All Entries in the "Emergency management" Category

A wrench in emergency planning for behavioral health facilities

Joint Commission (formerly JCAHO) standard EC.4.12, EP 7, requires hospitals to identify alternative sites for care, treatment, or service that meet the needs of patients during an emergency.

Behavioral health facilities run into a complication in this regard, because their options are likely to be somewhat more limited than those of a “regular” hospital.

I recommend that behavioral health facilities consult with their state departments of public health to help identify those resources for which it would be appropriate and, perhaps most importantly, useful to reach out to as alternate care sites.

Chances are, there are other organizations in your region that are in the same situation. This definitely has a lot of potential for “in helping one, we help all.”

If weapons of mass destruction are among your true worries . . .

While terrorism involving weapons of mass destruction (WMD) is possible, the defining question for hospitals is this: Is a WMD attack among those things for which we can reasonably expect to respond?

For most organizations, that answer would be probably not (never say never).

That being said, if you really feel that development of a WMD response plan for your organization is an appropriate utilization of resources, then my recommendation would be to start with your radiological and chemical exposure plans and build a terrorist scenario option into those plans.

The broader advice is to develop tight, functional, basic response plans and then weave in any nuances you might encounter.

You want this response plan to be as close to a “no-brainer” for staff members as you can possibly make it. If they know their first step is to take out the chemical exposure plan in the event of a WMD incident, that will get you the most consistent, appropriate response.

A federal emergency prep link to click

When developing or reviewing your emergency operations plan, it might not be a bad idea to come up with something that dovetails with the FEMA’s Homeland Security Exercise and Evaluation Program, which apparently represents a national standard for conducting emergency response exercises.

I can’t recall having run across this before in my travels (props to Steve Shea at Winchester Hospital in Winchester, MA, for bringing this to my attention), but it looks like a serious matter. It appears to tie in with eligibility for grant monies, etc., so it would seem that this is going to be, in my words, a big deal.

There’s a bunch of stuff through the link above, so run wild.

Speaking of EC.4.12 and the 96-hour rule . . .

My advice to clients has been to go through their hazard vulnerability analysis and identify those events that, either by themselves or in sequence, could result in community support and resources being inaccessible for a period of up to 96 hours.

Now my firm belief is that there are really very few events that would result in “isolation” of this magnitude, and if you know what those events would look like during incipient stages, you could probably take additional actions to mitigate that potential for isolation.

Additionally, I’ve also advised folks that once they have identified the cadre of events that meet the 96-hour mark, to further identify:

• Those events are likely to immediately result in that level of isolation
• Those events for which a period of time would pass before isolation sets in

Based on those deliberations, I tell folks to focus their planning activities accordingly.

What have you done to prepare for the 96-hour rule? Click the comments link below and let me know.

No plans for quick sand, meteors, or coffee running out

I have become rather reluctant, over time, to recommend that organizations develop too many event-specific disaster plans.

My best consultative advice is to focus on adoption and integration of an all-hazards approach to incident command (most folks seem to be going the HICS IV route). An adequately functional incident command process for your organization will serve you much better in the long run, as it is applicable regardless of the type of event.

Remember, the purpose, if you will, of an incident command structure is that you can respond appropriately to whatever emergency comes down the pike, regardless of its nature.

Emergency prep–it’s more than just compliance

When thinking about recovery efforts from disasters, you should consider Joint Commission (formerly JCAHO) standards EC.4.13 through EC.4.18, aka the six “critical areas” of emergency management:

• Communication
• Resources and assets
• Safety and security
• Staff responsibilities
• Utilities management
• Patient clinical and support activities

A key component of this whole process is coming up with a prioritized approach based on your organization’s real-life challenges. Once you’ve established the priorities, then it’s just a question (OK, with a whole heck of a lot of grunt work) to come up with the plan for each event.

But remember, there may be events for which you’re not going to have to address each of the critical areas, so if you don’t have to do it, don’t feel like there’s some sort of obligation to do so. Your responsibility is to prepare your organization in an appropriate fashion–no more, no less.

And so, when it comes to survey time, take an organized, logical approach to whatever the issue at hand might be.

Ultimately, the acid test is whether you are comfortable that you have prepared the organization to the extent necessary. If you can look yourself in the mirror and say, “We’re in good shape”–knowing full well that perfection in this area is nothing but elusive–then your comfort and confidence will carry the day during survey.

Compliance during survey is way down the list of objectives for this process. Adequate preparation for emergencies is everything, and Joint Commission compliance is a happy byproduct.

It’s not 96 hours or bust for EC.4.12

Contrary to popular interpretation, EC.4.12, EP #6 does not require hospitals to be self-sustaining for 96 hours.

No, really!

There is a note following this EP that indicates an “acceptable response effort would be to temporarily close or evacuate the facility, consistent with their designated role in their community response plan.” And, interestingly enough, this is a “B” element of performance, so the burden of proof is on the organization to determine what they need to do to meet this EP.

So, what EP #6 does require is that each organization has some sense of how such an event (effectively being cut off from the outside world for 96 hours) would be managed. Some hospitals might be able to do a 96-hour solo standing on their heads, while others might struggle to do 24 hours.

One of the clear lessons learned during Katrina is that many (if not most) of the hospitals involved didn’t know that an “acceptable” part of their response plan would be to get out in the event that they could no longer safely care for patients. I think this is partially the result of the whole “defend-in-place” strategy that has always applied to hospitals from a fire and life safety perspective. I think somehow defend-in-place crossed over into the management of disasters and catastrophes.

Don’t get tied down with event-specific emergency management plans

You will find surveyors who look for specific emergency response plans for each of your vulnerabilities identified in the HVA, which is not really a standards-based requirement.

That’s not to say there wouldn’t be a certain benefit to having some event-specific response plans–there are, after all, standards-based requirements for having specific plans relating to utility systems disruptions and medical equipment failures.

Only develop emergency response plans for specific events in a manner that makes sense to the organization. For instance, those hospitals in the northern half of the country probably don’t have to do a ton of planning relative to winter weather. Do you really need to have a documented policy or procedure to deal with a snow storm? I’d be inclined to think not.

As with just about anything in the EC that doesn’t involve specific requirements, what you do (or choose not to do) should be based on your risk assessment and then discussion at your safety committee or disaster planning committee.

The Joint Commission expects you to:

1. Look at the risks involved
2. Identify strategies for appropriately managing those risks
3. Implement those strategies
4. Monitor performance to make sure that everything turns out as you thought it would

When The Joint Commission reconfigured the emergency management standards, it moved towards a performance improvement model. I think we’ll see more of that kind of thing as the commission rolls out future standards revisions.

When a Joint Commission EP goes “ghost”

Suppose we have a pre-Nixon-era building in which we have not yet introduced emergency power into the patient rooms (no recent renovations of significance, etc.), but we do have emergency power outside each of the rooms.

The area complies with EC.7.20, EP #11 (providing emergency power for areas where electrically powered life-support equipment is used) because patients in this location don’t require ventilators and the usual run of life-support type equipment. If we had to provide emergency care, the defibrillator is plugged into emergency power out in the hall and, if really pressed, we could run an extension cord on a temporary basis into the room until the patient was stable enough for transport.

I mean, after all, we do have emergency power in this area “where electrically powered life-support equipment is used,” according to EP #11, so we-re on solid ground here–yes? Also, we’ve identified as a PFI plans to address this improvement opportunity, so again, we seem good to go.

Ah, not so fast grasshopper! It appears that, from a compliance standpoint, EP #11 is a veritable onion of a standard, with several layers of requirements that come into play.

Note EC chapter references to the American Institute of Architects’ Guidelines for Design and Construction of Hospitals and HealthCare Facilities (2001 edition) and NFPA 99, Standard For Healthcare Facilities (1999 edition).

Both of these august tracts reference a section of NFPA 70, National Electric Code, that requires hospitals to provide one duplex emergency power outlet per bed, connected to the critical branch of the emergency power distribution system, in general care patient rooms.

You might argue that when this building was constructed, these codes referenced above weren’t in effect, and you would be correct. But in a similar real-life case that I’m familiar with, an intrepid Joint Commission surveyor did not quite see it that way, resulting in an RFI under EC.7.20.

It took several back and forths with The Joint Commission before the determination was made that we had been in compliance with the EP as it was written in the standards, but the underlying NFPA 70 requirements had “caused” the noncompliance. Further relief came as the result of grandfathering this area’s configuration due to it not having been updated, since adoption of the applicable codes came long after the condition had been established.

So, the take-home lesson? It is in your best interest to use The Joint Commission’s clarification process and always:

• Look at what the surveyor has identified as the issue
• Lock at which EP is cited as the result of that identification
• Keep at it until you get relief

When a survey ends and you have any number of RFIs, start the clarification process as quickly as possible. Work with your organization’s survey coordinator, your Joint Commission account representative, even engage the assistance of a consultant–the important thing is to leave no stone unturned.

The last thing you want to have to do is to fix something that is not broken. In the long run, you have enough other things that legitimately require your attention.

24 + 24 + 24 + 24 = ?

In visiting with hospitals across the country since the unveiling of the new emergency management standards, there’s been an increasing murmur relative to the presence of a certain temporal indicator that you can find under EC.4.12, EP #6.

96 hours. Four days. 5,760 minutes.

That time span brings with it some questions:

• Is this a long time to be without the support of the local community?
• Does it vary within the six critical areas of EC.4.13 through EC.4.18 (communications, resource and asset management, safety and security, management of staff, management of utilities, and management of clinical and support activities)?
• Does it mean I need to have four days worth of stuff in my warehouse?
• What if I don’t have a warehouse?
• How prepared is prepared?

These are all excellent questions for which your organization is going to have to identify answers. For good or ill, there are no correct responses for these questions, and the practical applications are going to vary from organization to organization.

What’s important to remember is that this particular EP is not telling you that you have to do one thing or another (like having 96 hours worth of stuff in your warehouse). What is required is that you have a sense of what would happen if you were cut off from support for those 96 hours. Some organizations might be able to do 96 hours on their own with very little difficulty, while others might struggle to get to 48 or even 24 hours (probably not many in that group, but it is possible). The ultimate questions are: How far can you go? And what do you do when you’ve gone as far as you can go?

One of the clear lessons learned in the aftermath of Hurricane Katrina is that holding on past the point of reason is, well, not a reasonable strategy. But prior to recent tragedies, it’s almost as if the “defend-in-place” strategy of life safety management was carried across to the annals of emergency response. Right or wrong, getting out appeared to be entertained very infrequently in our response plans.

Now we know that in order to even approximate the safe management of a catastrophic event, we must consider the inconsiderable, think the unthinkable, try to gain some measure of control over situations that are, for all intents and purposes, uncontrollable.

What would we do if faced with an event of such magnitude? How far can we go? How do we tell when we’ve crossed that threshold? All questions to answer-and soon.