Guidance Article

The Emergency Management Plan

Summary.

Healthcare facilities have emergency management plans (EMPs) in place to respond to both natural disasters, such as earthquakes and floods, and man-made disasters, such as terrorist acts and transportation accidents. The devastation and massive disruptions caused by Hurricanes Katrina and Rita in New Orleans and numerous other communities along the U.S. Gulf Coast are sad reminders of just how critical such plans can be. In the wake of these storms, healthcare facilities in all parts of the world will undoubtedly be examining their EMPs to assess whether they are prepared to handle similar large-scale disasters. To help with this effort, we present below an overview of the hospitals role in handling major disasters and a discussion of how to ensure that a healthcare facility has an effective EMP. (Note that much of the information presented here has been excerpted from our September-October 2001 Guidance Article on emergency preparedness.*)

Hospital involvement will depend on the cause of the incident (e.g., explosion, chemical or biological exposure) and could include such roles as prevention, hazardous agent identification, and/or treatment. Hospitals will need to be able to respond to the emergency while at the same time continuing to treat their current patients and protect their staff as needed. Beyond this, in a large disaster especially one involving mass casualties the resources of a communitys entire healthcare system (including all the physicians offices, hospitals, and the general resources of the community) may be required, possibly for an extended period. Hospitals will need to work closely with government primarily the local government to meet community needs. They will need to coordinate with the police and fire departments; with officials responsible for transportation, utilities, schools, and public health; and also with churches, news organizations, telephone and other communication companies, volunteer organizations (such as the Red Cross and Salvation Army), and restaurants and food suppliers. Being ready for such a role is daunting. Most hospitals typically prepare for and respond to short, intense disasters. They tend to be less ready for mass casualty incidents, especially those that require numerous healthcare facilities to respond simultaneously. Understandably, large-scale disasters are much harder to prepare for. But despite the huge effort involved, hospitals need to be just as prepared for a mass casualty event as for any other patient care scenario.

Responding to a Large-Scale Disaster

A Broad Role for Hospitals
Disasters can have many forms. They may be of natural origin (geological or weather-related) or have man-made causes (including terrorism, armed conflicts, and technological disasters). They may be strictly internal, such as bomb threats and hazardous spills, or external, affecting an entire region. There may be advance warning, as for a hurricane or blizzard, or there may be no warning at all. Hospitals must be prepared for any of these types of disasters at almost any time. During disasters, especially when there are mass casualties, a hospital is required to operate simultaneously on many levels:
1. 2.

The Key to an Effective Response

The Emergency Management Plan
The emergency management plan (EMP) should be created by a committee consisting of representatives of medical staff, administrators, risk management, security, safety, telecommunications, engineering, admissions, pharmacy, support services, public relations, nursing, materials management, and the emergency department. The committee should also seek input from representatives of outside agencies such as the local civil preparedness office, the

as an individual organization, as a component of the communitys healthcare system, and as a part of the community as a whole.

3.

* ECRI. Emergency preparedness for hospitals: an overview. Health Devices 2001 Sep-Oct;30(9-10):365-9.

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Guidance Article
media, the Red Cross, the police and fire departments, and gas, electrical, and other utility companies. If representatives of these organizations cannot serve on the committee, a draft of the EMP should be sent to them for their review. Each facility should also have emergency management officers, who should be familiar with their counterparts or contacts in other community or federal emergency response agencies and be able to identify one main contact and a backup contact in each of the organizations. The committee should also coordinate its efforts with other nearby healthcare facilities to determine who can take care of issues such as patient overload. DEVELOPING THE EMP The first step in creating an EMP, as with developing any hazard policy, is identifying the levels and types of disaster risks. Assessing risks involves a number of tasks, including: identifying the probability that a disastrous event might occur during a certain period of time; estimating the impact or the degree of loss that could result from a disaster, including injury to people or damage to buildings, utilities, services, or infrastructures; determining the measures that could reduce the risk; and taking the appropriate action to reduce the threat or risk after an appropriate cost/benefit analysis. With this accomplished, the next step is to devise the EMP itself. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), in its emergency management standard EC.4.10, states that the EMP should provide processes for the following:*

Cooperative planning with nearby healthcare organizations Notifying external authorities of emergencies and notifying personnel when emergency response measures are initiated Assigning available personnel in emergencies to cover all necessary staff positions Managing patient, staff, and staff-family support activities, as well as critical supplies, security, and media interaction Evacuating the entire facility when the environment cannot support adequate patient care and treatment Establishing an alternate care site and planning for patient transport, transfer of necessities, patient tracking, and communication with the site Identifying alternative means of meeting essential building utility needs, backup internal and external communication systems, facilities for radioactive or chemical isolation and decontamination, and alternate roles and responsibilities of personnel

In separate standards, JCAHO also requires that facilities establish a staff orientation and education program for the emergency management plan (HR.2.20), that they conduct drills to test the plan (EC.4.20), and that they monitor performance and annually evaluate the plans objectives, scope, performance, and effectiveness (EC.9.10). REVIEWING AND TESTING THE PLAN The EMP should be routinely reviewed to ensure that it adequately addresses all likely situations, that staff are adequately trained, that emergency communication systems are operational, and that necessary supplies are on hand. In addition, it must be tested twice a year through emergency drills. (For more on this topic, see Designing, Executing, and Evaluating Disaster Drills on page 300.) When conducting drills, it is important to challenge the entire system, not just a few components. That is, dont simulate a train accident simply by sending your emergency department a large number of injured people. Rather, involve admissions (patient processing), laboratory services (lab tests), security (crowd control), pharmacy (medications), materials management (supplies such as bandages, saline, and gloves), etc., in the drill to fully determine whether you are ready for such an incident. COMMON SHORTCOMINGS OF EMPs According to the panel at the 2000 AHA Invitational Forum on Hospital Preparedness for Mass Casualties, there

Identifying specific procedures to be implemented in response to a variety of disasters or emergencies Initiating response and recovery phases of the plan (including a description of how, when, and by whom it is to be initiated) Defining and, when appropriate, integrating the hospitals role with community-wide emergency response agencies, including setting priorities for emergency management and linking the hospitals and communitys command structures

* Note that this is only a summary of some of the key requirements of standard EC.4.10. For the full text of this standard, see: Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Comprehensive accreditation manual for hospitals (CAMH). Update 3. EC.4.10. Oakbrook Terrace (IL): JCAHO; 2005 Aug. JCAHOs 2005 Hospital Accreditation Standards related to emergency planning are also currently available online at www.jcaho.org/news+room/ press+kits/ems/05_hap_stds.htm.

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are four common EMP shortcomings that will bring everything to a halt if not adequately addressed.*
Community-wide preparedness. Without adequate widespread planning, an individual hospital will be unable to deal with a disaster affecting the entire community. Communities must develop relationships with the organizations that they would work with during a mass casualty incident, both governmental and private, and hospitals need to be a part of this process. This includes coordinating patient care with other healthcare facilities.

patient services. These people must be trained beforehand, since there probably wont be time for intensive training during the disaster. But having enough people to deal with the disaster isnt the only issue; personnel must also be able to continue to function under conditions of extraordinary stress long hours, poor or absent communications, and concern about family and friends. Support services including access to vaccines and mental health counseling will be needed to help staff meet the demands placed on them. During a disaster, communications become chaotic, and accurate information is at a premium. The communication structure to be used during a disaster must be carefully set out in advance. For example, ordinary communication methods, particularly wired and cellular telephone services, often become overloaded, so redundant backup systems need to be available both inside and outside the facility. Also, to avoid a situation in which different facilities issue different and possibly conflicting public statements, a single community spokesperson should be designated. This person will serve as a conduit for information from the healthcare network to the community.
Communications.

Planning has traditionally overlooked scenarios in which the hospital itself experiences a disaster that completely disrupts its operations. Hospital planners should prepare for the possibility that they might have to evacuate or quarantine their patients or reroute incoming patients to other facilities. Its also important to agree on a common communication protocol to be used during disasters; otherwise, organizations using different communication methods may not be able to make contact immediately.
Staff readiness.

Hospitals faced with a disaster need to be sure they can obtain enough personnel to meet their emergency needs while continuing to maintain regular

* American Hospital Association. Hospital preparedness for mass casualties: final report [online]. Summary of an invitational forum convened on 2000 Mar 8-9. Published 2000 Aug [cited 2001 Oct 8]. Available from Internet: www.hospitalconnect.com/ahapolicyforum/resources/disaster. html.

There needs to be a broader recognition of the role that government at all levels must play in helping hospitals and other community organizations deal with disasters.
Public policy.

Examples of Disaster Scenarios

Understandably, the widespread devastation that can be caused by storms such as Hurricanes Katrina and Rita is foremost in peoples minds right now. However, hurricanes are not the only kind of disaster for which healthcare facilities must prepare. Following are just a few examples of disaster scenarios that could challenge a healthcare system:

The water supply fails or becomes contaminated. A healthcare worker spills a radioactive isotope on a patient room floor. Insects, rats, or other rodents infest the facility. Hackers break into the facilitys computer system, disrupting scheduling, records, and communications. An oxygen leak rapidly depletes the hospitals oxygen supply. An escaped felon takes hostages in the waiting area. A fungus or other organism is being spread by the heating, ventilating, and air-conditioning system. Seating collapses at a local stadium, causing injuries to several hundred people. A car bomb is reported in the facility parking garage. A freight train derails near town, resulting in fire and a toxic gas leak.

An earthquake causes a loss of all utilities and some structural damage to the facility. An airplane crashes in a nearby field, and victims are walking into the emergency department (ED). A farmers truck overturns and spills organophosphate near the center of town; dozens of people are affected. Several people present to the ED with symptoms of highly contagious disease. A nearby forest fire combined with weather conditions causes respiratory distress to residents who present to the ED along with injured firefighters.

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