June 08, 2011 | | Comments 1
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Questions you can’t answer (right away) are the hallmark of a useful emergency exercise

The “best” result you can really expect from an emergency response exercise is the identification of questions or issues that you can’t immediately resolve. That’s where you find your real improvement opportunities and/or vulnerabilities. There will always be quick fixes, but to find a real process opportunity—that’s real gold.

A client of mine recently happened upon one of these opportunities. (Now this may be something you’ve already dealt with—and good for you. Everybody comes to these things in their own way, form, time, etc. But if this is a concept you’ve not really addressed, then it’s something to consider for future exercises.)

The general scenario was one that resulted in an influx of patients. One of the downstream events during the exercise was that the ICU was directed by Incident Command to plan for the admission of pediatric and other patients who wouldn’t be considered typical to the populations served in the ICU. In the course of the exercise, concerns were raised by the ICU staff regarding how this “shift” would be accounted for in hospital policy, what happens to existing policies for “normal” operations, and the recognition that staff caring for these patients do not necessarily have demonstrated competencies relative to the needs of these patient populations. This finally led to the question of the accountability/liability of the hospital and any individual practitioner responding to the immediate needs.

As you can readily see, there are a lot of complications involved here, some of which are working in opposition. First we’ll start with Joint Commission requirement EM.02.02.11, EP 4, which requires the hospital to have a strategy for managing an increase in demand for clinical services for certain vulnerable populations, including pediatrics. Fortunately (I’m choosing to be optimistic about this), that’s pretty much all The Joint Commission says about it: we have to have a process, but how that process works is entirely up to us. The next complication is going to be under what circumstances would we need to plan for such an event? Would it be an emergency of such far-reaching consequences that the “normal” rules are suspended? In such a case, we may have a little leeway (note the “may” – more on that in a moment) in terms of how we emergently manage these patient populations, though I suspect that it will be of fairly limited duration (we could certainly look to post-Katrina New Orleans of an example of how “bad” things can get and there’ll still be someone to jump ugly on your decisions after the dust has cleared).

Part of our due diligence, now that the question is raised, is to consult with the state board of registration of nursing to see if they have any guidance. Clearly, we could get in a situation in which baseline competencies and scope of practice might be exceeded. From a risk management perspective, we need to have a very, very clear understanding of what that can and cannot mean. I can’t imagine that the question hasn’t been pondered by someone at the state level, maybe not quite as succinctly as this, but it’s a question that can equally apply to any and every healthcare organization in the state (not to mention the country, but I guess I just did). The other part of the due diligence would be to try and craft some basic expectations/competencies to be used as a framework during emergent events. I don’t know how much you could set up ahead of time (and I suppose from a compliance perspective, one would have to consider the merit of Memorandums of Understanding with healthcare organizations that may have ready access—and would be willing to share—to some of these “other” resources).

At any rate, this is something for which there is a regulatory expectation of planning and identification of response capabilities. Although the requirement does not force us to “have” these resources, it does require that we have a plan for managing such a situation should it arise.


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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Thanks for the great insight Steve. I really appreciate your comments and direction for digging into a system level change identified in the AAR evaluation and IP. I also applaud hospitals that are really willing to engage in this type of diligence for improving response competencies as well as meeting the needs of their communities while ensuring regulatory compliance. Just yesterday I attended a research presentation where 50 AAR’s were reviewed to demonstrate various levels of short and long-term corrective action plans. Sadly, a few of the plans simply “gamed” the AAR by identifying easy fixes to minimize the actual effort needed for the follow up. While I empathize with their intent, ultimately these short-cuts can only lead to disaster and are likely far from their organizations overall mission. Thanks again for your encouraging words.

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