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All hospitals in a major U.S. city are flooded up to three feet deep. Patients are evacuated by helicopters and boats because ground transportation is nonexistent. There is no electricity or phone communication whatsoever, and EDs in the area are closed for an entire month. This may sound like the plot of a Hollywood disaster movie, but it was a frightening reality in Houston recently after severe flooding.
"The disaster was not the actual flood itself. It was the loss of four major hospitals," reports Michael F. Boyle, MD, FACEP, medical director for emergency services at Memorial Hermann Southwest Hospital, one of the EDs that was evacuated.
Most ED managers have not considered the scenario that there may be no ED in which to treat patients, says Timothy Seay, MD, FACEP, regional medical director for Greater Houston Emergency Physicians. "We never entertained the thought that we would lose major hospital centers before this, but now we do," he says.
There is a tendency to focus resources on bioterrorism, notes Lisa Angell, RN, BSN, MICN, paramedic liaison nurse at Watsonville (CA) Community Hospital. "However, we have to prepare for natural disasters even if they are less trendy,’" she says. "Any actions taken in advance to avoid wasting time or resources will pay off a hundredfold." (For more information about preparation for terrorist attacks, see ED Management, August 2001, p. 85, and November 1999, p. 121.)
Here are effective strategies to prepare for internal disasters:
• Address internal disasters that could affect the ED itself.
Internal disasters are often overlooked in disaster plans/drills, warns Robert Suter, DO, MHA, FACEP, senior medical director of the North Texas region for Questcare Emergency Services, a 13-hospital group serving the Dallas-Fort Worth area. "We all have a sense of an organization’s invincibility that naturally leads us to this thinking," he says.
Every possible scenario must be addressed and practiced as a drill, says Suter. These include hurricanes; weapons of mass destruction; earthquakes; floods; loss of power; water, or climate control; epidemic illness affecting staff; bomb scares; and chemical spills, he says. "This should be done in conjunction with the hospital Safety and Environment of Care Committee," Suter adds.
• Address evacuation.
Your disaster plan should address arrangements for patients to be evacuated if necessary, says Boyle. Because Houston roads were completely submerged under water, patients were evacuated by helicopter or boat, he reports. "The evacuation was done without power, using flashlights and transporting patients on backboards down the stairs," says Boyle.
To evacuate without warning, with limited time and resources, could be chaotic, says Ann Stangby, RN, CEN, emergency response planner for San Francisco General Hospital. "Managers should consider this ahead of time," she urges. She recommends asking the following questions:
• Address power failure.
Disaster plans should address the scenario of not having any electrical power, even backup generators, says Boyle. The Houston hospitals had basement electrical systems that were flooded, he explains. Boyle reports that the facilities are looking into purchasing fuel-powered generators that don’t depend on electricity. (See "Resources" at the end of this article for a list of vendors.)
The complete loss of power was handled in a "chaotic but competent" way, says Seay. "Most medical equipment has battery back-up. Patients were hand bagged to the helicopter or ambulance and taken to other places," he reports.
• Plan for alternate types of communications.
The cell phone towers in Houston failed, and land-based lines were saturated and couldn’t be used, so the ED was forced to resort to other modes of communication, says Boyle. These included battery-powered walkie-talkies, he notes. Also, when all communication was failing, local ham radio operators got out the word about the evacuation through short-wave radios.
Managers at Memorial Hermann Southwest are looking into the possibility of using short wave radios to communicate in future disasters; however, there may be extenuating factors such as the signal interfering with hospital equipment. The cost of a short-wave radio is $50-$200.
To prepare for the loss of your ED, Seay recommends having all these options available, and making communications your No. 1 priority. He advises practicing the setup of command control communication centers. To do that, you’ll need to put together a crate of policies, phones, and radios that can be moved to a remote location as necessary, says Suter. "Then do an unannounced drill," he recommends. This requires moving materials and phones to a predetermined area that has been set up to accommodate multiple phones, switchboards, and radios, and practicing coordination communications from there, he adds.
Angell recommends asking yourself, "Have we really planned on a complete absence of communications? Do we have an effective plan A’ in place? What about a plan B, C, D, and so on?’"
• Assess your facility’s vulnerable areas.
Identify the catastrophes your ED is most vulnerable to, such as earthquakes, floods, or severe weather, Suter says. "For example, hospitals next to railroads or interstate highways are at higher risk for chemical spills," he says. "Government hospitals may be at higher risk for terrorist attacks."
New Environment of Care standards from the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, requires you to do a hazard and vulnerability analysis to pinpoint your weaknesses, notes Stangby. "This is now mandatory for 2001," she stresses. "Doing this will show you what can occur and the impact it would have on the ED. It is also a method by which you can justify monies for mitigation." (Click here to see Sample Tool for Medical Center Hazard and Vulnerability Analysis; Hazard and Vulnerability Assessment Tools for Human Related Events, Technologic Events, Naturally Occurring Events, and Events Involving Hazardous Materials; and Summary of Medical Center Hazards Analysis.)
For example, if you know that your building is particularly vulnerable to structural collapse due to its age, you should focus on that possibility, she says. Examples of solutions include strapping down equipment, and avoiding use of high shelves or cabinets that could fall and cause injury, she says. "In this case a small amount of money could not only lessen property damage, but also save lives," she says.
Stangby advises you to look around your work space. "Would you be injured by falling objects? Would furniture such as cabinets fall and block your exit?" she asks. "Now go to the patient care area and do the same thing. It can be eye opening!"
• Prepare for bomb scares.
When an individual left a suspicious looking package in the ED at Medical City-Dallas, the ED was evacuated for two hours. "Luckily, it occurred in the afternoon, so we diverted ambulance arrival and ran the entire ED out of the GI lab for an hour or so," recalls Suter, medical director of the ED. "If it had occurred during the day shift, it would not have been so easy." The package was found to be harmless, but the experience brought to light the need for an effective plan to move patients, both ambulance and ambulatory, to a safe area, reroute new patients, and secure needed equipment in a new area, says Suter.
• Prepare for a deluge of individuals after a disaster occurs.
Within 15 minutes after the 1989 Loma Prieta earthquake hit, there were more than 600 people at the Watsonville Community Hospital ED, including dozens of volunteer nurses and physicians, recalls Angell.
Stangby urges you to decide in advance how you will make the best use of volunteers. "We have all seen TV coverage of disasters with health care workers rushing to the nearest hospital to help," she says. Consider how you will validate credentials and how you’ll orient volunteers to your hospital, the charting system, and your organizational structure, Stangby advises. San Francisco General’s ED has a policy set up in advance for this scenario to avoid confusion, she adds.
Stangby suggests having phone numbers of licensing boards handy so you can call to verify credentials. "Also, you should have an intake form for who people are, what their level of licensure and training is [MD, DO, RN, LVN, etc.], and a competency list to determine familiarity with equipment," she adds. Stangby also recommends having a quick orientation packet for volunteer staff, including location of equipment, information on how to obtain food, and a list of who is in charge.
After the earthquake, members of the media tried to access the ED — often successfully. "An ABC news helicopter landed and tied up our helipad for 60 minutes before we knew what was happening," Angell reports. To avoid this scenario, you’ll need to immediately control and restrict access to your hospital’s central operations area, Angell urges.
To limit access to the ED, Stangby recommends the use of disaster identification vests. "If you are not wearing a vest that identifies you as either an ED staff person or a member of the Hospital Incident Command System, you do not get in," she says. At one disaster activation, the hospital’s chief financial officer came down to the ED, Stangby recalls. "He was not wearing a vest, so he was refused admittance," she says.
For more information about internal disasters, contact:
• Lisa Angell, RN, BSN, MICN, Watsonville Community Hospital, 75 Nielson St., Watsonville, CA 95076. Telephone: (831) 761-5651. Fax: (831) 728-4758. E-mail: email@example.com.
• Michael F. Boyle, MD, FACEP, Emergency Services, Memorial Hermann Southwest Hospital, 7600 Beechnut, Houston, TX 77074 Telephone: (713) 776-5552. Fax: (713) 937-6918. E-mail: BoyleEM@aol.com.
• Timothy Seay, MD, FACEP, Greater Houston Emergency Physicians, 211 Highland Cross, Suite 275, Houston, TX 77073. Telephone: (281) 784-1500. Fax: (281) 784-1522. E-mail: Tim.Seay@HCAHealthcare.com.
• Ann Stangby, RN, CEN, Emergency Response Planner, San Francisco General Hospital, 1001 Potrero Ave., San Francisco, CA 94110. Telephone: (415) 206-3397. Fax: (415) 206-4411. E-mail: firstname.lastname@example.org.
• Robert Suter, MD, FACEP, QuestCare, 101 E. Park Blvd., Suite 911, Plano, TX 75074. Telephone: (972) 881-8353. Fax: (972) 422-2208. E-mail: email@example.com.
The Joint Commission on Accreditation of Healthcare Organizations’ new Environment of Care Standards address disaster planning and performing a hazardous vulnerability analysis. The Environment of Care Essentials for Health Care book has been updated for 2001. It is on back order until approximately December 2001. The cost is $60 (order code ECE-01) plus a $10.95 shipping charge. To order, call the Joint Commission’s Customer Service Center at (630) 792-5800 between 8 a.m. and 5 p.m. Central time on weekdays. Web: www.jcaho.org.
Here is a partial listing of vendors that offer fuel-powered generators:
• Best Power Generators, Rick McClain, 446 E. First St., Lowell, OR 97452. Telephone: (541) 937-8734. E-mail: Sales@Best-Power-Generators.com.
• Bowers Machine, PO Box 600, Kent, WA 98035-0600. Telephone (800) 858-5881 or (253) 872-7800. Fax: (888) 246-2935 or (253) 872-4127. E-mail: firstname.lastname@example.org.