Program Details

Practice Type:	Promising
Program Name:	Brevard County Health Department Rapid Assist Surge Teams (BCHD RAST)
Organization:	Brevard County Health Department
Web site:
Overview:	Historically public health has worked to identify, assess, and control the presence of communicable diseases in our communities, and to prepare for and respond to natural disasters that could jeopardize the health and safety of its citizens. Since September 11, 2001, public health has taken the lead in responding to terrorist events as well. The Brevard County Health Department Rapid Assist Surge Team (BCHD RAST) model is our answer to filling in that early gap in providing care during a mass incident—natural or man made—in our community. Brevard County is centrally located along 72 miles of Florida’s eastern coastline with a higher than average density per square mile. It is well known for its beaches and nearby tourist destinations, such as Kennedy Space Center, Port Canaveral, Disney World, Sea World, and Universal Studios. Port Canaveral is second in size only to Miami as a United States cruise ship destination. A terrorist attack or mass event affecting our space or tourist industries would be a national event and provoke widespread panic—the utmost goal in terrorism. It wasn’t a terrorist event though, when in 2006, a Port Canaveral cruise ship with 3,400 passengers and 1,200 crew, “tilted” just outside of port. Brevard County’s mass incident plan was activated, emergency medical services responded to the scene, medical centers recalled staff for emergency duty, and the BCHD deftly handled the health and medical desk at the emergency operations center throughout the response. In the analysis of this event and its response, past lessons learned from multiple mass incidents such as the Madrid bombings, the Tokyo Sarin subway event, Israeli battle experiences, and Hurricane Katrina ran true to form. These rules demonstrate that most mass incidents occur during normal working hours, and what has been termed upside down triage, occurs at the hospitals. The “worried well,” self-referred survivors with minor or psychological injuries flood the local hospital’s emergency rooms. These worried well comprise 80 percent of the people seeking medical care and affect care for the more urgently injured 20 percent. Upon seeing these mass event rules play out in the “tilting” event, the BCHD took the lead, gathered its community partners, and identified the care of these walking wounded as part of its overall mission to protect the health and welfare of citizens, tourists, and visitors in Brevard County. Through this collaboration, the Brevard County Health Department Rapid Assist Surge Teams (BCHD RAST) was created. In this model, when a mass incident occurs in our county, our regular nonurgent county health department duties would be placed on hold and one of our RASTs would rapidly deploy to surge that early gap in care for the worried well before emergency hospital workers could arrive. The BCHD RAST model grew out of its core public health mandate to protect the health and welfare of its citizens and visitors. Analysis of mass incidents, compliance with national preparedness goals, and county disaster experience naturally mandated our local goal to provide rapid assistance surge team response to local hospitals to fill in the early gap of care for 100 percent of the worried well survivors of a mass incident in our county. To fulfill this goal, our objectives were to ensure that 100 percent of Brevard County Health Department’s medical staff are credentialed at each of our hospital systems, and trained in high quality response team logistics. The first real use of the BCHD RAST occurred nine months after our cruise ship tilting mass incident, when in April 2007, a Brevard County Housing Authority apartment complex in the city of Melbourne exploded. Fire officials responding to 911 calls alerting medical centers to expect many victims, who in turn called the BCHD and the RAST model was executed. Call downs placed teams at the ready, however when the smoke cleared, only three people required transport by emergency medical services and there was no worried well surge at the emergency rooms. Even though the BCHD RAST didn’t deploy, the success of the model was evident. Currently 100 percent of the BCHD RAST remain at the ready to respond to the closest hospital facility during normal working hours to bridge that early gap in the care for the walking wounded during a mass event.
Year Submitted:	2009
Responsiveness and Innovation:	On an international and national level, events such as the Madrid bombings, Tokyo Sarin gas attack, and 9/11 demonstrate the need for good community practices for mass incident response. Mass incident analysis demonstrate that events usually occur during normal business hours, and worried well survivors surge the local hospitals disaffecting care for the 20 percent who truly require tertiary care. Local experience with a Port Canaveral international cruise ship tilting event demonstrated that these lessons held true. The Brevard County Health Department (BCHD) in collaborative discussions with community partners identified the immediate response to the influx of the worried well to medical centers as a local preparedness need that could be filled with currently available community resources. Further dialogue led to the evident goal to provide rapid assistance surge team (RAST) response to local hospitals to fill in the early gap for 100 percent of the worried well survivors of a mass incident in our county. As part of its core public health mandate to protect the health and welfare of its citizens and visitors, and after a local mass international cruise ship tilting mass event, the BCHD gathered community health, medical, and emergency response colleagues to dialogue regarding mass incident response. These discussions led to community partnerships with mutual aid agreements culminating in the BCHD Rapid Assist Surge Teams (RAST) model; where BCHD workers, during their normal work day would immediately respond to support our local hospitals in a mass event. The BCHD RAST model practice grew out of both guiding principles of the National Response Framework and local experience with disaster management, and can be easily replicated in any locality. All communities must not only comply with Homeland Security Directive 8 to strengthen local preparedness capabilities, but as made evident by Hurricane Katrina and September 11, are ethically responsible for ensuring adequate local response to mass incidents. By following these guiding principles, the BCHD RAST is a natural triumphant outcome. The planned methodology assures clear communication and coordination among all entities and includes incident command training and national incident management system compliance, infection control practices, medical protocols and procedures, and response team logistics. This proactive response model has been successfully called upon once during an apartment complex explosion and has been triumphantly successful during multiple real time drills and table top exercises. As the current model evolved, the health department has assumed the lead role in implementation and coordination of activities on behalf of emergency management and health and medical partners. The model has also been adapted to comply with national, state, and local requirements for Alternate Medical Treatment Facilities and the Strategic National Stockpile. Predetermined medical and preparedness proficiencies and procedures assure clear communication and rapid action by all involved to meet the challenges of mass incidents including rapidly changing circumstances, delay of accurate information, media relations, and quick deployment of personnel through hazardous zones. A literature review using Medline Plus and using the key words, “mass casualty,” “mass incident,” and “public health preparedness,” was performed; and of the 901 references, none described a response team of county health department (CHD) staff rapidly surging to assist in local hospitals in a mass incident. Additionally, a Google search using these keywords returned more than 39 million hits, all of which could not be excluded, but the first three web page returns of each search were reviewed, and although there exist many plans, resource guides, and preparedness centers, none discussed the use of CHD staff in early worried well response using hospital resources. Mass incident response plans contain many common elements, including procedures and protocols and triage techniques. All discuss the fact that the worried well will flood the hospitals and suggest ways in which hospital staff can accommodate this influx or how hospitals can request mutual aid. After experiencing an international cruise ship with 4,600 aboard tilting just out of Port Canaveral, the Brevard County Health Department (BCHD) gathered community partners to discuss improving mass incident response with current available county resources. Analysis of our event demonstrated that the hospitals could not stand up, immediately necessitating a two- to four-hour window before full response capabilities. This interval is a critical time in mass incident response when the worried well inundate emergency departments disaffecting care for the more severely injured. As most mass incidents occur during normal working hours, BCHD through innovative collaboration created the Rapid Assist Response Teams (RAST) model where staff already at work could easily halt nonessential BCHD duties, and rapidly deploy to the closest medical facility to assist with the early influx of the worried well. The only start up needed was the creation of a Memorandum of Understanding between our entities and hospital credentialing of our employees. This is an innovative pooling of existing resources to cover the immediate first surge of the walking wounded after an event to our medical centers. This win-win situation incurs no extra costs for either the BCHD or the medical centers and provides immediate assistance for the worried well deluge. This one-of-a-kind BCHD RAST model could be easily implemented in any community to fill in that early gap before emergency hospital workers can report for duty.
Agency and Community Roles:	The Brevard County Health Department (BCHD) Rapid Assist Surge Team (RAST) model is partnership. Unique to our county, this proactive model works through a network of collaborative efforts first championed by the BCHD and supported by our county health, medical, and emergency management and response agencies to fill in that early surge interval. The BCHD has assumed the lead role in implementation and coordination of the RAST model and works with community stakeholders to ensure that it remains compliant with national, state, and local requirements, including Strategic National Stockpile, Points of Dispensing and Alternate Medical Treatment Facilities plans. BCHD incurs no extra costs to have our workers assist during normal business hours in the early care of the worried well. For an after-hours event, our Director can choose to implement RAST. In a governor declared state of emergency, financial obligations for nonbusiness hours pay would be easier to guarantee. And even though this model was created in the climate of preparedness existing in a state prone to hurricanes, tornadoes, wildfires, and floods, this model could be easily replicated by any other health department with medical workers to fill in that mass incident early response hiatus. This community-driven network long maintained by the BCHD grows through partnership driven evolution. The county medical centers were delighted to have the BCHD RAST accredited by their hospitals, offering their equipment and supplies. An extra successful outcome was that all county medical response agencies became trained in the same triage protocol, further fostering mass incident communication and teamwork. Completion of our county-wide mass fatality plan is another triumphant result with ongoing collaborative training and exercises building out further capacity and partnerships. Conjunctive efforts with fire and law enforcement from both the county and local municipalities, and with the local Florida Highway Patrol have also improved our response logistics and created information sharing and insight across disciplines. The BCHD helps maintain this network of stakeholders, but as this model’s partners’ missions all align, little effort is required to foster collaboration. This model functions as an interdependent community-based response to an essential public health preparedness need. Through these continued collaborative efforts, our county becomes better prepared for all eventualities. By allying together, this model fills the early surge gap, shares resources and costs, and creates buy-in for all response organizations who share the mission of ensuring the health and welfare of our citizens and visitors.
Costs and Expenditures:
Implementation:	On an international and national level, events such as the Madrid bombings, Tokyo Sarin gas attack, and 9/11 demonstrate the need for good community practices for mass incident response. Mass incident analysis demonstrate that events usually occur during normal business hours, and worried well survivors surge the local hospitals disaffecting care for the 20 percent who truly require tertiary care. Local experience with a Port Canaveral international cruise ship tilting event demonstrated that these lessons held true. The Brevard County Health Department (BCHD) in collaborative discussions with community partners identified the immediate response to the influx of the worried well to medical centers as a local preparedness need that could be filled with currently available community resources. Further dialogue led to the evident goal to provide rapid assistance surge team (RAST) response to local hospitals to fill in the early gap for 100 percent of the worried well survivors of a mass incident in our county. As part of its core public health mandate to protect the health and welfare of its citizens and visitors, and after a local mass international cruise ship tilting mass event, the BCHD gathered community health, medical, and emergency response colleagues to dialogue regarding mass incident response. These discussions led to community partnerships with mutual aid agreements culminating in the BCHD Rapid Assist Surge Teams (RAST) model; where BCHD workers, during their normal work day would immediately respond to support our local hospitals in a mass event. The BCHD RAST model practice grew out of both guiding principles of the National Response Framework and local experience with disaster management, and can be easily replicated in any locality. All communities must not only comply with Homeland Security Directive 8 to strengthen local preparedness capabilities, but as made evident by Hurricane Katrina and September 11, are ethically responsible for ensuring adequate local response to mass incidents. By following these guiding principles, the BCHD RAST is a natural triumphant outcome. The planned methodology assures clear communication and coordination among all entities and includes incident command training and national incident management system compliance, infection control practices, medical protocols and procedures, and response team logistics. This proactive response model has been successfully called upon once during an apartment complex explosion and has been triumphantly successful during multiple real time drills and table top exercises. As the current model evolved, the health department has assumed the lead role in implementation and coordination of activities on behalf of emergency management and health and medical partners. The model has also been adapted to comply with national, state, and local requirements for Alternate Medical Treatment Facilities and the Strategic National Stockpile. Predetermined medical and preparedness proficiencies and procedures assure clear communication and rapid action by all involved to meet the challenges of mass incidents including rapidly changing circumstances, delay of accurate information, media relations, and quick deployment of personnel through hazardous zones. A literature review using Medline Plus and using the key words, “mass casualty,” “mass incident,” and “public health preparedness,” was performed; and of the 901 references, none described a response team of county health department (CHD) staff rapidly surging to assist in local hospitals in a mass incident. Additionally, a Google search using these keywords returned more than 39 million hits, all of which could not be excluded, but the first three web page returns of each search were reviewed, and although there exist many plans, resource guides, and preparedness centers, none discussed the use of CHD staff in early worried well response using hospital resources. Mass incident response plans contain many common elements, including procedures and protocols and triage techniques. All discuss the fact that the worried well will flood the hospitals and suggest ways in which hospital staff can accommodate this influx or how hospitals can request mutual aid. After experiencing an international cruise ship with 4,600 aboard tilting just out of Port Canaveral, the Brevard County Health Department (BCHD) gathered community partners to discuss improving mass incident response with current available county resources. Analysis of our event demonstrated that the hospitals could not stand up, immediately necessitating a two- to four-hour window before full response capabilities. This interval is a critical time in mass incident response when the worried well inundate emergency departments disaffecting care for the more severely injured. As most mass incidents occur during normal working hours, BCHD through innovative collaboration created the Rapid Assist Response Teams (RAST) model where staff already at work could easily halt nonessential BCHD duties, and rapidly deploy to the closest medical facility to assist with the early influx of the worried well. The only start up needed was the creation of a Memorandum of Understanding between our entities and hospital credentialing of our employees. This is an innovative pooling of existing resources to cover the immediate first surge of the walking wounded after an event to our medical centers. This win-win situation incurs no extra costs for either the BCHD or the medical centers and provides immediate assistance for the worried well deluge. This one-of-a-kind BCHD RAST model could be easily implemented in any community to fill in that early gap before emergency hospital workers can report for duty.
Sustainability:	The sustainable nature of the BCHD RAST model actually derives from the strength of it community collaboration. Through stakeholder analysis of past international, national, and local disaster events, an obvious gap existed in our county’s ability to respond to the large influx of worried well. BCHD has taken the lead role in maintaining this model, and there will always remain a commitment from public health to respond to disasters. Maintaining this model not only requires very little effort, no extra funding, and can easily evolve to meet preparedness funding grant requirements, but it is the right thing to do. In this new age of preparedness, the entire community across all disciplines has a vested interest in ensuring the health and welfare of its citizens and visitors during a mass incident. Sustainability is realized because this model equitably meets the needs and missions of all involved with out the need for extra funding. As most mass events occur during normal business hours, any locality with health care staff, be they health department or community health center, can recreate this model at no cost to meet local needs. During a mass event in any region when alternate medical standards apply, local health center employees will appreciate the opportunity to serve their community in this front line gap of necessary capacity. As this model demonstrates its full effectiveness, it eventually serves as an interdependent community-based response to an essential public health preparedness need, thus perpetuating continuous buy-in from all involved.
Lessons Learned:	Information was not provided in 2009

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