As we discussed in our last blog post on Flexible Planning for Emergency Response, there are numerous types of emergencies and disasters that are taken into consideration when healthcare systems develop an emergency response plan.  The four FEMA emergency management phases are as follows:

Mitigation – preventing future emergencies and/or minimizing their effects.
Preparedness – proactively planning for disasters before they happen.
Response – the course of action taken in an emergency.
Recovery – returning to normal operation following emergency response.

As medical equipment planners, our team plays a variety of roles in helping our clients prepare for and respond to disaster situations.  In this blog post, we will discuss how we engage in each phase of emergency management.

Mitigation is defined as preventing future emergencies or minimizing their effects.  It includes any activities that prevent, reduce chances of, or reduce the damaging effects of emergencies. These activities occur both before and after emergencies.  Initiatives to mitigate emergency situations are often operational in nature and entail such things as community outreach, patient education, and preventative care. 
In the design world, because hospitals are built (in part) to respond to emergencies rather than prevent them, most flexible design discussions are geared toward minimizing the effect of emergency situations.  Most commonly, we see a combination of universal room design, overflow/surge units, and private rooms that can accommodate additional patients.
Universal Room Design (Versatility)
During design meetings, the subject of universal or ‘flex’ rooms often arises.  This is a common example of versatility in design.  In inpatient units, sections of a cardiology or med/surg ward can be converted to PCU or ICU when needed.  Headwall layouts are planned to allow the room to be used for both purposes.  Any additional equipment needed can be rolled in and out.  For equipment planning, the main difference is in choosing mobile equipment options and identifying storage locations for the mobile equipment.  This type of mitigation is commonly done for flu season but can be useful in almost any disaster.
Overflow/Surge Units (Scalability)
Another way that flexible design can assist in mitigation is through overflow rooms (scalability).  These rooms are part of the emergency management plan and can be activated quickly when needed.  A good example is the AIP Critical Care Annex at UCHealth’s Anschutz Medical Campus.  This 10-bed unit was converted and outfitted in Fall 2018 ahead of an intense flu season and has provided overflow/surge capacity ever since. 
Private to Semi-Private Conversion (Modifiability)
Another option for mitigation is designing rooms to handle multiple patients (modifiability).  This can be especially useful in an ED.  A second headwall in a patient room enables the ED to expand capacity quickly in an emergency.  The extra headwall can be hidden behind a panel to avoid giving patients the impression that they are not in a private room.
The Preparedness phase involves plans or preparations made to save lives and to help response and rescue operations.  Preparedness activities take place before the emergency or disaster happens and are often operational in nature.  Examples include developing evacuation plans, stocking up on supplies, negotiating mutual aid agreements, and creating sourcing plans. 
In most cases, hospitals do not have the resources to store and maintain excess medical equipment in anticipation of setting up a field hospital.  Even if storage space is available, there are labor costs associated with preventive maintenance that make this option infeasible.  Instead, hospitals negotiate mutual aid agreements and build sourcing plans to activate quickly.
Sourcing Plans and Mutual Aid Agreements
Strategic sourcing plans are a critical component of emergency preparedness.  When it comes to outfitting an overflow space or field hospital, sourcing plans can make all the difference in the time it takes to mobilize.
Sourcing plans can also be used to identify bottlenecks in the emergency response.  For example, if you are setting up a field hospital, crash carts are critical.  You cannot have any kind of inpatient facility without at least one crash cart.  Part of a standard crash cart configuration is a defibrillator.  These vary depending on the manufacturer, but some have 6-month lead times. Through review of procurement details, critical items with long lead times can be identified.  These items could be purchased as backup equipment or they could also become the focus of mutual aid agreements.
Mutual aid agreements are designed to allow multiple entities to share resources in emergency situations.  Many times, the shared resources consist of personnel, facilities, and supplies.  Healthcare organizations also use this type of arrangement to access expensive or long-lead-time equipment without purchasing it directly.  Mutual aid agreements can be activated quickly to enable rapid response to emergencies.
Another aspect of preparedness is emergency drills and training.  These can be physical exercises, such as life-safety drills, triage exercises, or day-in-the-life style training.  They can also be table-top exercises. 
Table-top exercises are useful both as prep for physical drills and as stand-alone activities.  For example, part of the emergency response plan might be to activate a field hospital.  A table-top exercise would enable the team to walk through the steps without expending resources on a complex exercise.  Both physical and table-top exercises are important to pair with flexible design activities. 
Designing alternative uses into a space is not sufficient for emergency preparedness.  Staff must also be aware of the changes that the emergency response plan makes to their environment.  Remembering the different procedures and workflows is not easy while under pressure.  Using exercises, muscle memory is built in and the actions become automatic.
The response phase is defined as responding safely to an emergency. It includes actions taken to save lives and prevent further property damage in an emergency. The Emergency Response Plan is put into action. These activities take place during an emergency.
Response actions vary widely depending on the type of emergency.  After all, a wildfire and a pandemic put different stresses on a healthcare facility.  Here are some examples, organized by Cadre’s flexibility attributes.
Versatility – Immediate Multifunctional Use
Screening stations can be set up at parking lot entrances. Since this is the entry-point for the facility, controlling access from there makes sense.  Very little extra signage or traffic control is needed since it is along a route that all patients travel.  Hotels and dorms are ready-outfitted quarantine facilities during outbreaks.  Churches and schools are often designated as check-in and evacuation locations during wildfires and hurricanes.  Very little configuration changes need to be made for the space to meet these new functions. 
Modifiability – Speedy Reconfiguration
Movable partitions can convert a lobby into a triage space. Private patient rooms can be changed shared rooms.  Rooms can be flexed to meet the needs of the emergency.  Overflow spaces can be activated.  In a pandemic, testing facilities can be set up almost anywhere, from inside existing buildings to tents in parking lots.  In other types of emergencies, triage spaces can be set up in any large facility.  School gymnasiums and churches are common locations. 
Convertibility – Ease of Re-Design in the Future
These responses require some construction.  Spaces are re-designed to a new purpose.  In a pandemic, it can be worth the construction cost and time to convert areas into patient rooms.  This can involve adding or removing walls and/or outlets (including med gases).  Stadiums and convention centers can be converted into temporary hospitals through the addition of modular walls. 
Scalability – Ease of Expansion or Contraction
Scalability solutions take time to implement.  Healthcare scalability is typically not useful most emergencies.  It is only an issue in drawn out disasters, such as a pandemic.  These solutions can be temporary or permanent.  Outfitting shell space in existing facilities is an example of a permanent solution.  It would not make sense to return it to shell space after the emergency is over.  A field hospital set up in the city park is an example of a temporary response.  When the emergency is over, the hospital will be taken down and the park will reopen.
Fluidity – Flow of Information
Flow of information is crucial to any emergency response.  During the preparedness phase, communication avenues should operate as normal, but this often changes after the onset of the emergency.  Establishing and distributing a communication plan as part of the mitigation phase can help offset the disruption this causes to the emergency response effort.  Identifying a space as the incident command center during design can also help.  A space designed to meet the space, utility, and equipment needs of a command center can be functioning quickly after the onset of the emergency.
This phase consists of actions taken to return to normal following an emergency.  These activities occur after an emergency.
One of the important activities that occurs during recovery is a review of the event.  This should be an all-inclusive review.  Opinions and comments should be collected by all players, including patients, first responders, medical and administrative personnel, etc.  Anyone involved in the response in any way can have an insight on what went well or poorly.  Once the data is compiled, it is applied to the emergency response plan.  Chances are there will be a few revisions or addendums.
Another important part of this phase is physically shifting operations back into their normal parameters.   As the temporary facilities (field hospitals, testing centers, etc.) are closed, the permanent facilities need to be ready to take over.  The field hospital will close before the last patients are ready to be discharged.  The remaining patients must be transferred to a permanent hospital.  As satellite testing centers shut down, communication must be clear on where the new location is.  Overflow wards are closed as the hospital census falls back into normal capacities.
Emergency management is a continuous cycle.  As recovery wraps up, the process rolls back into mitigation.  A good emergency management strategy balances prevention with preparation. Seasonal events can be counted on to test the plan regularly, but attention must also be given to the outliers. 
For example, flu season comes around every year.  Depending on the virulence of the yearly strain, the stress on hospital capacity varies.  However, most of the time, hospitals can take the additional stress through use of their overflow and flex spaces.  Since flu season comes around every year, many facilities have designed their response into their standard operations.  However, that does not mean that they are ready for any outbreak.  The established flu season operations can be a steppingstone to a response to a pandemic.  They may even mitigate the effect of the pandemic.  They will not, however, be sufficient to deal with the pandemic alone.
The emergency response plan must also address man-made incidents.  These can be explosions, fires, large-scale auto accidents, etc. They can be accidental or acts of terrorism. 
To prepare for an emergency, the response plan must be tested. Physical drills, table-top exercises, and data analysis are all useful tools.  The results of these tests show weaknesses in the plan.  They can also provide quantified support for flexible design options in the next construction project.

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