Prepare for disaster with scenario-based planning

Scenario-based planning helps cover contingencies

You're a case manager in an ICU unit and your hospital is in the path of a Category 5 hurricane. How do you make sure your patients get to safety?

Or, you coordinate care for patients in an orthopedic unit at a hospital that is near a major dam that's about to break. Some of your patients must remain immobile following surgery; others who are almost ready for discharge live in a low-lying area. What do you do?

Suppose there is an earthquake. How will you get your patients moved out of harm's way when the roads are impassible?

Case managers can help their hospitals come up with solutions to these and other potential disasters by participating in scenario-based planning exercises, says Nathan Szenjniuk, a member of the Center for Healthcare Emergency Response, based in Nashville, TN.

Disaster planning is more than just drafting agreements and letters of understanding and putting them in a large book of complicated plans that nobody will have time to read when a disaster strikes, Szenjniuk asserts.

Decision making during a disaster

A lot of the work in a disaster goes into decision making, and people have to have an understanding of what they need to do, he adds.

"The real planning for a disaster occurs when the staff take the time to look at every single scenario that could happen and what the hospital's response will be. It all gets down to what you are going to do to get your patients out of the hospital safely. When you consider that it took nearly 44 hours to evacuate a hospital that was flooded during Hurricane Allison, you can see that having a system in advance of need is critical," Szenjniuk says.

He encourages case managers to meet with the physicians on their unit and the hospital's disaster planner periodically to discuss hypothetical situations in which patients may need to be moved and to brainstorm on ways to get patients safely out of the hospital and to another venue of care.

Look at the potential scenarios and determine what you need to do to keep your patients safe and what capabilities your hospital has to do so, he adds. Then, come up with where you can get the resources you don't have and develop a contingency plan. For instance, if you are a case manager in a 20-bed neonatal unit, know what other resources are available for your patients in case the hospital has to be evacuated. This means finding out what hospitals in the state have neonatal units, determining how long it will take to get your patients transferred there, and knowing what resources, such as ambulances and nurses, will be needed in order to transfer the patients safely, Szenjniuk says.

"What hospitals really need are simple planning matrixes that show how many hospitals there are in the state, what capacity each has for each kind of patient, travel distance, and travel time to each. This matrix can be used as simple planning tool," he says.

Think about how many people and what kind of resources will be needed to evacuate patients in case of a disaster. Look at where they can be moved, how they will be transported, and how long it will take. Determine who will coordinate the move, who will make the calls to facilitate transporting the patients, and who they will call.

Szenjniuk suggests developing a scenario and doing a trial run with a volunteer.

For instance, the scenario may be that the city is experiencing major flooding and water is already six feet high on the first floor of the hospital. How do you get an ICU patient to safety?

Look at what equipment such as portable ventilators will be needed, what kind of transportation will be necessary, and how you will get the patient to the transportation.

As an exercise, tape all of the equipment the typical ICU patient needs onto a volunteer and see what it takes and how long to move him to a place where he can be transported to safety. Suppose you have a patient who just had a laminectomy and has to remain immobile. Think about how you would transport him or her out of the hospital.

"Case managers should talk with physicians about how certain types of patients can be safely moved. Ask if someone who has to remain immobile would be better off being moved in a helicopter vs. a boat. Get the physician's first choice, second choice, etc. If Option 1 is not available, decide whether the physician has to be around to determine what Option 2 would be," Szenjniuk says.

Determine what your hospital's capabilities are for caring for the patients and where you will get whatever resources may be needed. "Capability-based planning is critical. It cannot be done in a vacuum. Everyone in the hospital has to work as a team with the hospital disaster planner who will interact with the county emergency planner," he says.

Hospital disaster planning is a dynamic process because the hospital has a different population with different needs every day. "You can't just make a disaster plan today and look at it again in 30 days," Szenjniuk says.

When case managers and physicians meet with the hospital's disaster planner, they should explore ways to tie critical disaster planning information to the medical record, starting with the preadmission orders, he says. "A disaster evacuation or disaster discharge plan needs to be part of the admissions process. Hospitals need to have a patient evacuation and tracking form within their admissions software and electronic medical records. Thinking about evacuation from the beginning is the only way to understand its impact on any given day," Szenjniuk adds.

Case management directors should encourage their staff to think beyond their day-to-day care of patients and keep in mind a contingency plan for every patient in case the hospital has to be evacuated, he suggests.

As soon as patients are admitted, case managers should keep in mind what would happen to the patient in the event of a disaster.

"The real issue is contingency planning. Plan in such a way as to know who you would use to move the patient safely if necessary," Szenjniuk says.