The Joint Commission is watching: Is your disaster response plan in order?

Terror attacks are more likely as presidential election approaches

So you’ve worked long and hard at putting an effective plan in place to respond to emergency incidents, and your feel you’re as prepared as you can possibly be. Then, the attorney general comes on the TV and says there’s an increased threat of a terrorist attack as we approach the fall presidential campaign, and we all need to be better prepared. You look at the tube in frustration and say, But I’ve done everything I can!’ . . . But have you?

"Is every single hospital in the United States perfectly prepared? I would be silly if I said yes," said Charles A. Schable, MS, director of the National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC).1

The Joint Commission on Accreditation of Healthcare Organizations now requires hospitals to implement their emergency management approach through a Hospital Emergency Incident Command System (HEICS), and preparedness is an area of focus for surveyors, says Steven J. Davidson, MD, MBA, FACEP, chairman of the department of emergency medicine at Maimonides Medical Center in New York City.

"Presuming that people have implemented a HEICS, they now have the opportunity to operate it with regularity," Davidson advises.

HEICS is a generic crisis management plan expressly for comprehensive medical facilities; it is modeled closely after the Fire Service Incident Command System. HEICS was created in the 1960s to help multiple agencies work together to deal with disasters such as wildfires. Davidson’s own hospital completed a switch to HEICS in June.

It is imperative for ED managers to revisit their major incident plans, agrees James J. Augustine, MD, FACEP, vice chair of clinical operations in the department of emergency medicine at Emory University in Atlanta and director of clinical operations at EMP, a physicians group based in Canton, OH.

"After what happened in Madrid, terrorists learned they could manipulate a political process based on their activities," he observes. (Editor’s note: On March 11, 2004, terrorists bombed a commuter train in the Spanish capital, killing nearly 200 and wounding 1,400.) "You would have to think that with a major election time coming up and very bad feelings about America based on recent events, we are at a dreadful crossroads where people want to do terrible things to our country."

Broaden your horizons

To be adequately prepared for a disaster, take these steps:

  • Prepare for various levels of incidents.

ED managers need to look beyond a repeat of 9/11, Augustine warns. The world is different now, he says. Bioterrorism and dirty bomb plots are real, he adds.

"We ask ED managers to broaden their horizons and be able to apply a little more science to how we face challenging patient encounters," he says. "Our plan has to include events where something terribly unexpected happens." These can include events such as a tornado striking the area or a major train derailment/hazardous material release.

But preparation should not be limited to only the most serious incidents, adds Davidson. "Hospital systems can and should be prepared at levels appropriate to occurrences, and those may happen at a Level 1 or where there’s an incident with potential for producing casualties that don’t happen, like a severe thunderstorm watch, where you also could lose power," he explains.

A fire alarm in the hospital also can spur a Level 1 activation of HEICS, he says. "This begins preparing the organization for thinking in this way and becoming fluent in communicating through the system should bigger things happen," he explains.

Each level of HEICS hones preparedness that much more, Davidson says. For example, Level 2 presupposes a minor impact on hospital operations. "It may be nothing more than holding more patients than anticipated in an overcrowded ER," he notes.

But such all-level preparedness is critical, says Davidson. "You are appropriately rehearsing, and as an ED leader, that is your case to make to your management: Let’s activate HEICS in Level 1 every time we know we’re having a bad thunderstorm.’ In other words, Let’s practice.’"

Augustine agrees with the importance of practice. "Have every department in your hospital conduct at least a small drill," he says.

  • Reassure staff about safety and communication.

In times of increased danger, it also is important to reassure staff, says Augustine. "It’s appropriate to let staff know that everything will be done to protect their safety," he advises.

Provide this reassurance on an everyday basis, with scourges such as tuberculosis or methicillin-resistant Staphylococcus aureus. "Make sure you have developed a good security plan and good lockdown procedures and have a communication plan that assures staff you will be able to get a hold of them," Augustine says.

"Every hospital and ED leader should understand what type of incident would automatically require him/her to report to the hospital," he explains. "That response should be trained down to X’ level of personnel in the leadership path."

The largest incidents should result in an automatic response of every clinical member of the ED, says Augustine. "Then the department staff would organize themselves and specifically send some people to sleep somewhere n the hospital, to make sure a few fresh bodies’ are available to work the shift in 12 hours," he notes.

Other incidents may require the hospital to notify staff through the electronic media, Augustine says. Some hospitals and communities have pager systems that are more durable and would be functional even if the phones are incapacitated, he adds. "Other incidents which involve the hospital, but not the community at large, would require the hospital to use local police or EMS to notify important ED leaders and have them report for duty," he says.

When preparing your staff, Augustine says, the message should be simple: "Even if the phones fail, you will know when it’s time to come in; you will be safe, and we will provide a way for you to provide excellent care."

  • Obtain buy-in from administration for hospitalwide preparation.

Finally, advises Davidson, don’t think of your department as separate and apart from the rest of the hospital. "If your hospital leadership is not willing to do what should be done in working through these [different levels of disaster drills], the ED will not be getting the practice it requires," he says.

ED management leadership should be teaching that lesson to the hospital leadership, Davidson maintains.

"The ED can’t be rehearsing in isolation," he adds.


1. CNN Saturday Morning News, June 5, 2004.


For more on major incident response plans, contact:

  • James J. Augustine, MD, FACEP, Director, Clinical Operations, EMP, 4535 Dressler Road, Canton, OH 44718. Phone: (330) 493-4443. E-mail:
  • Steven J. Davidson, MD, MBA, Chair, Emergency Medicine, Maimonides Medical Center, 4802 10th Ave., Brooklyn, NY 11219. Phone: (718) 283-6030/ 6042 (voice/fax)] E-mail: