In disaster preparation, try to imagine the unimaginable

There were lessons learned . . . things that went well’

When hospitals across the country began re-evaluating their disaster response plans in the wake of Sept. 11 and anthrax, Riverside HealthCare in Kankakee, IL, found itself in better shape than most.

Riverside had gone through a mock disaster drill for a hazardous chemical spill the previous May, says Cindy Hagenow, director of patient access, and in March 1999 had experienced a true disaster when an Amtrak train crashed in its community.

"We thought we had a good plan, but after you have a real disaster you have to review your plan," Hagenow says. "There were lessons learned and there were things that went well. There were things that happened that you couldn’t have imagined."

After the Amtrak disaster, Sherry Mayes, RN, BSN, the hospital’s trauma coordinator and disaster chairwoman, attended a workshop on the Hospital Emergency Incident Command System (HEICS). That plan, developed in California and now in effect at more than 800 hospitals, is endorsed by the American Hospital Association, which encourages all hospitals to adopt it.

After attending the workshop, Mayes notes, she was so excited about HEICS that she came back and rewrote the hospital’s plan over the course of a year, modeling it on that system. Since Sept. 11, she says, the Illinois Department of Public Health has recommended that all hospitals adopt HEICS, as has the Joint Commission on Accreditation of Healthcare Organizations.

"We’ve tested it, and it works," Mayes says, "and now I feel like we’re ahead of the game."

"It’s a system that’s based on an organizational chart and a job action sheet," she says. "Old disaster plans are basically in paragraph form, and in a disaster, people don’t read paragraphs." ("See HEICS: The way to go, but takes time, money," in this issue.)

Riverside already had made it a priority to develop a biological exposure plan, and completed it in September as the anthrax cases were beginning to surface, Mayes says. "We had inservices for all of the safety representatives from each department and reviewed the new plan."

Registrars were instructed on what to do if someone came to their desk with a potentially hazardous substance, she adds. "I trained the safety reps and then they were to do an inservice with their staffs. So Cindy trained her employees and then I double-checked their knowledge, asking what they would do if this happened."

That training was put to the test when a man approached the emergency department (ED) registration desk, explaining that he had opened an envelope containing white powder and soon after had developed a rash.

The registrar directed the man back through the door he had just entered, to an outside entrance to the decontamination shower, and then called back to the ED to have someone unlock the door, she says. From a safe distance, ED staff questioned the man and determined that he had opened the envelope two days before, and so had showered since that exposure, Mayes adds.

Meanwhile, the registrar called the operator and had security personnel paged to contain the area, she notes.

"As it turned out, the rash and the envelope had nothing to do with each other, but we called the police and they picked up the envelope and treated it as suspicious," Mayes says.

Patient ID system crucial

With the May 2001 countywide hazardous materials disaster drill, the focus for patient access personnel was on identifying ways to register patients and gather demographic information without exposing themselves to the hazardous material, Hagenow says. That drill, conducted by the Federal Emergency Management Administration (FEMA) and funded through a FEMA grant to the county in which the hospital is located, was based on the premise that the driver of a chemical truck had lost control and backed into a dock, leaking anhydrous ammonia, she notes.

Patients were triaged under a covered area outside the ED ambulatory entrance, Hagenow explains, and those who were exposed to the chemical and had not been decontaminated in the field were taken to the decontamination shower entrance outside the ED. In the shower, she notes, air is circulated so as not to send any contaminants into the normal air of the hospital. "It’s like a filtration system."

An ED "float nurse" who works outside the negative pressure room has radio communication with the staff in the room with the patient, Hagenow says, and passes information on to patient access personnel. "We do any rework that needs to be done."

There is a difference in the way chemical and biological disasters are handled, Mayes points out. "With the chemical, people have immediate reactions, and with the biological, the reaction can be days later." For that reason, she adds, the decontamination process is much more involved with chemical exposure.

"People are very sick and can’t do it themselves, and the staff have to wear respirators," Mayes says. "The training is a lot more detailed."

As part of the FEMA grant, Riverside was given a hazardous materials software program, she notes. "We can look up any hazardous chemical in the computer database and get immediate information on antidotes and decontamination."

Before the chemical drill was conducted, Mayes says, the hospital ran a tabletop drill with the hospital leadership to acquaint them with the new HEICS job action sheets and test Riverside’s emergency preparedness.

"We had an incident command table," she adds, "and the administrator on call had to pull the files out of the disaster response cabinet and distribute them to the appropriate people."

(Editor’s note: Look for more descriptions of how hospitals and their access managers are re-evaluating their disaster response plans in the next issue of Hospital Access Management.)