A 96-hour wait: The Joint Commission's new emergency plan for hospitals

'Employee health should definitely be at the table for disaster planning'

It was an eerily familiar scenario: A huge storm barreled through the Gulf of Mexico with New Orleans in its sights. Hospitals began implementing their disaster plans, calling in employees who would remain on duty throughout the storm. Days later, yet another huge storm entered the Gulf, again threatening the region and straining health care resources.

The emergence this year of those two storms (Gustav and Ike) — just three years after Hurrican Katrina — reminded those involved in emergency management just how sudden and unpredictable disasters can be. That is why The Joint Commission revised its emergency management standard for 2008 to emphasize the need for hospitals to have a response plan that assumes no outside support for up to 96 hours — and to conduct at least one exercise a year that addresses that predicament. (The Joint Commission delayed the scoring of eight Elements of Performance until 2009 to give hospitals more time to collaborate within their communities.)

The U.S. Occupational Safety and Health Administration also announced that it is considering changes to standards to address emergency response and preparedness.

More is being expected of hospitals than ever before. "We now have eight separate standards that are all related [to emergency management] in much more detail on all the topics we consider to be important, with 45 additional elements of performance," says Jerry Gervais, CHSP, CHFM, associate director- engineer with The Joint Commission's Standards Interpretation Group, based in Oak Brook Terrace, IL. "The scope of what we're looking at, and the depth of what we're looking at, is markedly different [compared to the prior standard]."

Occupational health professionals should be a key part of hospital preparedness planning as hospitals review their programs, says Mark Russi, MD, director of occupational health at Yale-New Haven (CT) Hospital and associate professor of medicine and public health at the Yale University School of Medicine. "Occupational medicine is an expertise area for preparedness because we're dealing with exposures," he says.

Yale maintains stockpiles that range from antidotes for chemical exposures in the pharmacy to 200,000 N95s, stored in a building on the hospital campus. Annual drills keep employees' skills fresh — and remind them that the hospital has planned for their safety. That helps counteract the fear of working through a disaster or infectious disease outbreak. "It's part of what they end up weighing in the backs of their minds. 'Can I walk into that hospital and be safe?'" says Russi.

Toxic events happen '7 or 8 times a day'

Hurricane Katrina revealed much about the vulnerabilities of hospitals, and not just of those in the path of a storm. Small disasters happen literally every day around the country. In 2006, there were more than 6,000 hazardous material accidents involving railroad or truck incidents reports Gervais, citing federal government data.

"These were transportation accidents that released liquids or vapors into the atmosphere," he says. "It's occurring across the country seven or eight times a day, every day."

Katrina was a disaster of historic proportions. A Joint Commission analysis concluded that it actually comprised four distinct disasters: the hurricane itself, the levee breach and flooding, lawlessness and civil disturbance, and the breakdown in local, state and federal response.

A post-Katrina analysis influenced the Joint Commission to ramp up its expectations for hospitals to coordinate their plans with other hospitals and community entities.

"They compete against each other in normal operations, yet an emergency has a way of turning that around 180 degrees," says Gervais. "Your competitor may be your lifeline. Yet there was little being done to coordinate among facilities. You really should be working together in a disaster scenario to a common goal, and that's to serve the citizens of the community."

Hospitals must network with other hospitals to share supplies including personal protective equipment, Gervais says. That may mean making an arrangement with a hospital outside the immediate area that might not be affected by the same disaster scenario, he says.

In some states, health care professionals can risk losing their license if they fail to report to duty if summoned during a disaster. But whether or not your state has such a law on the books, your hospital still needs to consider how to accommodate employees' needs.

"You can't ask the nurse to leave the kids at home with no roof over their head, no running water, no food, and come to work," says Gervais. "It has nothing to do with your rank at all. It's a reality. If you're put into a horrible position of having to make the decision about taking care of your family or coming to work to take care of your employer's needs, there's no mystery about it. People simply don't show up."

The Joint Commission requires hospitals to survey their employees to find out what their employees' needs would be in case of disaster. For example, if schools are closed during a pandemic, will employees feel compelled to stay home to take care of their children?

You may or may not be able to take care of children, spouses, elderly parents, dogs, cats, and birds. In fact, agreeing to take in family members may have unintended consequences. For example, during Katrina, one hospital noted that one of its greatest challenges came from family members who had been cooped up for three days with no food, no water, no air conditioning, and no working bathroom facilities, says Gervais.

Explain the limits of what you can provide to employees' families during an emergency, and encourage employees to create personal plans to cover their gaps. "At least they'll know where they stand," says Gervais.

Drill baby drill

Annual drills, which are required by The Joint Commission, are an important way to continually educate employees so they'll feel comfortable with the measures they need to take during an emergency. It's a challenge to keep disaster planning on the front burner, says Russi.

The focus on possible disasters may rise or wane based on media reports. Amid news of new cases of avian influenza around the world, concerns grew about pandemic influenza. But when it recedes from public view, it also becomes less immediate for health care workers.

"Take advantage of times when there is greater public awareness, when the issue becomes active again," advises Russi. "That's a good time to provide lots of education to people because they're going to be receptive to it."

Meanwhile, assert the role of occupational health as critical to any planning effort. After all, a hospital's emergency response will be weak if there aren't enough health care providers to respond.

"Employee health should definitely be at the table for the disaster planning," says Russi. "None of these disaster plans work without the people. If employees are at risk [in a disaster scenario], it's critical to consider their health and safety in any of the planning that is done."

(Editor's note: A resource guide on emergency preparedness, "Disaster preparedness for Healthcare Facilities: Stories, Statistics, Solutions," is available from AHC Media, the parent company of HEH, at www.ahcpub.com. Resources also are available from Joint Commission Resources, www.jcrinc.com, including a book that incorporates case studies, titled "Emergency Management in Health Care: An All-Hazards Approach.")