Providing care to patients during an emergency or disaster event is dependent upon having an effective response. Natural and human-made disasters can strain the capacity of healthcare facilities, disrupt care and treatment, and create potentially life-threatening situations.

Wentworth-Douglass Hospital (WDH) in Dover, New Hampshire, conducted an emergency preparedness drill on October 30, 2018, that involved more than 50 staff members and emergency responders from the community.

"We want to fail," Victoria Dillion, CHEC, emergency management coordinator at WDH told participants during training about the drill. "That is how we will learn what we need to improve." While the statement surprised participants, it also realigned their thinking about the drill. Hearing that the organization expected problems to occur during the drill, staff understood that the exercise was not about getting everything "right" but identifying what did not go as expected. Failures that occur during drills help an organization identify gaps in emergency procedures and provide the opportunity to improve processes before an actual emergency.

The scenario was based on a simulated mass-casualty event that occurred when an individual drove a truck into a pedestrian crowd at a fair in Dover.

According to Dillion, the exercise had four main goals:

• Test how well the hospital can continue to provide care during an emergency.
• Identify gaps in communications and information flow across the hospital.
• Assess the ability of executive leadership to make timely decisions.
• Evaluate processes to manage common operational and business impacts and response actions.

Many departments and personnel were involved in the drill, including the emergency department (ED), the operating suite, care coordination, behavioral health, transport, security, nursing education research and innovation, physicians, nurse supervisors, and incident command center staff. Responders from the local emergency medical services (EMS) also participated. Additionally, the hospital's auditorium wing was set aside to house a family assistance center and a behavioral health center.

The drill included a detailed timeline of events. Predrill orientations were used to educate the drill "evaluators," who were stationed across the hospital and took notes throughout, and "controllers," who provided drill situational updates. The hospital used standard hospital incident command system titles, forms, and job action sheets to document the drill activities.

"Victims" were staff acting as patients who came to the hospital for treatment. Ten "victims" were made up to look injured; a "cut-suit" was used to simulate serious injuries. Other simulated trauma included uncontrolled bleeding, internal injuries, shock, and emotional trauma. Some patients were able to speak, while others were unconscious and unable to communicate with the staff. The most seriously injured victim was a "smart dummy" on loan from a local medical supply company. The dummy had a GoPro camera that recorded its treatment throughout the drill; the video was reviewed after the drill. The video would later provide information on whether information was successfully communicated during the drill. 

While hospital staff knew a drill would take place that day, they were not given specifics. "Code White" was announced over the public address system throughout the hospital at 9:30 a.m. and the code was identified as a drill. A Code White announcement represents an internal or external event. Signs had been posted in all participating departments alerting patients that a drill was taking place. The hospital incident command center was activated at the start of the exercise and staffed by WDH executive leadership throughout the drill.

The drill was partly designed to test staff response to patient surge. All 10 patients arrived at the ED within six minutes of each other by a variety of transportation means. The first two patients arrived in private cars, almost simultaneously at 9:34 a.m. Dover EMS brought in two severely injured patients by ambulance—one within six minutes, and the other eight minutes after the code was initiated. Six additional patients walked into the ED within 10 minutes of the start of the drill.

Next came an onslaught of concerned family members; six different family members arrived within a 20-minute period. While the hospital previously performed hospital drills at least twice a year, this drill was the first time the hospital included staff posing as family members arriving at the hospital and needing staff attention. Family members were quickly escorted to the family assistance center to await information on their loved ones; this area was located far away from the ED.

To simulate the effect of information on social media, before the drill began, a staff member who would be posing as a family member took pictures of the bloodied victims. When she was brought to the family assistance center, she started sharing the pictures as if they were posted on social media. This heightened the stress of other family members waiting for information about their loved ones. Being faced with social media accounts of the event added to the burden of the family assistance staff. Ultimately, behavioral health staff tended to this "disruptive family member" and moved her to a different room. Social workers were present to help family members deal with their stress, fears, and concerns.

The drill ended around 11:00 a.m., 90 minutes after it began, with an announcement that the Code White was over. A detailed debriefing took place from 1:00 to 2:15 p.m.; an extensive cross-sectional group of more than 50 staff who participated in the drill attended the debriefing. The debriefing participants included WDH executive leadership, physician leadership, nurse supervisors, operating suite nurses, ED clinicians, behavioral health staff, administrative staff, security staff, emergency preparedness staff, and EMS participants. The simulated victims and families were asked for feedback on what went well and what could be improved; evaluators reported their observations. The participants were energized by the experience, eager to share what went well, and willing to offer suggestions for improved strategies.

Much of the emergency response went smoothly; the staff stated that they learned a lot but also acknowledged that the organization could improve its response in some areas. The hospital effectively managed patients and resources during the drill.

Areas identified for improvement included the following:

• Improve communication from incident command about the nature and scope of the event to staff throughout the hospital.
• Address communication gaps between the ED and the operating suite and the incident command center and behavioral health staff.
• Conduct a routine review of emergency supplies through preventive maintenance to ensure resources used during an emergency are not outdated (e.g., missing mass-casualty tags, wrong names on phone lists, old forms).
• Enhance communication method between the ED and staff tending to family members in the family assistance center and the behavioral health center (e.g., use dedicated runners). Because this drill was the first time these assistance centers were tested, the identified gaps were not unexpected.

A disaster drill should test elements of the organization's emergency management plan with the goal of training staff and improving the organization's ability to deal with disasters. The drill should include unanticipated or unexpected events that can cause confusion and disruption, just like those that can occur during a real disaster.

For more information on developing and planning a disaster drill, see the guidance article Disaster Drills and the self-assessment questionnaire Disaster Drills. Additional information is also available in the guidance articles Emergency Preparedness: Planning and Mitigation and Emergency Preparedness: Response and Recovery.

WDH is affiliated with the Partners HealthCare system, which also operates Massachusetts General Hospital and Brigham and Women's Hospital in Boston.