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ED Accreditation Update
Prepare for emergency management committee meeting as part of Joint Commission survey
Using a disaster tracer, surveyors will ask staff about their roles
Beginning this year, the Joint Commission on Accreditation of Healthcare Organization has added an emergency management committee meeting and a disaster tracer. The tracer will be conducted mostly as a tabletop exercise, with additional questions for your staff about their roles. While these steps will be taken only for all hospitals with more than 200 beds, many of the disaster planning exercises are helpful for facilities of every size, sources say.
"We’re digging in deeper to make sure not only that plans are in place, but to see that they’re working and that there’s substance behind what’s presented to us as to how they would work," says Jerry Gervais, CHFM, CHSP, engineer in the Standards Interpretation Group at the Joint Commission. No new standards have been added, but the Joint Commission will be evaluating disaster plans differently at the survey, he emphasizes.
John L. Hick, MD, medical director for emergency preparedness at Hennepin County Medical Center in Minneapolis says, "For those who have surveys upcoming, this is a wake-up call." This evaluation will be a priority, Hick emphasizes. "The Joint Commission used to not get into detail [with disaster plans]" he says. "That’s not the case anymore."
Consider these suggestions for your disaster planning:
• Be prepared to explore your disaster planning as a tabletop exercise.
The emergency plan will be the last item on the agenda at the environment of care (EOC) review, Gervais says. The plan will be reviewed in the hospital’s incident command center, and the full incident command team will attend, he says.
A mock disaster exercise will be conducted over 1½ hours without using any outside hospital staff, Gervais says. The disaster will be chosen from one of the top three potential disasters identified by the hospital’s hazard vulnerability analysis, he says. The exercise will begin with the surveyors describing a disaster scenario.
"With most emergencies, you’ll get some preliminary information" but not a lot of detail, Gervais says. The situation will escalate as more information comes available about the number of victims. "We’ll ask what would they do internally," he says. "We’re trying to assess that and, most importantly, how they would work together as a team to address issues."
Depending on how the exercise is progressing, it can be escalated or slowed down, he says. "If it’s going well, we’ll throw some more detail in to require them to dig deeper," Gervais says. "If it’s going poorly, we tend to slow down to see how things work."
At Maimonides Medical Center in Brooklyn, NY, the Emergency Management Committee (EMC) is reviewing the new Joint Commission publication "Surge Hospitals: Providing Safe Care in Emergencies" to be as thorough and compliant as possible with the recommendations, says Carl Ramsay, MD, medical director of the department of emergency medicine. Hospitals and communities must be prepared to establish temporary care facilities when a major disaster or disaster cripples the hospitals and forces patients and staff to evacuate. "That is a tall task and will be a significant challenge for most EMCs to undertake," Ramsay says.
• Your staff must be prepared to be questioned.
When that mock disaster session concludes, surveyors will go out into the operating areas of the hospital and question staff, Gervais says. Staff will be asked about what the surveyors were told during the mock disaster in terms of job responsibilities and supply availability. "We want to know if you’re walking your talk," Gervais says.
A mock disaster victim will be traced through the facility, he says. Hennepin County already has experienced this step at their recent survey, Hick says. The mock mass casualty incident involved a 60,000-seat domed stadium across the street from the hospital, he says. The victim was traced from the ED to surgery to intensive care, and even members of the housekeeping staff were questioned along the way, Hick says. "It was very across the board," he says.
Staff members were asked what their roles would be in the hypothetical disaster. "The surveyors didn’t want to talk to people on committees — just people who happened to be working that day," Hick says. In the ED, surveyors questioned the charge nurse about specifics including the location of disaster equipment, such as radios, and asked how the emergency nursing department would operate, he says.
• Have a backup ED person. Ensure that as part of your planning, you have a backup person in the ED responsible for disaster response, Gervais says.
"Emergencies aren’t ever scheduled, and you must be able to handle them 24/7, 365 days a year," he says. "Have more than one layer, in case someone is out of commission."
• Have public safety contact information.
Be prepared to give surveyors the name of the public safety contact persons, including those who work for the fire and police departments, and tell them how you would contact those people, Gervais says. This step is especially critical in an external disaster, he says. "You need formality in what for many places has been informal," Gervais says.
• Regardless of your size, have a plan for responding to biological and chemical disasters.
Gervais has seen many EDs scrambling to develop disaster plans for biological and chemical events. "Many aren’t prepared that well right now," he says.
Even rural hospitals need a plan, which can be as simple as transferring patients to larger facilities with more capabilities, Gervais says. All ED managers should keep in mind that there are more than 600 accidents every year involving chemicals, and those accidents can occur anywhere, he emphasizes. Also, epidemics can spread to any location, Gervais says.
"We’re warning hospitals to be prepared for what they would do if those types of patients presented: a biological epidemic, whether it be avian flu, SARS [severe acute respiratory syndrome], a terrorist attack releasing smallpox, etc.," Gervais says. "All are biological threats, and the hospital needs specific measures and plans to deal with that in its preplanning."
• Your staff must be trained, not just drilled.
Traditionally, EDs rely on drills to educate staff, Hick says. Drills are not training, he emphasizes. Training is providing education that health care workers need to accomplish the task, Hick says. A drill is when you show confidence in training previously delivered, he says. EDs have to provide training, and then test that training with drills, Hick says. "I think that’s the biggest problem" that hospitals have with their disaster preparation, he says.
For example, during a chemical event, ED managers need to be able to draw on hospital resources and staff and integrate with community resources for additional decontamination support, Hick says. Specifically, many hospitals are weak in their training for chemical decontamination, he says. "There’s been a lot of equipment purchased, but there is a deficit in training for people who are supposed to be operating that equipment."
• Use drills to help your disaster planning evolve.
Disaster planning is always on the mind of Dan Hanfling, MD, FACEP, director of emergency management and disaster medicine at Inova Health System in Falls Church, VA. Inova is located eight miles from the Pentagon, and two inhalation anthrax cases were diagnosed in the hospital’s ED. "We seem to be living here at the crossroads of disaster," Hanfling says.
The facility conducts two drills a year, then makes improvements based on the measurements and assessments of how well they’ve done, he says. In other words, disaster planning is not occurring in a vacuum, Hanfling says. "It’s happening in real time, and you’re forever learning and making improvement as your health system and community develops, and as threats change," he says. "In that regard, it’s a living, breathing process, not just an item on a shelf to be dusted every so often."
For more information on preparing for accreditation surveys, contact:
"Surge Hospitals: Providing Safe Care in Emergencies" includes case studies on temporary health care facilities established after Hurricanes Katrina and Rita. A free copy is available at www.jcaho.org/about+us/public+policy+initiatives/surge_hospital.htm.