Management of Emergencies and Disasters

Chapter Objectives

1. Define environment of care.

2. Identify hospital safety and security policies and procedures.

3. Define sentinel event.

4. Discuss strategies for implementation of proper procedures in the event of a disaster.

5. Identify and evaluate the implementation of all hospital codes.

6. Incorporate management of environment of care in everyday tasks.

Definitions

Accreditation survey (The Joint Commission)

An evaluation of an organization to assess its level of compliance with applicable Joint Commission standards and to make determinations regarding its accreditation status

Code A

Sudden emergency

Disasters

Unforeseen and often sudden events that cause great damage, destruction, and suffering. The disaster is caused by nature or humans

Emergency

Any unplanned event that can cause deaths or significant injuries to patients, employees, volunteers, or visitors or can shut down the hospital, disrupt operations, cause physical or environmental damage, or threaten the hospital’s financial standing or public image

Emergency management plan

Component of an organization’s environment of care program designed to manage the consequences of natural disasters or other emergencies that disrupt the organization’s ability to provide care and treatment

Hazardous wastes

Any solid waste that exhibits any of the characteristics of hazardous waste identified by New Jersey hazardous waste management regulations

Internal emergencies

Abnormal conditions that arise within the hospital and require a special response by the hospital

External emergencies

Abnormal conditions that arise outside of the hospital and require a special response by the hospital

Evacuation

Removal of all people from within the facility to outside of the facility

Material safety data sheets (MSDSs)

Written descriptions of each hazardous chemical used in a workplace

THE JOINT COMMISSION STANDARDS

The Joint Commission (TJC) is an organization whose mission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations (TJC, 2007). A TJC survey is an evaluation of an organization to assess its level of compliance with applicable TJC standards and to make determinations regarding its accreditation status. TJC accreditation is a requirement to receive federal funding. The survey includes evaluation of documentation of compliance provided by organization staff; verbal information concerning the implementation of standards or examples of their implementation that will enable a determination of compliance to be made; on-site observations by surveyors; and an opportunity for education and consultation regarding standards compliance and performance improvement (TJC, 2003).

This chapter deals with those TJC requirements that measure an institution’s level of performance and compliance with standards of environment of care (TJC, 2005). These standards encompass a variety of hospital functions and processes such as the following:

• How the organization manages its safety risks

• How the organization maintains a safe environment

• How the organization identifies and manages its security risks

• How the organization manages hazardous materials and waste risks

• Education that the staff members, students, and volunteers receive as appropriate for work in their particular environment to provide care

• Description of the roles and responsibilities of each staff member, student, and volunteer when dealing with environment of care issues

• How the organization meets the standards of all applicable agencies (Occupational Safety and Health Administration [OSHA], etc.)

As a result of the response to the Hurricane Katrina disaster, there has been increased focus on the total emergency response of all institutions. All health care agencies are required by TJC and the Health Insurance Portability and Accountability Act (HIPAA) to have a detailed emergency management plan in place to deal with natural and other occurrences. The hospital-wide safety committee usually has the responsibility for compliance with environment of care standards. The environment of care as defined by TJC as the provision of a safe, functional, supportive, and effective environment for all individuals within the hospital (TJC, 2007). The standards of environment of care require each hospital to develop a plan of care for the following:

• Safety management

• Security management

• Hazardous materials and waste management

• Emergency management

• Fire safety

• Medical equipment management

• Utilities management

EMERGENCY MANAGEMENT PLAN

This hospital plan ensures effective responses to disasters or internal or external emergency conditions affecting the safety of patients. The goal of the emergency management plan is to achieve a safe environment for patients, staff, volunteers, and visitors. Hospitals must meet regulatory compliance guidelines. The plan clearly identifies those individuals responsible in the event of a disaster. Only one appointed individual has the power and authority to implement an evacuation.

Hospitals are required to have available alternate sources of electrical power, safe water, safe medical gas, safe waste disposal, and communications.

The plan should meet the following objectives (OSHA, 2008):

• Pre-emergency drills implementing the emergency management plan

• Practice sessions with other local emergency response organizations using the ICS

• Personnel roles and responsibilities, including who will be in charge of directing the response, training, and communications

• Lines of authority and communication between the incident site and hospital personnel regarding hazards and potential contamination

• Designation of a decontamination team, including emergency department physicians, nurses, aides, and support personnel

• Description of the hospital’s system for immediately accessing information on toxic materials

• Evacuation plan and designation of alternate facilities that could provide treatment in case of contamination of the hospital’s emergency department

• Plan for managing emergency treatment of noncontaminated patients

• Decontamination equipment, procedures, and designation of decontamination areas (either indoors or outdoors)

• Hospital staff use of protective personal equipment (PPE) based on hazards present or likely to be present, routes of exposure, degree of contact, and each individual’s specific tasks

• Location and quantity of PPE

• Prevention of cross-contamination by airborne substances via the hospital’s ventilation system or other means

• Prevention of cross-contamination by hazardous substances that are not airborne (e.g., surface contamination)

• Air monitoring to ensure that the facility is safe for occupancy following treatment of contaminated patients

• Post-emergency critique and follow-up of drills and actual emergencies

Patient, employee, volunteer, and visitor safety is of utmost concern to hospital administration. The emergency management program must be compatible with federal, state, and local laws. Because state laws differ, all policies and procedures must be up to date and reviewed annually or by the time specified for each hospital according to state regulations. Priorities must be clearly defined and outlined.

The hospital president/chief executive officer appoints an individual, usually the hospital safety officer, to be the lead person in the event of an emergency situation. This individual is responsible for the coordination and implementation of the policies and procedures for the emergency management of the hospital. Department heads and managers are responsible for instituting these policies and procedures. Staff members and volunteers are responsible for being aware of these policies by completing new employee orientation and annual competencies regarding the policies and procedures. You will be first exposed to your roles in emergency management during your new employee orientation (Box 5-1). Then, you will be expected to participate in routine drills that allow the safety committee members to evaluate and improve the institution’s response to emergency situations.

Box 5-1 NEW EMPLOYEE ORIENTATION

• Specific roles and responsibilities during emergencies

• Patient safety activities and requirements

• Sentinel event review

• Skills and information required during emergencies

• Backup communication services

• Supplies and equipment procurement

EMERGENCY PREPAREDNESS DRILLS

The most common emergency drill that you will participate in will be routine fire drills. All institutions are required to hold fire drills at regulated intervals. A localized fire within an institution is an example of an internal emergency. Other internal emergencies include electrical failure, communication failure, and internal security concerns such as infant abductions. Drills mimicking such potential internal disasters will occur routinely in your institution.

Hospitals are often the first responders to emergency situations that occur outside of the hospital. For example, during the 9/11 disaster, all hospitals and potential first responding facilities within the radius of the World Trade Center towers were placed on alert to assist potential victims of the disaster. Such external disaster responses require careful planning and collaboration by all members of the community. This collaboration has resulted in community-wide external disaster drills that mimic the wide variety of potential threats to the community. The federal agency that oversees disaster management is the Federal Emergency Management Agency (FEMA).

The purposes of these drills are to evaluate and improve the response of all agencies and to determine what changes need to be made to the emergency response plan. Your role will be to participate in such drills and to assist in the evaluation of response and the creations of improvements to the plan. Some institutions have named these plans “all-hazards disaster plans.” All-hazards is a general term that describes all types of natural and terrorist events such as biological accidents or disasters, chemical spills or exposure, conventional disasters caused by weapons, radiological or nuclear exposures, bombings, agricultural contamination, and cyber viruses (Box 5-2).

Box 5-2 ALL-HAZARDS DISASTERS

Biological accident or disaster	An incident involving a natural or deliberate outbreak of a pathogen affecting large numbers of adults and children
Chemical spills or exposures	Exposure to hazardous chemically toxic materials that may produce a wide range of adverse health effects
Conventional disaster, bombings	A catastrophic event caused by the use of weapons such as bombs, missiles, grenades, etc.
Radiological/nuclear exposures	A radiological or nuclear emergency that may result from accidents occurring within a facility or from external sources involving vehicles transporting radioactive materials or caused by terrorism events involving nuclear weapons or radiologically contaminated conventional weapons
Cyber viruses	A catastrophic event affecting large numbers of people and lasting more than a few hours that affects the ability to use information technology
Agricultural contamination	An event involving deliberate introduction of an animal or plant disease with the intent of generating fear, causing economic losses, and undermining stability

Modified from Inova Health System (2001a, 2001b, 2001c).

TOPOFF 2 INITIATIVE

Top Officials 2 (TOPOFF 2) was a congressionally mandated, national terrorism exercise that was designed to identify vulnerabilities in the nation’s domestic incident management capability by exercising the plans, policies, procedures, systems, and facilities of federal, state, and local response organizations against a series of integrated terrorist threats and acts in separate regions of the country.

TOPOFF 2 was the largest and most comprehensive terrorism response exercise ever conducted in the United States. The exercise scenario, which was played out from May 12 to May 16, 2003, depicted a fictitious, foreign terrorist organization that detonated a simulated radiological dispersal device (RDD) in Seattle, Washington, and released the pneumonic plague (Yersinia pestis) in several Chicago metropolitan area locations. There was also significant preexercise intelligence play, a cyber attack, and credible terrorism threats against other locations. These exercises brought together top government officials from 25 federal, state, and local agencies and departments and the Canadian government to test the domestic incident management in response to weapons of mass destruction (WMD) terrorist attacks in the United States.

NATIONAL RESPONSE FRAMEWORK

The National Response Plan was replaced by the National Response Framework effective March 22, 2008. This plan establishes a comprehensive all-hazards approach to enhance the ability of the United States to manage domestic incidents. The plan incorporates best practices and procedures from incident management disciplines such as homeland security, emergency management, law enforcement, firefighting, public works, public health, responder and recovery worker health and safety, emergency medical services, and the private sector, which integrates them into a unified structure. It forms the basis of how the federal government coordinates with state, local, and tribal governments and the private sector during incidents. It establishes protocols to help (Department of Homeland Security, 2007):

• Save lives and protect the health and safety of the public, responders, and recovery workers

• Ensure the security of the homeland

• Prevent an imminent incident, including acts of terrorism

• Protect and restore critical infrastructure and key resources

• Conduct law enforcement investigations to resolve the incident, apprehend the perpetrators, and collect and preserve evidence for prosecution and/or attribution

• Protect property and mitigate damages and impacts to individuals, communities, and the environment

• Facilitate recovery of individuals, families, businesses, governments, and the environment

HAZARDOUS MATERIALS AND WASTE

While hospitals are often perceived as safe environments, there are a variety of chemicals, energy sources, and waste products that can cause damage to the individual and the environment if not dealt with properly. Hospitals are required to have specific plans and processes for the use and disposal of such hazardous materials. Examples of hazardous waste commonly used within health care agencies are

• Diagnostic radioisotopes

• Oxygen and other combustible gases

• Surgical and other medical waste

• Chemotherapeutic agents

• Needles, syringes, and surgical equipment

• Cleaning fluids

• Energy sources, such as lasers and radiation

Hospitals must have a program in place for the safe management of hazardous materials and waste. The goal is to achieve a safe environment for patients, employees, volunteers, and visitors. The use of hazardous materials and the management of hazardous waste must be monitored and reviewed to ensure regulatory compliance throughout the hospital.

Federal Agencies for Environment of Care Issues (Box 5-3) provide information on bloodborne pathogens, radioactive waste, infectious waste, workplace safety, and national patient safety goals.

Box 5-3 FEDERAL AGENCIES FOR ENVIRONMENT OF CARE ISSUES

Agency	Category
Occupational Safety and Health Administration (OSHA)	Bloodborne pathogens: blood and blood-soaked items, workplace safety
Nuclear Regulatory Commission (NRC)	Radioactive waste
Centers for Disease Control and Prevention (CDC)	Infectious waste
National Institute for Occupational Safety and Health (NIOSH)	Workplace safety
Environmental Protection Agency (EPA)	Workplace safety
The Joint Commission (TJC)	National patient safety goals