NDMS Operational Readiness: A Proposed

OWG Sail Plan

CAPT Arthur J. French MD FACEPOperations WorkgroupNDMS Conference 2006

Vision vs. Policy

CAVEAT!NDMS Section sets policy- we

assist in development and implementation

OWG “vision” is where we hope to sail together based upon what we see as current capability gaps

NDMS OWG 2006 Goals

• Develop Concept of Operations (CONOPS)– Aligned with NDMS “Capstone” documents

i.e. “nesting”• Address “Report on the NDMS 2005

Hurricane Response” (Malcolm Pernie)• Develop recommendations for logistics,

training, and C4I aligned with CONOPS defined operational capabilities

CONOPS

Concept of Operations - (DOD) A verbal or graphic statement, in broad outline, of a commander's assumptions or intent in regard to an operation or series of operations. The concept of operations frequently is embodied in operation plans; The concept is designed to give an overall picture of the operation.

CONOPS vs FOG vs SOP

• Level 1 CONOPS: Overview, a brief concept summary of a disaster-related function, team, or capability.

• Level 2 Standard Operating Procedure or Operations Manual: A complete reference document, with procedures for performing a single function (SOP), or a number of interdependent functions (Ops Manual).

• Level 3 Field Operations Guide (FOG): A durable pocket or desk guide, containing essential nuts-and-bolts information needed to perform specific assignments or functions.

• Level 4Job Aid/Task Books: A checklist or other aid for job performance or job training.

“Nesting” of NDMS CONOPS & SOPs

• National Homeland Security Strategy– HSPDs/PDDs

• Department of Homeland Security– National Response Plan & NIMS– DHS & HSC “Capstone” documents

• Department of Health and Human Services– Agency for Healthcare Research and Quality– CDC & NIOSH

• DoD/SBCCOM Improved Response Program

HLS Capstone Documents

• National Planning Scenarios• DHS Universal Task List 2.1 (Dec 2004)• DHS Target Capabilities List: Version

2.0 (Jan 2005) • HSPD-8 National Preparedness Goal

(Dec 2005) • DHS National Preparedness Guidance?• Found at WWW.LLIS.GOV

National Planning Scenarios:

The NDMS “World of Work” • Nuclear Detonation

• Radiation Device• Biological- Anthrax• Biological-Influenza• Biological- Plague• Chemical- Nerve

Agent• Chemical-

Industrial

• Chemical- Blister• Chemical- Chlorine• Explosion- IED• Earthquake• Hurricane• Food

contamination• Foreign Animal

Disease

DHS Universal Task List 2.1

• NDMS-related Tasks– Incident Management– Command and Control

• Do we need an NDMS Response Team Task List?– NDMS Mission Essential Tasks Lists?– Team & position specific?– Scope of practice for clinical

providers?

DHS Target Capabilities List: Version 2.0

• How do we define capabilities of NDMS Response Teams and type teams per NIMS typing scheme?

• Does/ should one size fit all missions?– Currently only one type of DMAT/VMAT

• Should NDMS team typing be based on predesignated team capabilities versus operational readiness metrics?

HSPD-8 National Preparedness Goal

• “Standards for preparedness assessments and strategies”

• Critical Tasks– Associated Conditions– Performance Standards

• Competency-based training• Performance assessment standards• Preparedness scorecards

How Do We Incorporate HSPD-8 Capability Elements

Into NDMS?• Personnel• Planning• Organization & Leadership• Equipment & Systems• Training• Exercises, Evaluations, and Corrections • Personnel• Facilities

Team Capabilities & Typing: What’s Important & Why?

• NIMS aligned capability-based team typing to manage resources efficiently

• Type 1 not better than Type 2/ Type 3• Clinical operational capabilities (DMATs)• Non-clinical operational capabilities• Response capability “building blocks”

– Unit– Individual

Proposed Clinical Capability Parameters (DMAT)

• Defined Echelons/Levels of Care – Critical care vs acute care vs outpatient care

• Staff mix – physicians, nurses, allied health

• Biomedical equipment (EKG)• Medical supplies• Pharmacy operations• Laboratory capabilities (I-Stat, POC)• Diagnostic Imaging (US, X-ray, Doppler)

Can We Align Team Types With Mission Scenarios?

• Type 1- Level 1/2 emergency department with ICU (without surgery)

• Type 2- Level 2/3 community hospital emergency department without ICU

• Type 3- Outpatient clinic/ urgent care center

• Type 4- Forward needs assessment/ advance BOO C4I-coordinating team

Team Typing Versus Team Readiness: A Difference?

• Should all teams have same operational readiness requirements? – Ability to deploy within specified time with full

team– Training & qualifications current– Passed team performance assessment

• Team typing team readiness• Team type = groups of designed

operational-clinical capabilities• Team readiness = ability to meet their

type-defined operational-clinical capabilities

Individual Target Capabilities

• Front End Analysis: What is the NDMS responder’s “world of work”?– Human performance technology approach– Operational work– Clinical work

• Defined Competency-Based Training Requirements– Equipment skills checklist

• Deployment Checklists (job aids/ tasks books)

Beyond CONOPS: Other Potential Areas of OWG Focus• Patient safety and quality

improvement– Standardization of procedures– Defined privileges & qualifications

• Triage doctrine • Surge operations models• Patient movement doctrine (PRT)• Clinical practice guidelines

Clinical Privileging

• Privileging vs credentialing vs qualifications– Privileging applies to scope of patient care– Qualifications applies to skills

• All physicians should be “resuscitationists”– Require ACLS-EP, PALS,ATLS, FCCM?

• Establish core NDMS acute care privileges?– Define minimum competencies e.g. GMO

• Non-intensivist critical care providers? – ED/ICU RNs

Which Triage System is Best? • Need ESF-8 standardization

– NDMS– VA– DoD– HHS

• Primary triage – situationally dependent– START?– Sacco Triage Method ?

• Secondary triage - disease vs. injury?– AHRQ Emergency Severity Index

Patient Movement Issues

• Patient Reception Team SOPs• Patient transport equipment (litters-gurneys)• Joint medical operations

– NDMS-DoD-VA interoperability– State-local- EMS aeromedical interoperability

• DoD medical regulating procedures/policies• NDMS-DoD common patient movement items

– Integrated critical care modules (SMEED, LSTAT)

How Can We Leverage Existing Federal Models?

• AHRQ & CDC– “Alternate Care Site Selection Tool” – “Community-Based Mass Prophylaxis: A

Planning Guide for Public Health Preparedness”

– “Smallpox Response Plan and Guidelines”– “Pandemic Influenza: A Planning Guide for

State and Local Officials”

• SBCCOM Improved Response Program– “Acute Care Center: A Mass Casualty Care

Strategy for Biological Terrorism Incidents”

Surge Capacity Protocols

• HHS-DoD Improved Response Program

• HHS Agency for Healthcare Research and Quality (AHRQ)– Surge operations models & protocols

• Centers for Disease Control and Prevention (CDC)– Bioterrorism/ pandemic protocols

Possible Clinical Guidelines?

• Infectious disease Rx (SARS, influenza)

• Critical care surge triage– Physician-nurse staff ratios– Indications for mechanical ventilation

• CBRNE triage-treatment• Palliative Rx • Dialysis criteria & priority of patients

C4I – Situational Awareness

• Command, Control, Communications, Computers, and Intelligence

• “Battlefield information dominance” elements– Team comms, wireless LANs, telemedicine– Electronic Patient Tracking– PDAs (BMIS-T) performance support systems– Electronic Medical Records – decision support

• Use of patient simulators for NDMS FTXs?• Tabletop computer modeling and simulation

for NDMS command & control exercises

C4I Interoperability

• DHS SAFECOM Project– “Statement of Requirements for

Public Safety Wireless Communications & Interoperability”

• Integrated Wireless Network (IWN)• Integrated Patient Tracking

Initiative– COMCARE Alliance

Tiered IMT (MST) Deployment?

• Do we need Type 1, 2, & 3 IMTs?– Group Supervisors?

• Group/ Task Force IMT C4I teams scaled & aligned with missions & geography to maintain span of control in AOR

• How should IMT be staffed?– External - FT/PT NDMS, NDMS-1– Internal - recruit from on-scene team staffs

• IMT position qualifications-designations?

NDMS Is a “System of Systems”

The OWG Can’t Do This Alone!• Intra-NDMS collaboration

– NDMS staff– Senior Medical Policy Group– MWG, DPWG, TWG, & LWG

• External collaboration – ACEP Disaster Section

• Electronic collaboration- Disaster Help