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Local heroes: JCAHO says rural areas must be ready to stand alone
Joint Commission issues emergency planning guide
As the aftermath of Hurricane Katrina so dramatically showed, the initial community response to a natural disaster or terrorist attack has to be local.
"Like politics, every disaster is local," says Joseph L. Cappiello, vice president for accreditation field operations at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). "The community preparedness plan cannot say, 'If we have a disaster we will hold our breath until the cavalry comes.' That is not a plan."
While large cities have all-hazard disaster plans in place in the wake of 9/11, small communities may be relatively unprepared for a catastrophic event. To address that need, JCAHO published a step-by-step guide, Standing Together: An Emergency Planning Guide for America's Communities, to help small, rural, and suburban communities respond to major local and regional emergencies.1
The planning is applicable to a variety of events, including hurricanes, floods, terrorist attacks, major infectious outbreaks, hazardous materials spills, or other catastrophic occurrences. The document emphasizes two planning strategies of particular significance to small, rural, and suburban communities. The first is to enable people to care for themselves, and the second is to build on existing relationships.
"We're trying to prepare communities to stand alone if necessary," Cappiello says. "The magic hour, the accepted [timeframe] is 72 hours. If you can get past the 72-hour mark there is a pretty good chance that the state and federal government will be able to muster some resources to support you."
Many small communities in the United States struggle with emergency preparedness because they face common barriers. Those include lack of clarity about who is responsible for preparedness and response planning, what elements of the planning and response processes are critical, how to coordinate with state and federal emergency management programs, and how to obtain and sustain funding, JCAHO reports.
The JCAHO document is designed to remove such barriers by providing expert guidance on the emergency management planning process. The target audience is local leaders, including elected or appointed officials, health care practitioners and providers, and public health leaders.
"Our point of view comes from health care, but over the years, as we have looked at our emergency management standards and tried to think about how health care can be better prepared to deal with the issues of its community, it became apparent that the issue is the community," he says. "No matter what level of [accreditation] standards or requirements we put on health care, if there isn't connectivity between health care and the community it is all for naught."
Though the guidance document has been under development for some time, its publication is particularly timely in the wake of a series of domestic and global natural disasters. To develop the document, JCAHO partnered with the Illinois Department of Public Health, the Maryland Institute of Emergency Medical Services Systems, and the National Center for Emergency Preparedness at Columbia University and convened two expert roundtable meetings in May and October 2004. The meetings addressed the issue of emergency management planning in small, rural, and suburban communities; synthesized the challenges; and framed potential solutions. That resulted in the listing of 13 key preparedness components for small communities.
Planning that prepares the community to help itself can serve to reduce the potential surge in demand for services experienced during an actual emergency, JCAHO emphasizes. The plan needs to include a well-defined risk communication plan that contains information on the guidance that will be provided to the public and how that guidance will occur (for example, distribution of fliers or other written material, or public service announcements on local radio and television stations).
Some types of emergencies can be managed in homes with proper information, such as how to prevent and treat influenza in low-risk individuals during an outbreak in the community. For certain kinds of chemical exposures, the instruction to stay at home and take a shower rather than go to the hospital to be decontaminated is appropriate, JCAHO's plan states. Other types of emergencies will require mass evacuation, which is best supported by ongoing public communication, education, testing, and drills. With regard to the latter, many small communities may actually have disaster plans but typically few drills are conducted.
"It is partly a resource problem," Cappiello says. "Drills are not inexpensive. It takes staff time and the smaller the community the bigger the drain. Also, if you are really going to run drills effectively you have to run drills that continue to proceed until the system begins to break down. The value of drills is knowing what is not going to work. There is this belief that, 'We ran our drill and everything worked great so it's an A-plus, gold star drill.' It's exactly the opposite. If you run a drill that proves that everything that you are doing is correct you have learned nothing. That is not really a drill."
The guidance document emphasizes the important of drilling collaboratively.
"A lot of times communities drill with the triad of fire, police, and EMS, but they don't drill with their health care infrastructure," he says. "Or often times hospitals drill without the community. There are things learned in doing it that way, but they are not in sync. For community-based drills to be effective all players have to participate. Certainly, one of the key players is the health care system within the community."
The guidance recommends that communities consider such programs as the Community Emergency Response Teams (CERTs). A key component of Citizen Corps, the CERT program trains citizens to be better prepared to respond to emergency situations in their communities. When emergencies occur, CERT members can give critical support to first responders, provide immediate assistance to victims, and organize volunteers at a disaster site. The CERT program is a 20-hour course, typically delivered over a seven-week period by a local government agency, such as the emergency management agency or fire or police department. Training sessions cover disaster preparedness, disaster fire suppression, basic disaster medical operations, light search and rescue, and team operations. The training also includes a disaster simulation in which participants practice skills that they learned in the course.
"There are a number of things that the guide talks about that are available at the federal and state level," he says. "They are well established and communities can plug themselves in. We give them some ideas of how they can be employed in the community plan."
While resources and coordinated training are challenges, there may be a bigger obstacle to preparedness in rural and suburban communities.
"They may have a certain level of complacency," he says. "They are in middle America, a suburb or smaller community. They don't think of themselves as a terrorist target and may have not had weather [related disasters] in a number of years. They are not as tuned in to this as they probably should be. But the idea of planning is not just for a terrorist attack. It can be for anything that could eventually threaten the community — a natural disaster, pandemic flu, whatever. It allows a certain responsiveness for a variety of things."
Finding dual uses for existing or emerging capabilities is also particularly critical for resource-strapped small, rural, and suburban communities. A reverse 911 call system established by a community for law enforcement emergencies could also be used to communicate information about other types of emergencies. Motels and college dormitories can be used for additional bed capacity, the document states. Investments made by local public health departments in upgrading laboratory services for smallpox, severe acute respiratory syndrome, anthrax, and other specialized testing can buttress routine laboratory services in the community. Boats or school buses can provide alternative means of emergency transportation. Businesses with call-center capabilities can support community communication needs during a disaster.
1. Joint Commission on Accreditation of Healthcare Organizations. Standing Together: An Emergency Planning Guide for America's Communities, Chicago: JCAHO: 2005. http://www.jcaho.org.