Joint Commission zeroes in on disaster plans: Is yours up to par?

As if the events of Sept. 11 weren’t enough to convince you to fine-tune your disaster plan, there is now another compelling reason. A new report issued by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations warns that surveyors will be paying "special attention" to your disaster plan. You also will need to comply with new Environment of Care standards that require a hazard vulnerability analysis, working with community groups, and educating staff. The new standards are EC.1.4: Planning for emergency management, EC.2.4: Implementing the emergency management plan, and EC.2.9: Conducting emergency drills.

"The Joint Commission wants to see disaster plans that address all possible hazards, including terrorist attacks," says Mary Schmidt Roth, RN, FNP, CCRN, an ED nurse practitioner at Jamaica (NY) Hospital Center. "This is new territory for most institutions, and frankly, for America," Roth says.

Here are ways to comply with the new Joint Commission standards for disaster planning:

• Ensure that staff can answer surveyors’ questions.

Your staff must be prepared to answer direct questions from surveyors, stresses Kathryn Perlman, MS, RN, clinical specialist for the ED at Presbyterian Hospital of Dallas. For example: "Does the unit participate in emergency preparedness drills regularly? What was your role in the most recent drill?" Perlman gives the following as an example of an appropriate response: "We have disaster drills twice a year. Our performance during the drill is evaluated afterward. I was responsible for directing family members to the holding area."

• Address large-scale decontamination.

You can’t get away with telling surveyors you’ll call the fire department to decontaminate patients, says Bettina Stopford, RN, chair of the national Weapons of Mass Destruction (WMD) work group for the Des Plaines, IL-based Emergency Nurses Association and chief nurse for the Denver-based U.S. Public Health Service’s Central U.S. National Medical Response Team for WMD. "Surveyors will ask What you will do if the fire department can’t come?’" Stopford warns.

She notes that before the terrorist attacks, surveyors had vague expectations for decontamination. "Usually if you could show them you had a shower room, you were OK," says Stopford. "But now they are looking for something more — they want to know how you would address a large-scale casualty event." At a bare minimum, show that you can provide patients with an area where they can undress and get rid of their contaminated clothing, she says.

Revamping the decontamination process was a key priority at East Jefferson General Hospital in Metairie, LA, according to Trudy A. Meehan, RN, CHE, administrative director of its ED. "Upon notification of a disaster, security will lock down the hospital, controlling all access to the ED," she says. "The ED ramps will be blocked so patients arriving by private vehicle cannot enter without going through the staging areas." The ED uses carts that contain everything needed to set up a triage station and decontamination area, says Meehan. "There will be a separate location to decontaminate patients arriving by ambulance," she says. "This entrance will also be used for those triaged as critical or acute who arrive by private vehicle once they have been decontaminated." The goal is that no patient crosses the ED threshold without decontamination, says Meehan.

A color-coded system is used for triage, using plastic arm bands (red for critical, yellow for acute, and green for nonurgent). "A change in the patient’s condition is a matter of replacing the arm band with one of the appropriate color," says Meehan. Paper tags were used previously, but patients could have lost them if they became wet during decontamination, Meehan explains.

The ED has requested approximately $100,000 to obtain additional personal protective equipment and three decontamination tents: one for male patients, one for female patients, and one for emergency medical services (EMS). Rollers allow patients to remain on boards during the decontamination process. Each can handle six patients at a time. "We need to be ready for larger volumes needing prompt decontamination, and that can only be done with more capability," says Meehan.

• Integrate with communitywide emergency response agencies.

Stopford suggests inviting representatives from the following four organizations to your ED during tabletop drills: the office of emergency management, police and fire departments, and EMS. "Those four groups can tell you where the bugs are and whether your plan is realistic, before you bring in your whole staff in," she says. Stopford notes that the tabletop exercise won’t satisfy the Joint Commission’s requirements for two annual disaster drills. "They both have to be live drills involving your staff. For one of those drills, they will potentially accept paper’ patients instead of real’ patients," she explains. "However, the paper patients must go through the entire system, not just the ED."

• Perform a hazard vulnerability analysis.

The new standards require you to analyze the areas where you are most vulnerable, says Stopford. "You also have to address how you will continue to provide medical care throughout the disaster, for each of these scenarios you identify," she says. Your analysis must have a terrorism component, says Stopford. "Many hospitals say they are not vulnerable to this, but this absolutely needs to be addressed," she adds. "You need to have a plan for personal protective equipment and decontamination ahead of time."

• Assess the amount of pharmaceuticals you have available.

The new standards require that you have enough pharmaceuticals to treat 100 victims and your staff for at least three days, says Stopford. "But people in larger cities probably need to have more. Surveyors realize that you can’t have unlimited drugs in a nonrotating stock, but you have to address this in your plan." You also should factor in treatment for the immediate family of staff members, says Stopford. "Your staff will not come to work if they are worried about their family being infected," she explains.

For bulk atropine needed for chemical agents, Stopford advises obtaining the reconstitution formula that the Department of Health and Human Services uses. "This is very inexpensive but you have to prepare it quite carefully," she says. "This is something you should already have on hand, because if a nerve agent casualty comes in, you can’t wait." (See excerpt of American Hospital Association checklist for equipment and supplies/training and personnel, below.)



• Establish alternative care sites.

You’ll need to select alternative care sites to care for patients if needed, says Gregory L. Terrell, MS, CSP, ARN, director of risk management at Children’s Hospital Medical Center of Dallas. When doing this, consider how you’ll handle medical records, patient tracking, communication between the ED and the site, and transportation of patients and equipment to the alternative care site, he adds.

• Have a plan to isolate patients if needed.

Meehan’s facility is going to use an unused wing of the hospital as an isolation ward if a bioterrorism attack occurs. "By re-routing the airflow in this area and keeping it isolated from the general public, we hope to keep further contamination from invading the facility," she says. "It is not unreasonable to assume, for the purposes of disaster planning, that an entire hospital could be quarantined."


For more information on disaster plans, contact:

Trudy A. Meehan, RN, CHE, Emergency Department, East Jefferson General Hospital, 4200 Houma Blvd., Metairie, LA 70006. Telephone: (504) 454-4018. Fax: (504) 456-5428. E-mail:

Kathryn Perlman, MS, RN, Emergency Department, Presbyterian Hospital of Dallas, 8200 Walnut Hill Lane, Dallas, TX 75231-4496. Telephone: (214) 345-6301. Fax: (214) 345-6486. E-mail:

Mary Schmidt Roth, RN, FNP, CCRN, Jamaica Hospital Center, 8900 Van Wyck Expressway, Jamaica, NY 11418. Telephone: (718) 206-6066. E-mail:

Bettina Stopford, RN, CNE, Denver Health Medical Center, 777 Bannock St., MC 0261, Denver, CO 80204. Telephone: (303) 436-4331. Fax: (303) 436-6213. E-mail:

Gregory L. Terrell, MS, CSP, ARN, Children’s Medical Center of Dallas, 1935 Motor St., Dallas, TX 75235. Telephone: (214) 456-2020. E-mail:


The Joint Commission on Accreditation of Healthcare Organizations has issued a special report advising health care organizations on ways to prepare for terrorists attacks involving nuclear, biological, or chemical incidents. It also contains lessons learned from hospitals in New York City and Washington, DC, following the Sept. 11 attacks. A copy of the report is available free of charge at (Click on "Publications," "Joint Commission Perspectives," "Past Issues," and "December 2001, Volume 21, Number 12 — Special Free Issue.")

The revised language on emergency management for standards EC.1.4 and EC.2.9.1 is included in the Revised Environment of Care Standards for the Comprehensive Accreditation Manual for Hospitals (CAMH). To order, contact: Joint Commission on Accreditation of Healthcare Organizations, PO Box 75751, Chicago, IL 60675. Telephone: (630) 792-5800, between 8 a.m. and 5 p.m. Central time on weekdays.