Tabletop drills not enough for testing disaster plan

But paper patients can suffice

Question: Our facility is not an acute-care hospital and does not provide emergency services, so we don’t expect to provide care in any community disaster. Do we still have to conduct the emergency preparedness drills that are required by the Joint Commission on Accreditation of Healthcare Organizations? Can we get by with doing just tabletop drills or using "paper patients" instead of people acting as victims?

Answer: Emergency preparedness plans and drills are getting more attention because of terrorist threats and recent revisions to accreditation requirements, raising questions about exactly what the Joint Commission requires, says Britton Berek, MBA, CCE, associate director in standards interpretation with the Joint Commission. The Joint Commission’s requirements for emergency planning are found in the "Environment of Care" chapter under EC.1.4, and the required drills are found in EC.2.9.1.

The emergency preparedness requirements were revised in 2001. Among other changes, the term "emergency preparedness" was changed to "emergency management" to focus more on the overall effects of an emergency rather than just what the health care provider does on the day of a disaster.

"Providers used to put all their effort into planning how they would respond on the day the disaster struck, planning how they would handle the influx of patients and the other problems that come with a hurricane or a snowstorm," Berek says.

"Under the revised standard, we want to see more focus on anticipating emergencies that could strike, and how you handle the long-term problems they bring. We’re thinking about problems like breaks in your supply chain and staffing issues when the flood goes on for days and people need to go home and take care of their own family," he says.

Health care providers are considering more types of possible emergencies than they might have before, which will please Joint Commission surveyors. Prior to Sept. 11, 2001, hospitals typically planned for bus crashes, severe storms, and similar emergencies that were considered likely. Now Berek says hospitals are broadening their scope to include terrorist acts such as bioterrorism and weapons of mass destruction.

How much you need to plan and drill for those emergencies will depend on your facility’s circumstances. No accredited facility is exempt from the requirement for emergency preparedness, Berek explains, but the Joint Commission expects your plans to be commensurate with the way in which you actually would be involved in an emergency.

A small outpatient clinic with no emergency services can get by with a relatively compact emergency preparedness plan, possibly a few paragraphs that detail how the clinic will shut down for the duration of the emergency or how the clinic will switch to cell phones when phone service is lost. But a larger facility providing emergency services must have a more complex plan, he adds.

Determining factor

A major determining factor is whether your facility is a "designated disaster receiving station." If you have an emergency department, you are. Even without an emergency department, you can declare yourself a receiving station if you think victims might seek help at your facility. But beware: Some facilities that might not normally be considered a receiving station still can be designated in times of emergency, Berek explains.

"If you’re a nursing home and have an arrangement with the hospital next door to offload less acute patients at your facility during an emergency, you’re a designated receiving station," he says.

Disaster receiving stations must plan for the influx of patients, which greatly increases the need for emergency planning and drills, Berek says. The Joint Commission requires two emergency preparedness drills per year — unless your organization meets certain standards that indicate you would have very little involvement in a community disaster, he points out.

The standard explains that if your facility provides only outpatient care, is not a designated disaster receiving center, and is "equivalent to business occupancy" as defined in the Life Safety Code, the Joint Commission requires only one drill per year. A physician’s office, for instance, probably would meet those criteria, he adds.

For all other health care providers, the Joint Commission requires two drills per year. If the facility is a designated receiving station, at least one of the drills must include rehearsing the influx of patients, he explains. The other drill may, if you choose, involve only an "internal" emergency such as the loss of utilities.

"The idea of the drills is to work out any kind of weaknesses in the plan," Berek says. "You have to force the stress on the organization to see if plans need to be changed or improvements can be made."

One source of confusion involves the use of tabletop drills instead of full-scale drills. Tabletop drills, in which you play out an emergency scenario by discussing it among involved parties, do not meet the requirements for twice-yearly testing of the emergency preparedness plan, Berek says. The two required drills must be actual physical drills involving all the necessary staff and departments. However, the Joint Commission allows a tabletop drill to suffice for one component of the required drills.

"If you’re designated as a receiving station, one of the drills must include interaction with community responders, such as your local fire department or civil defense," Berek says. "That can be difficult for some communities, especially if they have a lot of hospitals in the area that have to do that. So for this component, a tabletop drill meets the requirement. You can even get four or five hospitals together to do a tabletop drill with community responders in a conference room if you like."

The paper chase

Another common question concerns the use of paper patients — a packet of symptoms, vital signs, and similar information presented for care — instead of volunteers who pretend to be disaster victims. It used to be more common to enlist Boy Scouts or other groups to aid in drills, but some hospitals have found that liability concerns and other issues make that more difficult now. Berek says the Joint Commission accepts paper patients as an alternative.

"It still has to be an actual drill, even if you use paper patients," he says.

"You have to actually put the packet on a gurney and wheel it through the system just as you would a real patient, take it to X-ray to simulate the care a person would receive, and find it an available bed when the patient would get a bed," Berek concludes.

[For more information, contact:

  • Britton Berek, MBA, CCE, Associate Director in Standards Interpretation, Joint Commission on Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000.]