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Threats to continuity of care can come in many forms, and those with the responsibility of ensuring that continuity face new challenges every day. For example, how many health care executives were worried about bioterrorism 10 years ago? Was "going postal" as much a threat in the 1970s as it is at the dawn of the 21st century?
Because of these constantly changing realities, experts say, plans outlining a facility’s response to crises must be living documents, continually updated and tested. Many even have changed the names they give these plans, to reflect the evolution of their environment and the planning process.
"Instead of calling it disaster planning,’ it’s referred to more often now as emergency planning,’ and it’s much more broad," points out Debbie Zuege, RN, MS, operations director for medical specialty care with Kaiser Permanente in Denver. "There are a lot of different things you should be prepared for," she continues. "It’s not only the tornado that rips buildings apart; it could be a water main break or anything that disrupts your service. We’ve really seen an evolution of this process over the years."
"Preparedness starts with a risk assessment within your specific environment — areas in which your specific facility is potentially at risk," says Denny Thomas, CPHRM, director of risk management at St. Joseph’s Hospital/Ministry Healthcare in Marshfield, WI. "It can be anything from employees with issues to infant abduction. "Here, we have trains that go through our area that carry toxic agents," adds Thomas, who is also a board member of the American Society for Healthcare Risk Management in Chicago.
"If we have a derailment and toxic gas is being spread, we must be concerned with shutting down our air-handling system while still meeting patients’ needs," he adds. "So the type of preparedness required will be dictated by your environment. For example, we are in a dry area, so we’re not especially worried about floods or hurricanes — but tornados are a very real [threat]. Also, we are subject to severe winter storms, so we have to be concerned with maintain staffing levels."
David L. Tibbals, president of D.L. Tibbals Risk Management Consulting Inc. in Atlanta, advises organizations to do some investigation. "The first step is to really determine the array of potential risks that the hospital or health care provider could be exposed to," he says. "Take a long look at what that array is, and what the potential impact of each situation is. Then, determine what needs to be done and who will perform the functions necessary to mitigate the potential impact."
Observers agree that maintaining care during a crisis must be of paramount importance. "How you do that is dependent on the type of scenario you face," says Thomas. "For example, you may have a rapid influx of patients with an emergency. One facility I worked at had 100 patients arrive all at once due to carbon monoxide exposure; they were brought in by bus in respiratory distress. We needed to meet those unique needs; however, your [emergency department] must continue to operate as well. You need to ensure that staff levels are adequate, so alternative plans must be in place to meet the immediate needs of the disaster and still not place the other patients at risk."
Kaiser Permanente plans for emergencies in a number of broad categories, such as fire, tornados, bomb threats, power outages, earthquakes, flood and water main breaks, snow and ice, and hazardous materials, says Zuege. She notes that her committee must plan for an outpatient hospital, 16 medical offices, and 22 buildings.
"We always look at the safety of patients and employees first," she says. "We don’t want to put them in any kind of jeopardy. For example, we have a 12-story building, and if we can’t use the elevators, we have designated certain areas to which we have to stage. If you have to evacuate the building, you would do it by the stairs. There are certain procedures on emergency patient transport you learn as a health care provider. And, of course, most facilities have backup generators. In the [intensive care units], ventilators may not be working, so you have to be prepared to do it manually; you need to have more people for workarounds."
While emergencies may be unique situations, on one level they call for going back to the basics of nursing and health care delivery, Zuege points out. "We have all of this great equipment, and that’s awesome, but if you have a power outage over a long period of time you may have to end up closing your facility, or canceling every non-emergent procedure," she explains. "You have to start prioritizing. We have a six-bed ambulatory surgery department, and once when we had a six-hour power outage, we began canceling patients. We had one on the table, and we got [that patient] off as quickly as we could."
Do patients appreciate such a high level of preparedness? You’ll never see it reflected in a satisfaction survey, says Zuege. "I really don’t think they have any idea," she observes. "There are a lot of situations they are totally blind to; they don’t even know something’s going on. We do patient satisfaction surveys quarterly, and I’ve never seen dips or raises after an emergency."
It’s critically important that your facility’s emergency preparedness plan stay fluid, as well as current, says Thomas. "I’ve had the opportunity to engage in various disasters in Wisconsin, and when a plan was very descriptive but without latitude, it backed you into a corner.
"A good plan interfaces with the community; you need to know its capabilities," he continues. "One hospital I worked with had a very prescriptive plan on how to evacuate the building, including contacting the fire department, which, they asserted, had all the equipment.’ When I checked, the fire department had only one piece of apparatus to help move patients."
Your plan also must be kept current, Thomas advises. "Our facility even has a subcommittee that reports to the safety committee, to include another set of eyes and to keep the plan reality-based," he says. "And even though some people don’t care for outside agencies like the Joint Commission [on Accreditation of Healthcare Organizations], they are an excellent resource. They help keep your place up to date. To me, the survey process is a good risk-assessment tool. I’d much rather have them identify a potential gap and take corrective action than to place my facility at risk and have a potential disaster on my hands." (The Joint Commission also is continually updating its emergency preparedness standards. See "JCAHO standards add community emphasis," in this issue.)
Don’t assume that your community will remain unchanged from year to year, either, Thomas warns. "Some trends that historically were characteristic of large cities are now in suburban and rural areas, such as widespread violence or babies being abducted. You’ve got to look at which of these factors may affect you now, and where you may be potentially at risk," he observes. "Your staff need to be trained in early recognition; we’ve had a multidiscipline team put together a patient-assessment gradient. Now, upon admission, we can conduct an anger assessment, note any history of being arrested or convicted for violent crimes, and check for a history of domestic abuse."
Keeping your plan up to date requires constant vigilance, says Zuege. "Our committee meets every other month, and that’s where new issues get raised," she says. "We currently redo our policies and procedures every couple of years. They get dusted off on a fairly routine basis." Kaiser Permanente holds drills about twice a year, says Zuege. "Our committee decides what kind of drill it will be. This year, we will work with our central operators regarding how call-down works if we have to open our ECC [emergency command center]."
The drills have been very helpful, she says. "Every time we have one we find something out," she explains. "For example, the ECC used to be located on the first floor of this building, but through a drill we found that we had to move it."
"You’ve got to test the plan to make sure that it is really effective," Tibbals adds. "For example, will these people really be able to respond? Periodically, you also have to take a look at whether any new risks have emerged, either as a result of changes in internal operations, or perhaps external changes that have occurred in the surrounding environment."
A good way to do that is through a risk-management audit, says Tibbals. "An audit is essential and should be done, depending on your growth, certainly no less than on an annual basis, and perhaps every six months. It can either be done internally or with the periodic involvement of various outside sources, such as the fire department. And of course, it is routinely done within the mandates of the Joint Commission."
Finally, Zuege notes, there’s an added incentive for properly creating an emergency preparedness plan and updating it on a regular basis: chances are you’ll have to use it. "There have been a couple of times when we had to open our [ECC]," she recalls. "The most significant challenge was in March 2000; we are a unionized organization, and our professionals went on strike.
"[Opening the ECC] is a judgment call that is made by our vice president of operations, and it’s based on how significant and widespread the problem is. If somebody loses power in mid-summer for an hour, you probably won’t bring it up, but if a building is hit by a tornado, then for sure it will swing into action," Zuege adds.
For more information on emergency preparedness, contact:
• Denny Thomas, CPHRM, Director, Risk Management, St. Joseph’s Hospital/Ministry Healthcare, 611 St. Joseph’s Ave., Marshfield, WI 54449. Telephone: (715) 387-1713.
• Debbie Zuege, RN, MS, Operations Director for Medical Specialty Care, Kaiser Permanente, 2045 Franklin St., Denver, CO 80205. Tele-phone: (303) 861-3415.
• David L. Tibbals, President, D.L. Tibbals Risk Management Consulting Inc., 519 Johnson Ferry Road, Suite 430, Marietta, GA 30068. Telephone: (770) 565-1200. Fax: (770) 565-1204. E-mail: firstname.lastname@example.org.