomy tube (balloon tipped with


feeding port, medication port and
balloon inflation port)

History
You have an 8 month old infant with a gastrostomy tube, which is a feeding catheter that is surgically
inserted in through the abdomen wall directly into the stomach. Liquid feedings are attached to the Gtube to manage nutritional needs of children that are unable to take food or adequate amounts of food
by mouth for long periods of time. The G-tube was inserted three months ago for failure to thrive, a
condition where babies fail to gain weight as expected and is often accompanied by poor height
growth. Children with failure to thrive dont receive or are unable to take in, retain or utilize the
calories needed to gain weight and grow as expected. Failure to thrive is a general diagnosis, with
many possible causes. Most diagnoses of failure to thrive are made in infants and toddlers. Poor
nutrition during this period can have permanent negative effects on a childs mental development.
Causes can include: parents causing the failure to thrive by restricting the amount of calories they
give their infants, gastrointestinal conditions such as chronic diarrhea and cystic fibrosis (body cannot
absorb and retain food), cleft lip or a milk intolerance. In some cases, doctors are unable to pinpoint a
specific cause. In this case, the doctors are still trying to find the cause.
Instructions
Please inform the emergency department staff that it is time for your babys tube feeding and he/she
is hungry. Tell them your doctor said it is very important to give the feedings on time so your baby
can gain weight. Tell the staff he /she takes Similac 160 cc every four hours. Hospital staff should
obtain supplies for the feeding. Once they obtain the supplies, pretend they administer the feeding
and your baby is fine.

29

PATIENT SCENARIO:
SPECIAL NEEDS INFANTS: HOME OXYGEN THERAPY

History
You have a six month old infant with bronchopulmonary dysplasia (BPD), which is a chronic lung
disease that develops in low birth weight infants. Your child was born with respiratory distress
syndrome (RDS), a lung disease common in premature babies when they do not have enough
lubricant (surfactant) to keep their air sacs (alveoli) open. BPD can result from lung disease,
exposure to prolonged high oxygen concentrations and mechanical ventilation after birth. The
combination of fewer air sacs with a lack of surfactant can result in abnormally stiff lungs. This
increases the work of breathing causing fatigue.
BPD causes the most problems during the first year of life. Home management of BPD may include
oxygen therapy and respiratory medications to assist breathing.

30

Instructions
Your child is on continuous oxygen by nasal cannula at 2L/min. Today he/she feels hot and you think
he/she has a fever (you have not taken the childs temperature yet). Your child has also been cranky
and a little short of breath so you decided to bring him/her to the Emergency Department to be
checked out. Your child is not on any medications. Please tell the staff your oxygen tank is almost
empty and your child needs to be connected to oxygen.

31

APPENDIX D
Patient Scenario Materials

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

32

2006

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NASOPHARYNGEAL
SPECIMEN

NASOPHARYNGEAL
SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NASOPHARYNGEAL
SPECIMEN

NASOPHARYNGEAL
SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NASOPHARYNGEAL
SPECIMEN

NASOPHARYNGEAL
SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NASOPHARYNGEAL
SPECIMEN

NASOPHARYNGEAL
SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NOTE TO HOSPITAL STAFF: Follow your


hospitals normal procedures for specimens.

NASOPHARYNGEAL
SPECIMEN

NASOPHARYNGEAL
SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.

NOTE TO PATIENT: Give this to the hospital staff


if a swab of your nose is done.
33

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\NP-Specimen\NASOPHARYNGEAL LARGE ENV LABEL.doc

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

NOTE TO HOSPITAL STAFF: Transport the


Nasopharyngeal specimen in this envelope to the lab.
To be opened by the Lab ONLY.

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

TEST RESULTS FOR:


NASOPHARYNGEAL SPECIMEN

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.

NOTE TO LAB STAFF: Report results in usual manner


i.e., once normal test run time has elapsed.
34

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\NP-Specimen\NASOPHARYNGEAL SMALL ENV LABEL.doc

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Positive

Positive

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Positive

Positive

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Positive

Positive

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Positive

Positive
35

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Negative

Negative

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Negative

Negative

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Negative

Negative

Rapid Antigen Test


for Influenza

Rapid Antigen Test


for Influenza

Negative

Negative
36

All Other Tests for


Influenza

All Other Tests for


Influenza

Negative

Negative

All Other Tests for


Influenza

All Other Tests for


Influenza

Negative

Negative

All Other Tests for


Influenza

All Other Tests for


Influenza

Negative

Negative

All Other Tests for


Influenza

All Other Tests for


Influenza

Negative

Negative
37

All Other Tests for


Influenza

All Other Tests for


Influenza

Positive

Positive

All Other Tests for


Influenza

All Other Tests for


Influenza

Positive

Positive

All Other Tests for


Influenza

All Other Tests for


Influenza

Positive

Positive

All Other Tests for


Influenza

All Other Tests for


Influenza

Positive

Positive
38

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN

BLOOD SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN

BLOOD SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN

BLOOD SPECIMEN

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO PATIENT: Give this to the hospital staff


if they pretend to do Blood Tests.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

NOTE TO HOSPITAL STAFF: You must provide


your own appropriate empty Blood Specimen tube.
Follow normal procedures.

BLOOD SPECIMEN
NOTE TO PATIENT: Give this to the hospital staff
if they pretend to do Blood Tests.

BLOOD SPECIMEN
NOTE TO PATIENT: Give this to the hospital staff
if they pretend to do Blood Tests.

39
J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\Blood-Specimen\BLOOD SPECIMEN LARGE ENV LABEL.doc

CBC

CBC

Results: WNL

Results: WNL

CBC

CBC

Results: WNL

Results: WNL

CBC

CBC

Results: WNL

Results: WNL

CBC

CBC

Results: WNL

Results: WNL

40

CBC

CBC

Results:
WBC: 12.2
All else: WNL

Results:
WBC: 12.2
All else: WNL

CBC

CBC

Results:
WBC: 12.2
All else: WNL

Results:
WBC: 12.2
All else: WNL

CBC

CBC

Results:
WBC: 12.2
All else: WNL

Results:
WBC: 12.2
All else: WNL

CBC

CBC

Results:
WBC: 12.2
All else: WNL

Results:
WBC: 12.2
All else: WNL
41

All Other
Tests

All Other
Tests

Results: WNL

Results: WNL

All Other
Tests

All Other
Tests

Results: WNL

Results: WNL

All Other
Tests

All Other
Tests

Results: WNL

Results: WNL

All Other
Tests

All Other
Tests

Results: WNL

Results: WNL
42

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results

Blood Test Results

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results

Blood Test Results

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results

Blood Test Results

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO LAB STAFF: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

NOTE TO HOSPITAL STAFF: Transport this envelope


to the lab with the mock blood specimen (empty tube).
To be opened by lab only!

Blood Test Results


NOTE TO LAB STAFF: Report the results in the usual
manner using the appropriate time frame.

Blood Test Results


NOTE TO LAB STAFF: Report the results in the usual
manner using the appropriate time frame.

43
J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\Blood-Specimen\BLOOD SPECIMEN SMALL ENV LABEL.doc

X-RAY

X-RAY

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

X-RAY

X-RAY

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

X-RAY

X-RAY

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

X-RAY

X-RAY

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

X-RAY

X-RAY

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.

NOTE TO PATIENT: Give this to the


hospital staff if they take you to X-Ray.
44

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\X-Ray\X-RAY LARGE ENV LABEL.doc

Chest
X-RAY

Chest
X-RAY

Results:
WNL

Results:
WNL

Chest
X-RAY

Chest
X-RAY

Results:
WNL

Results:
WNL

Chest
X-RAY

Chest
X-RAY

Results:
WNL

Results:
WNL

Chest
X-RAY

Chest
X-RAY

Results:
WNL

Results:
WNL
45

Chest
X-RAY

Chest
X-RAY

Results:
Left lower lobe infiltrate

Results:
Left lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Left lower lobe infiltrate

Results:
Left lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Left lower lobe infiltrate

Results:
Left lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Left lower lobe infiltrate

Results:
Left lower lobe infiltrate
46

Chest
X-RAY

Chest
X-RAY

Results:
Right lower lobe infiltrate

Results:
Right lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Right lower lobe infiltrate

Results:
Right lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Right lower lobe infiltrate

Results:
Right lower lobe infiltrate

Chest
X-RAY

Chest
X-RAY

Results:
Right lower lobe infiltrate

Results:
Right lower lobe infiltrate
47

Chest
X-RAY

Chest
X-RAY

Results:
Bilateral lower lobe infiltrates

Results:
Bilateral lower lobe infiltrates

Chest
X-RAY

Chest
X-RAY

Results:
Bilateral lower lobe infiltrates

Results:
Bilateral lower lobe infiltrates

Chest
X-RAY

Chest
X-RAY

Results:
Bilateral lower lobe infiltrates

Results:
Bilateral lower lobe infiltrates

Chest
X-RAY

Chest
X-RAY

Results:
Bilateral lower lobe infiltrates

Results:
Bilateral lower lobe infiltrates
48

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

X-RAY RESULTS

X-RAY RESULTS

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

X-RAY RESULTS

X-RAY RESULTS

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

X-RAY RESULTS

X-RAY RESULTS

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

X-RAY RESULTS

X-RAY RESULTS

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

NOTE TO HOSPITAL STAFF: Transport this envelope


to X-Ray with the patient. To be opened by X-Ray only.

X-RAY RESULTS

X-RAY RESULTS

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.

NOTE TO X-RAY DEPT: Report the results in the usual


manner using the appropriate time frame.
49

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\X-Ray\X-RAY SMALL ENV LABEL.doc

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION

PRESCRIPTION

(Blank Form)

(Blank Form)

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION

PRESCRIPTION

(Blank Form)

(Blank Form)

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION

PRESCRIPTION

(Blank Form)

(Blank Form)

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION

PRESCRIPTION

(Blank Form)

(Blank Form)

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

NOTE TO HOSPITAL STAFF: If a prescription is


ordered, the physician should use the enclosed blank
prescription form.

PRESCRIPTION

PRESCRIPTION

(Blank Form)

(Blank Form)

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

NOTE TO PATIENT: Give this to the hospital staff if


you are told you will be getting a prescription or medication.

50

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\Pharmacy\PRESCRIPTION LARGE ENV LABEL.doc

PHYSICIAN: Write the prescription here

PHYSICIAN: Write the prescription here

PHYSICIAN: Write the prescription here

PHYSICIAN: Write the prescription here

PHYSICIAN: Write the prescription here

PHYSICIAN: Write the prescription here

51

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\Pharmacy\PHYSICIAN Prescription Form.doc

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

PRESCRIPTION

PRESCRIPTION

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

PRESCRIPTION

PRESCRIPTION

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

PRESCRIPTION

PRESCRIPTION

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

PRESCRIPTION

PRESCRIPTION

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

NOTE TO PATIENT: Transport this envelope to the


Pharmacy with the prescription.

PRESCRIPTION

PRESCRIPTION

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.

NOTE TO PHARMACIST: Dispense this candy as the


prescribed medication. Follow normal procedures using
your true inventory. If you run out, you cannot dispense
anything.
52

J:\CAPES\LO ONLY DRILL\2006\State Drill\CD-Materials\Envelopes\Pharmacy\PRESCRIPTION SMALL ENV LABEL.doc

APPENDIX E
Injects

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

53

2006

A
TWENTY-FIVE KINDERGARTEN CHILDREN
AND TWO TEACHERS FROM A NEARBY
ELEMENTARY SCHOOL ARRIVE IN THE ED
SEEKING TREATMENT. THEY ARE
COMPLAINING OF NOT FEELING WELL.
SOME OF THE CHILDREN HAVE BEEN
VOMITING. MANY CHILDREN DO NOT SPEAK
ENGLISH.

40% OF THE NURSING STAFF AND


30% OF THE HOUSEKEEPING
STAFF FOR THE NEXT SHIFT HAS
CALLED IN SICK.

EIGHT FAMILY MEMBERS HAVE ARRIVED LOOKING


FOR THEIR LOVED ONE. THEY TELL THE
RECEPTIONIST THAT THEY HEARD THEIR LOVED
ONE WAS NOT FEELING WELL; THEY DEMAND TO
SEE THEIR SICK FAMILY MEMBER.

TWO OF THE FAMILY MEMBERS ARE COUGHING


AND SNEEZING INCESSANTLY.

TWELVE OF THE CHILDREN FROM THE


ELEMENTARY SCHOOL REQUIRE ADMISSION
DUE TO DEHYDRATION. YOU ARE UNABLE
TO TRANSFER THE CHILDREN TO A
PEDIATRIC TERTIARY CARE CENTER DUE TO
UNAVAILABILITY OF INPATIENT BEDS.

PRESIDENT BUSH IS GIVING A COMMENCEMENT


SPEECH IN THE AREA. THERE ARE MASSIVE
TRAFFIC JAMS IN THE AREA AND FAMILY
MEMBERS THAT ARE COMING TO PICK UP
PATIENTS THAT HAVE BEEN DISCHARGED
CANNOT GET TO THE HOSPITAL. THE PATIENTS
AWAITING DISCHARGE ARE COMPLAINING THEY
ARE HUNGRY.

STAFF IS REFUSING TO GO HOME AT THE


END OF THEIR SHIFT. THEY ARE
WORRIED THAT THEY MIGHT BRING
WHATEVER THESE PATIENTS HAVE
HOME TO THEIR FAMILIES. SOME OF
THEM HAVE INDICATED THAT THEY ARE
PREPARED TO STAY FOR A WEEK OR
LONGER.

A CITY GARBAGE TRUCK HAS A BLOWN


TRANSMISSION WHILE ON A TRASH RUN
ACROSS FROM THE HOSPITAL ER ENTRANCE.
THE TRUCK CREW PARKED THE TRUCK AND
WAS PICKED UP BY ANOTHER CITY CREW. A
LARGE POOL OF TRANSMISSION FLUID HAS
FORMED AND IS FLOWING DOWNHILL TOWARDS
THE ER DOORS.

AFTER LEARNING THAT THE ED IS


EXPERIENCING A SIGNIFICANT NUMBER OF ILL
PATIENTS, PASTORAL CARE REPORTS THEY
HAVE 25 FAITH LEADERS IN THE HOSPITAL
THAT WERE AT A HOSPITAL-SPONSORED
LUNCHEON READY TO PROVIDE SPIRITUAL
AND PSYCHOSOCIAL SUPPORT TO PATIENTS,
VISITORS AND STAFF.

A LOCAL NEWS STATION IS REPORTING


THAT THE AREA IS IN THE MIDDLE OF AN
OUTBREAK OF PERTUSSIS (WHOOPING
COUGH). YOU HAVE NOT RECEIVED ANY
OFFICIAL COMMUNICATION FROM THE
LOCAL PUBLIC HEALTH DEPARTMENT.

THE LOCAL LONG TERM CARE


FACILITY CONTACTS THE HOSPITAL
AND INDICATES THEY ARE UNABLE TO
ACCEPT ANY TRANSFERS OF
DISCHARGED PATIENTS.

54

J:\CAPES\LO ONLY DRILL\2006\PATIENT SCENARIOS\Inject Labels.doc

THIS PATIENT NEEDS TO BE


ADMITTED

THIS PATIENT NEEDS TO BE


ADMITTED

THIS PATIENT NEEDS TO BE


ADMITTED

THIS PATIENT NEEDS TO BE


ADMITTED

THIS PATIENT NEEDS TO BE


ADMITTED

55

J:\CAPES\LO ONLY DRILL\2006\PATIENT SCENARIOS\Inject Labels.doc

APPENDIX F
Disaster Exercise
Evaluation Form

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

56

2006

MCHC
Metropolitan Chicago
Healthcare Council

222 South Riverside Plaza


Chicago, Illinois 60606-6010
Telephone (312)906-6000
Facsimile (312)627-9002
http://www.mchc.org

DISASTER EXERCISE EVALUATION FORM


For Hospitals Receiving Patients

Observer
(Name & Title)
Hospital Observed

Date

1.

Explain how the patients began arriving at the facility (e.g., ED, front lobby, from physician
offices, etc):

2.

Time the first patient/victim arrived:

a.m.

p.m.

3.

Did the hospital implement their emergency


management plan?

YES

NO

4.

Time hospital implemented emergency management


plan:

a.m.

p.m.

5.

What was the reason stated for implementing the plan?

6.

Was the HEOC1 staffed/opened?

7.

If not, provide the reason it was not staffed or opened.

YES

Hospital Emergency Operations Center

57

NO

8.

Were the following assessed?

YES

NO

N/A

a. Blood availability?
Time(s)
b. Monitored bed availability?
Time(s)
c. Total bed availability?
Time(s)
d. Decontamination availability?
Time(s)
e. Pediatric beds?
Time(s)
f. Specialty beds (i.e., burns)?
Time(s)
g. Adult ventilators?
Time(s)
h. Pediatric ventilators?
Time(s)
i. Combination adult/pediatric ventilators?
Time(s)
j. Pharmaceuticals?

9.

Were any external agencies/authorities notified?

10.

If yes, what was the response of each of the the agencies notified?
Agency

YES

Response

58

NO

11.

Were patients placed in isolation?

12.

If yes, what type of isolation was used (check all that apply)?

YES

NO

Airborne
Pre-existing negative pressure rooms
Temporary negative pressure rooms
Droplet
Contact
None
13.

Did staff wear (check all that apply):


Mask
Procedure/surgical mask
Mask with fluid & eye shield
N-95 respirator
Gloves
Gown

14.

Was there enough personal protective equipment


available?

YES

NO

15.

Was the facility adequately secured?

YES

NO

16.

Indicate how this was accomplished (check all that apply):


Access control
Crowd control
Traffic control
Other ______________________________________________________________________
___________________________________________________________________________

17.

Were alternative care sites within the facility


established?

18.

Indicate how this was accomplished:

19.

Were alternative care sites outside the facility


established?

59

YES

NO

YES

NO

20.

Indicate how this was accomplished (i.e., through an MOU2, etc ).

21.

Indicate how the facility addressed any special needs patients that were received:

22.

Was the facilitys family/visitor center activated?

YES

NO

DEPARTMENT SPECIFIC ISSUES


Laboratory
23. How many specimens were received by each lab area?
Chemistry
Hematology
Histology
Microbiology
24.

Were the mock specimens transported appropriately to


the lab?

YES

NO

25.

Were the mock specimens (and envelopes) labeled


correctly with the patients information?

YES

NO

26.

Were you able to report the results to someone


following your normal procedures?

YES

NO

YES

NO

Pharmacy
27.

Were patient prescriptions brought to the pharmacy?

28.

How many prescriptions were ordered?

29.

How many prescriptions were able to be filled based


upon the facilitys true inventory?

Memorandum of Understanding

60

Radiology
30.

Were the patients brought to x-ray?

YES

NO

31.

Was the transport of the patients appropriate and done


with the appropriate PPE?

YES

NO

32.

Was the x-ray department notified of any special


needs of the patients?

YES

NO

33.

Was the department able to handle any increased


volume of patients?

YES

NO

34.

Were the x-ray results communicated appropriately


and in the proper time frame?

YES

NO

35.

How many mock x-rays were taken?

36.

Total number of drill patients received :

37.

Differential diagnosis of patients:

38. Please indicate which departments in the facility and approximately how many staff in each
area participated in the exercise:
DEPARTMENT
Administration
Emergency Department
Facilities
Finance
Housekeeping
Human Resources
Infection Control
Laboratory
Materials Management
Medical Staff
Nursing
Pastoral Care
Pharmacy
Psychiatry
Public Affairs
Radiology
Respiratory
Security
Social Services
Other (specify)
Other (specify)
Other (specify)
Other (specify)

NUMBER OF STAFF PARTICIPANTS

61

39.

Comments on your observations:

Signature:

This report should be completed in duplicate: one copy to be left at the hospital observed,
one copy to be submitted to:

Clinical, Administrative, Professional


and Emergency Services
Metropolitan Chicago Healthcare Council
222 South Riverside Plaza, 19th Floor
Chicago, Illinois 60606
FAX: 312/627-9002

5/2006

62

APPENDIX G
Additional Evaluation
Material
(To Meet HRSA Grant Requirements)

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

63

2006

MCHC
Metropolitan Chicago
Healthcare Council

222 South Riverside Plaza


Chicago, Illinois 60606-6099
Telephone (312) 906-6000
Facsimile (312) 803-0661
TDD
(312) 906-6185

To Whom It May Concern:


MCHC and the councils HRSA grant partners have developed a means to perform a more
quantitative analysis of performance of drill/emergency response activity. The data collected will
allow MCHC and the grant partners to provide an enhanced report to the federal government
concerning drill activity and disaster preparedness in the State of Illinois. Your individual facilitys
data will be included anonymously in the overall analysis. The analysis of your facilitys data will
be made available to you for your use in emergency preparedness and compliance with JCAHO.
The first is the Department Evaluation Form which is to be completed by the director or designee
of selected departments at your facility. The second is the Department List which identifies the
departments selected for the 2006 drill. The third is the Individual Staff Member Questionnaire
which is to be completed by each staff member in the selected departments, whether or not they
participated in the recent drill. The Individual Staff Member Questionnaire allows for education of
all staff even if they did not have the opportunity to participate in the drill.
Please return the completed forms to MCHC with 14 days of the disaster exercise.
Thank you for your assistance. Please contact me at 312-906-6062 if you have any questions.

Patrick Finnegan
Director, CAPES

64
J:\CAPES\LO ONLY DRILL\2006\State Drill\HRSA-Ltr.DOC

Selected Departments for May 2006 Drill Analysis


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Admitting
Administrators-on-call/Nursing supervisors
Communications/Call Connection Center
Emergency Department (physicians, nurses, technicians, secretaries, and other
support staff)
HEICS Administrators
Infectious Disease/Infection Control
Laboratory
Media Relations
Nursing (Inpatient)
Pharmacy
Radiology
Respiratory
Safety & Security
Transportation
Trauma

Note on Department Evaluation Form if department report not applicable or if


department did not participate at your facility.

65

Page 1 of 2

__________________________________Hospital/Medical Center
Disaster/Emergency Response
Departmental Evaluation
Department: _______________________________________ Date: ______________________
Completed by (Chair/Manager or designate):______________________________________

Total number of Individual Staff Member Questionnaire distributed:


Total number of Individual Staff Member Questionnaire collected:
I. Emergency Response Plan(s) Activated:

Time:

II. Time notification received

Method of notification

III. Effectiveness of Hospital in Responding to Plan


(Please Grade on A, B, C, D, F traditional scale or indicate NA)
Criteria

Hospital Support
A

On-Site staff notification


Appropriate PPE available
Procurement and assignment of
staff
Procurement of supplies
Patient & family communication
Patient information flow
Media interface
Coordination with EMS, fire,
police, etc.
Recovery of normal operations
Staff support & debriefing

66

N/A

Page 2 of 2

IV. Effectiveness of Staff in Responding to Plan


(Please Grade on A, B, C, D, F traditional scale or indicate NA)
Criteria

Staff Knowledge & Performance


A

N/A

Location of plans
Assembly site
Notification of external authorities
Off-site staff notification
Assumption of responsibilities &
alternate roles
Appropriate PPE used
Patient management

V. Analysis
a.

Plan changes indicated:

______________________________________________________________________________
b.

Communication needs:

______________________________________________________________________________
c.

Personnel or Supply needs:

______________________________________________________________________________
d.

Staff education needs:

______________________________________________________________________________
f.

Helpfulness of drill as training exercise to accomplish objectives:

______________________________________________________________________________

g.

Other opportunities for improvement:

________________________________________________________________________

Please return forms to Emergency Management Committee Chair.

67

__________________________________Hospital/Medical Center
Disaster/Emergency Response
Staff Questionnaire
Name:____________________________________________ Date: ___________________________
Department:_____________________________ Position: __________________________________
1.

Estimate the total hours of all Mass Casualty Incident disaster/emergency response
training (excluding drills) you have participated in over past three years. Include
trauma, chemical, biological, radiation/nuclear & other events.
NONE

1-5

6-10

11-20

>20

Hours
2.

How many disaster drills have you participated in over the past three years?

3.

Where would you find the Emergency Response Plans for your department?

4.

Where should you go (assembly site) if a Mass Casualty plan is activated?

5.

What precautions are required in caring for patients with Influenza A?

Standard
6.

Droplet

Airborne

Is decontamination required for patients with possible Influenza?

7.

Contact
YES

NO

Is there a medication you can take to help prevent Influenza if you are exposed?

YES

NO

8.

What is the best way to prevent the spread of germs and contagious diseases?

9.

Did you participate in the Influenza disaster drill at your hospital on 5/13 or 5/20/06?

10.

YES

NO

If yes, how was the drill in preparing for you an epidemic?

Very helpful Helpful Slightly helpful Not helpful I am more confused

68

APPENDIX H
Lessons Learned
Worksheet

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

69

2006

MCHC
Metropolitan Chicago
Healthcare Council

2006 DISASTER EXERCISE


Lessons Learned Worksheet
Things your hospital did well:

Things your hospital could improve upon:

Hospital: _____________________________________ Completed


by:______________________________
Please forward this form to MCHC - FAX: 312-627-9002.

70

222 South Riverside Plaza


Chicago, Illinois 60606-6099
Telephone (312)906-6000
Facsimile (312)627-9002
TDD
(312)906-6185

FORMS

METROPOLITAN CHICAGO HEALTHCARE COUNCIL

71

2006

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM


SECTION PERSONNEL TIME SHEET
Date:

Hours: From:

Section: ________________________________
To:______________________

(Please Print)
Employee/Volunteer Name

Title/Job Class

Signature

Time In

Time Out

1
2
3
4
5
6
7
8
9
10
11
12
13
Certifying Officer:

Date/Time:______________________________________________

72

Total
Hours

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM


EMERGENCY INCIDENT MESSAGE FORM
_______________________________________________________________________________
FILL IN ALL INFORMATION
TO (Receiver):
____________________________________________________________
FROM (Sender):

_____________________________________________________________

DATE & TIME:

_____________________________________________________________

PRIORITY

 Urgent-Top

 Non Urgent-Moderate

 Informational-Low

Message:

Received By:

Time Received:

Comments:

Time Received:

Comments:

Forward To:

Received By:
Forward To:

KEEP ALL MESSAGE REQUESTS BRIEF, TO THE POINT AND VERY SPECIFIC.
Original: Receiver

Copy #1: Communications Officer

73

Copy #2: Sender

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM


ACTIVITY LOG
Date:

Section: ______________________________________
Individual Name:_______________________________

Position Title:
#

Time

Incident - Problem Situation

Action

1
2
3.
4
5
6
7
8
9
10
11
This form is intended for use by all individuals as an accounting of their personal action or the section activity.
Original: Immediate Supervisor or
Section Chief

Copy: Position/Section Documentation

74

HEICS
PROCUREMENT SUMMARY REPORT
#

P.O. #

Date/Time

Item/Service

Vendor

$ Amount

Requester

1
2
3
4
5
6
7
8
9
10
11
12
13

Certifying Officer:

Date/Time: ___________________________________

75

Approval

HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM


RESOURCE ACCOUNTING RECORD
Date:

Section: __________________________________

(Use military time 0000-2359)


Time

Item/Product Description

Received
From

Certifying Officer:

Dispensed To

Initials

Date/Time: ______________________
Original: Section Chief

Copy: Finance Chief

76

MCHC

POST-EXERCISE CRITIQUE FORM

PROBLEM/
IMPROVEMENT

SOLUTION

RESPONSIBLE
INDIVIDUAL

77

EXPECTED TIME
FOR COMPLETION

MCHC
Metropolitan Chicago
Healthcare Council

222 South Riverside Plaza


Chicago, Illinois 60606-6099
Telephone (312)906-6000
Facsimile (312)627-9002
TDD
(312)906-6185

The Metropolitan Chicago Healthcare Council (MCHC) is a membership and service association
comprising more than 140 hospitals and health care organizations working together, since 1935,
to improve the delivery of health care services in the greater metropolitan Chicago area. More
information is available on the MCHC Web site at www.mchc.org.
MCHCs Clinical, Administrative, Professional and Emergency Services (CAPES) department
provides information and support hospitals need to operate effectively and keep up with
evolving patient care, administrative and regulatory standards. CAPES assists hospitals in
addressing clinical, emergency preparedness and EMS, patient safety, ethics, environment of
care, infection control and perioperative issues.
CAPES provides a wide range of consultation, advocacy, education, networking, planning and
technical assistance services. These include regular electronic communication with participating
hospitals; development of guidance, resource and training documents on emerging topics;
regular member surveys and forums to identify important issues and exchange best practices;
and educational programs and seminars.
CAPES prepares hospitals for disasters by providing disaster bioterrorism preparedness training
and resources, and running disaster drills. CAPES supports and coordinates regional hospital
services should a disaster or terror attack strike. CAPES helps members develop the tools and
skills they need to meet patient care, safety and regulatory challenges and fulfill their
community service mission.
For more information contact Patrick Finnegan, director, CAPES (312) 906-6062,
pfinnega@mchc.com or Linnea ONeill, assistant director, CAPES, (312) 906-6061,
loneill@mchc.com.

78