The Four Phases of Comprehensive Emergency Management.
The American Society for Healthcare Engineering of the AHA pioneered the development of hospital HVA in 2001. That same year, the Kaiser Permanente Foundation Health Plan issued their version of HVA. Both are now used extensively by U.S. hospitals. The Kaiser Permanente HVA worksheets are shown in Figures 22.2 and 22.3, and Tables 22.2–22.5.16
Medical Center HVA.
Summary of Medical Center HVA.
Hazard Vulnerability Assessment Tool for Environmental Events
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Hazard Vulnerability Assessment Tool for Technological Events
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Hazard Vulnerability Assessment Tool Related to Human Activity
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Hazard Vulnerability Assessment Tool Events Involving Hazardous Materials
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Once complete, the HVA requires a thorough review. After examination of the report, hospital emergency managers can determine the most likely threats to the community and hospital. Given this information, the institution can develop mitigation, preparedness, response, and recovery portions of the emergency management plan that address these hazards. The chair of the EMC must challenge members to think “what if” and “worst-case scenario,” as well as to consider the impact of multiple events occurring simultaneously.
The hospital should collaborate with the community. The HVA should be compiled with the assistance of the local emergency management agency, fire department, EMS agency, police, hazardous materials unit, and with input from community organizations. In the United States, these entities include the American Red Cross Disaster Services, Salvation Army Disaster Services, and Voluntary Organizations Active in Disaster, as well as neighboring hospitals and the area hospital council. Similar organizations exist for other countries. If there is a major waterway or airport in the area, then HVA discussions should include additional bodies such as airport authorities, Army Corps of Engineers, Coast Guard, and state waterway police.
After generating the HVA, the next step is to rate the probability of occurrence and level of preparedness for each event. The resulting information can then be used to prepare or strengthen the facility and the emergency management plan. Nevertheless, it is possible that the HVA will not identify all potential casualty-producing incidents. The potential risks from poorly controlled nuclear weapons and radioactive material are increasing. Although the danger of all-out nuclear warfare is probably minimal, the possibility that terrorists could use one or several nuclear devices against a modern city should be addressed.
Common Factors in Disasters
To facilitate their work, the EMC should consider several factors that are common to many disasters.
1. Uncertainty – In the early stages of a disaster, it is often unclear what is transpiring, to what extent additional resources are needed, how many casualties have resulted, and the extent of the medical requirements. In addition, the exact location and magnitude of the incident may be unknown.
2. Casualty Arrival – In mass casualty incidents, especially those occurring over a wide area, the standard operating procedure of ambulance crews triaging patients and removing them in an orderly manner may not occur. In such disasters, it is common in some countries for up to 80% of the casualties to self-refer and arrive at the hospital without prehospital care on scene and en route. Casualties able to ambulate or be moved with assistance will often self-transport to area hospitals rather than waiting for arrival of EMS professionals. Well-intentioned bystanders will often transport victims in their automobiles, including those with severe injuries. Patients contaminated with hazardous materials will arrive at the hospital without having first been decontaminated at the scene. This convergence phenomenon can inundate the hospital closest to the scene with casualties, whereas other nearby facilities may receive few to none of the victims. Last, less serious cases may arrive well ahead of the most seriously injured, many of whom may be trapped in rubble.
3. Communications – Communication systems connecting the hospital to the rest of the community are vulnerable. Telephone service may fail due to overloaded circuits or physical damage. Cellular telephone communication is unreliable as the available cells can quickly become saturated. This also occurs with satellite telephones, as reported during Hurricane Katrina in the United States. Monitoring local fire, EMS, and police frequencies and having direct radio communication with first responders can greatly aid the hospital incident commander in decision making. The hospital emergency management plan should also include a provision for the use of messengers to carry information throughout the hospital in the event of telephone and computer failures. Other back-up communications options include the use of amateur radio operations and installation of emergency phones on an exchange that does not normally service the hospital.
4. Patient Care Capacity – Maintaining patient care capacity (including for those requiring hospital admission) may be problematic due to the influx of numerous casualties or a high inpatient census. The early discharge of stable patients can help the situation but the process of doing so is time-consuming, especially when family members are unable to assist. Another option includes the use of other areas in the hospital such as meeting rooms, physical therapy suites, or auditoriums for patient care to temporarily increase surge space. Hospitals must plan for supplies and staffing of these areas during the preparedness phase.
5. Staffing – Ensuring the presence of sufficient numbers of physicians, nurses, and other support personnel to staff existing patient care areas and temporarily expanded space used for surge can be problematic, depending on the type and location of the disaster. In a severe blizzard, many individuals may have difficulty reaching the hospital. In anticipation of such circumstances, the emergency management plan should contain a list of volunteers who have four-wheel drive vehicles and are willing to transport employees and medical staff members to the hospital. In a hurricane, employees and physicians may be victims themselves, dealing with destroyed homes and offices and injured family members. In such instances, the hospital must support the staff and their family members (including pets) with sleeping accommodations, shower facilities, and food service. In an infectious disease outbreak, some staff may be unwilling to report to work. Thus, the plan must account for the fact that not all staff will be willing or able to come to the hospital. The emergency management plan must provide a method for temporarily credentialing medical volunteers and a strategy for using medical personnel from country-specific volunteer medical systems such as the Medical Reserve Corps or the National Disaster Medical System in the United States.
6. Decontamination – Hospital personnel must be prepared to decontaminate victims needing such treatment prior to allowing them to enter the facility. Decontamination is essential not only to support patient care but also to prevent contamination of the hospital, potentially rendering it nonfunctional. The healthcare institution must maintain sufficient quantities of PPE to permit rotation of decontamination staff, taking into consideration the fatigue factor and heat load stress when wearing PPE. The selection of PPE is a complex task (see Chapter 15). Maintaining a variety of types of PPE to protect against multiple hazards and ensuring appropriate staff training is essential for worker safety.18,19
7. Prophylaxis – It may be necessary to offer hospital employees and the medical staff antibiotics and vaccinations as prophylaxis during an epidemic or after the terrorist release of a biological agent. A protocol is needed to ensure adequate supplies and efficient distribution methods.
8. Laboratory Support – Most hospital laboratories lack the capability to safely and definitively identify many biological weapons agents, emerging infectious diseases, or hazardous materials. The EMC must know the capabilities of the in-house laboratory and ensure that arrangements have been made with state, national, or international reference laboratories to supplement diagnostic resources within the facility in the event of an outbreak or exposure. Such diagnostic resources must be available 24/7.
9. Media Relations – Members of the media will telephone or quickly arrive at the hospital when disaster strikes. A plan must be in place to accommodate the media and also to manage them, restricting their access to patient care areas and preventing them from disrupting the hospital’s response. Often, accurate information may not be immediately available to the healthcare facility’s designated public information officer. Other information may be known but disclosure may not be possible as it would violate federal privacy laws. Social media has complicated information management during disasters. The FEMA Emergency Management Institute offers disaster public information training for health department and hospital personnel.
10. Morgue – Hospitals generally have limited refrigerated space for the temporary storage of the deceased. Consideration must be given to a potentially large death toll and the subsequent need for increased storage space for remains (see Chapter 23).
11. Utilities – A disaster event could curtail some or all of the hospitals utilities. Water is especially critical for hospital operations and backup supplies must be organized in advance. Storage of water on the grounds of the facility is one option. Generators supplying emergency power may prove unreliable for extended operations. Plans should exist for renting generators and wiring them to the hospital’s electrical grid. If the hospital uses fuel oil to power the generators or boilers, the EMC should calculate the number of hours or days of supply the institution has on hand under both temperate and winter conditions.
12. Supplies – With the healthcare industry relying on just-in-time inventories, supply shortages may quickly manifest. Plans are needed for emergency resupply if contracted vendors cannot respond or normal supply channels are disrupted. Community-wide planning is essential to prevent multiple hospitals depending on the same supplier if that entity has inadequate resources for the number of facilities that need them. Additionally, hospitals must include items appropriate for pediatric care in their supply inventories as they must prepare for the arrival of pediatric patients.
13. Blood Products – During a disaster, blood and blood product usage may rise above normal levels. Hospitals must anticipate this contingency and plan to address any shortfalls. Conversely, in some types of disasters, additional blood is not needed. However, well-meaning volunteers may present in large numbers wanting to donate. A system for volunteer management is important to avoid redirecting resources needed for control of the incident to handle this influx.
14. Medical Equipment – In a disaster situation, a hospital may face a shortage of beds, ventilators, respiratory therapy equipment and supplies, oxygen cylinders, intravenous infusion pumps, wheelchairs, and gurneys. Institutions must plan for supplemental delivery of these items.
15. Service Deliveries – Ensuring continuity of critical service deliveries such as medical gases, generator fuel, linens, medical and surgical supplies, foodstuffs, and waste removal is essential to continued operations. Plans must exist that maintain availability of these critically needed items.
16. Security – Plans are required for securing the facility and grounds, directing traffic, protecting human remains, and managing personal effects. During a disaster, requirements may exceed the capacity of the security department. In support of increased security demands, the emergency management plan should assign non-security personnel to provide some security duties, such as traffic direction or supervision of facility entrances. In addition, hospital security plans must permit rapid implementation of a total facility lockdown, allowing only certain supervised entrances to remain open. This is especially important when faced with contaminated casualties. Reliance on local law enforcement personnel to respond and assist is usually not an option as they will be occupied managing the disaster within the community.
17. Care of Relatives and Friends – During a disaster, family members and friends of patients may rush to a hospital, even with just the suspicion that a relative was taken there. Plans must exist for receiving and assisting family members of victims.
18. Damaged Hospitals – Hospitals are susceptible to physical damage. Tornados, hurricanes, and earthquakes have repeatedly compromised hospital function. Healthcare institutions must plan for emergent damage inspection and repair. In severe situations, hospitals must also have a strategy to evaluate hospital structural integrity and evacuate the facility if indicated.21,22
Health Facility Management of Disaster
When a disaster occurs, the emergency management plan must be activated and the healthcare facility must quickly mobilize its resources and key personnel, ideally before the first casualty arrives. The hospital may organize its response in a variety of ways, as long as The Joint Commission or similar requirements for coordination with community plans are met.
The Incident Command System
The Incident Command System (ICS) is a disaster management strategy that is growing in popularity among hospitals. ICS was first developed in the 1970s by California firefighters for better management of wide-scale forest and wildfires. The group who developed the ICS was known as FIRESCOPE. ICS was later adapted to the hospital setting. It offers hospitals many advantages in managing their disaster responses:23
Standard organization and procedures
Modular and scalable system for any size disaster
Interactive management components
Management by objectives
Manageable span of control
Designated incident facilities
Comprehensive resource management
Integrated communications
Procedures for establishing and transferring command
Accountability
Easy integration with the community response
Avoiding duplication of effort
ICS is essentially a toolbox that provides utilities for the command, control, and coordination of resources during a disaster. ICS clarifies roles and responsibilities between all persons in the system, while also organizing resources, personnel, facilities, equipment, and communications through common procedures.
The basic ICS is composed of an Incident Commander assisted by an Operations Section, Planning Section, Logistics Section, and Finance/Administration Section (see Chapter 11).
Directly manages all incident activities and implements the Incident Action Plan.
Works closely with other members of the command and general staff to coordinate response tactics.
Gathers, analyzes, and disseminates intelligence and information gleaned from available sources.
Manages the planning process and maintains incident documentation.
Compiles and develops the Incident Action Plan.
Tracks all incident resources.
Manages the activities of assigned technical specialists.
Develops the demobilization plan.
Meets the support needs for the incident, including ordering resources through appropriate procurement authorities from non-incident locations.
Provides facilities, transportation, supplies, equipment, maintenance support, fueling, food service, and communications.
Finance/Administration Section
Establishes whether there is a specific need for financial, reimbursement, and/or administrative services to support incident activities.
Takes responsibility for time-keeping records and compilations of hospital costs incurred during the disaster response.
Multiagency Coordination Systems
In large incidents, a Multiagency Coordination System (MACS) may be established. A MACS is a combination of facilities, equipment, personnel, procedures, and communications integrated into one common system and principally relying on an Emergency Operations Center (EOC). Within the EOC, a medical operations center or joint public health command center is usually established. The hospital disaster command structure will usually report to this entity. A MACS is especially helpful in areas of high population density or where the disaster is geographically widespread. Figure 22.4 illustrates the basic incident command structure.
Basic Incident Command System Diagram.
The Hospital Incident Command System
Initially developed as the Hospital Emergency Incident Command System, in its fourth revision, the name was changed to the Hospital Incident Command System (HICS). The historical development of HICS is as follows.23
- 1987 –
Hospital Council of Northern California adapts FIRESCOPE ICS to hospitals.
- 1991 –
Hospital Emergency Incident Command System, version 1 (HEICS I) first released.
- 1993 –
HEICS II released.
- 1998 –
HEICS III released.
- 2006 –
U.S. government-funded project to revise HEICS. The development of version IV creates the HICS in compliance with the National Incident Management System (NIMS).
- 2014 –
HICS V released with multiple updates since the 2006 version.24
The HICS resources include25
Exercise scenarios;
Planning guides;
Job action sheets;
HICS forms; and
Training materials.
HICS adds healthcare-specific titles to the ICS. On the organizational chart for the command and general staff, the Incident Commander (IC) has the prerogative to add components to the chart, identifying individuals who report to the IC. An example is a medical/technical healthcare specialist needed for a response to a particular disaster. Such individuals would include:
Infectious disease consultants;
Chemical and radiological consultants;
Hospital administration representatives;
Hospital legal officers;
Hospital risk managers; and
Medical staff officers.
As previously mentioned, all ICS systems including HICS are modular and scalable according to the requirements to manage the disaster, the hospital size, and the availability of personnel and medical staff. The EMC should decide in advance what roles will be needed and initially staff these positions with on-duty personnel. Following activation of HICS, additional personnel determined by the hospital’s response needs would then be recruited to backfill these positions. The HICS chart is based on emergency functions and differs from the hospital’s routine organizational or functional chart.
The command and general staff sections of Operations, Planning, Logistics, and Finance/Administration have a hierarchical structure that translates into a manageable span of control. Depending on the size and duration of the event, each section may need division into branches, with various defined groups, led by a supervisor, under the branch and reporting to the branch director. Graphically, the Operations Section could appear as shown in Figure 22.5.23 An example of a Planning Section chart appears in Figure 22.6.23 The Logistics Section is graphically depicted in Figure 22.7.23
Operations Section.
Planning Section.
Logistics Section.
The Finance/Administration Section of HICS includes important units for documenting costs and hospital and employee compensation during the hospital response and recovery phases. Because many hospitals have cash flow problems, this is a very significant post-disaster function. In the United States, the hospital may be eligible for reimbursement from the federal government if the president declares the event a disaster, but only if the expenses are properly documented. Also, the procurement unit within this section must keep the hospital supplied with consumable items and must arrange contracts for emergency supplies. A typical Finance/Administration Section chart would be similar to that shown in Figure 22.8.23
Finance/Administration Section.
While every hospital has a defined organizational chart for normal operations, the command and control system necessary to manage an emergency differs from the routine reporting structure. HICS tables of organization provide a logical framework with which to coordinate the hospital’s response. Additionally, these tables allow individuals with particular strengths, not listed on the standard organizational chart for normal operations, to be used in the most effective manner. For example, the chief of surgery may request the assistance of another surgeon, perhaps with military combat medical experience, to head the medical care branch that manages mass casualties.
In smaller incidents, it may not be necessary to activate and staff the five basic HICS positions. The IC may perform all the functions alone in some cases. What is essential is that the IC has a clear picture of the incident, the estimated casualty load, and the response needed, and staffs the HICS system accordingly. HICS training is available without cost online.24
The National Incident Management System
ICS is an integral part of a post-September 11, 2001, U.S. initiative in managing all-hazard incidents. In 2003, the president of the United States issued Homeland Security Presidential Directive 5 (HSPD 5), directing the Secretary of Homeland Security to develop and administer NIMS. This system provides a consistent nationwide framework that enables federal, state, local, and tribal organizations to work together effectively to prepare for, respond to, and recover from all-hazard incidents regardless of cause, size, or complexity, including terrorist attacks. NIMS is built on existing concepts of incident management that have stood the test of time. NIMS represents a core set of doctrines, concepts, principles, and terminology that permit effective collaboration in incident management at all levels of governments and private organizations. HSPD 5 requires all federal departments and agencies to make adoption of NIMS by state and local organizations a condition for funding from federal preparedness grants. The components of NIMS include:26
Command and Management;
Incident Management System;
Multiagency Coordination Systems;
Public Information Systems;
Preparedness;
Planning;
Training;
Exercises;
Personnel Qualifications and Certification;
Equipment Acquisition and Certification;
Mutual Aid;
Publications Management;
Resource Management;
Communications and Information Management;
Supporting Technology; and
Ongoing Management and Maintenance.
NIMS was launched by then-Secretary of Homeland Security Tom Ridge on March 1, 2004. In September 2006, FEMA announced the publication of NIMS Implementation Activities for Hospitals and Healthcare Systems.26 The publication outlines the seventeen elements healthcare facilities must accomplish to become NIMS compliant and eligible for federal preparedness grants:
Element 1 – Adopt NIMS at the organizational level.
Element 2 – Manage all emergency incidents, exercises, and “preplanned” events utilizing the HICS.
Element 3 – MACS: Develop connectivity capability with the area hospital command center, as used in catastrophic, wide geographical area, or smaller incidents, to the local EOC, local 911 centers, local public health, EMS, local emergency operating center, and others as appropriate.
Element 4 – Public Information System – The healthcare facility manages information with the various healthcare partners and response agencies through a Joint Information System and Joint Information Center.
Element 5 – The hospital/healthcare facility/healthcare system will track NIMS activities annually as part of the organized emergency management plan.
Element 6 – Development and coordination of a system to track local, state, and federal preparedness grants. Document that preparedness grants received meet any funding commitments.
Element 7 – Revise and update plans and procedures to incorporate NIMS components in all emergency phases and activities.
Element 8 – Participate in and promote interagency mutual aid agreements with public and private sectors.
Element 9 – Train those personnel who have emergency preparedness and response duties in NIMS by completing the free online course IS-700.a National Incident Management System: An Introduction. This online course can be found at http://training.fema.gov/IS (Accessed August 22, 2013).
Element 10 – Train those personnel who have emergency preparedness and response duties in the National Response Plan by completing the free online course IS-800.b National Response Framework: An Introduction. This course can be found at: http://training.fema.gov/IS (Accessed August 22, 2013).
Note: for both courses, it has been recommended that a phased approach would allow employees and physicians to complete the training without a time constraint burden on the hospital. Successful completion of both courses could be an element in the employee periodic performance evaluation.
Element 11 – The organization’s primary emergency preparedness and response personnel complete free online courses: IS-100.HCb Introduction to the Incident Command System for Healthcare/Hospitals and IS-200.HCa Applying ICS to Healthcare Organizations. These free online courses can be found at http://training.fema.gov/IS (Accessed August 22, 2013).
Element 12 – Preparedness Exercises – The organization’s emergency management program training and exercise documentation reflects the use of NIMS/ICS.
Element 13 – Participate in an all-hazard exercise program based on NIMS that involves responders from multiple disciplines, agencies, and organizations.
Element 14 – Hospitals and healthcare systems will incorporate corrective actions into preparedness and response plans/procedures.
Element 15 – Maintain a current resource inventory of medical-surgical supplies, pharmaceuticals, PPE, staffing, and so forth.
Element 16 – To the extent possible and permitted by law, the organization should work to establish common equipment and communications data interoperability with other local hospitals, EMS, public health, and emergency management agencies.
Element 17 – Apply standardized and consistent terminology, including the establishment of plain English communication standards across the public safety sector.
Hospital Physical Plant Preparedness
While the EMC is focused primarily on direct patient care capacity and capability, optimal patient outcomes depend on a functioning physical plant. Rarely do hospital personnel, even executives, think about the physical plant becoming non-operational. Hospitals and other healthcare facilities have suffered significant damage resulting from hurricanes, tornadoes, fires, and earthquakes. Therefore, the EMC must become familiar with the physical plant and its systems, and work with the plant operations leader to maximize preparedness. Ideally, the head of plant operations should be a member of the EMC. The critical hospital systems that must remain functional include
Electrical;
Heating, ventilating, and air conditioning (HVAC);
Water and sewer;
Medical equipment including vacuum and medical gases;
Various life support and critical care systems; and
Communications systems: pagers, public address, computers, and radios.
Electrical
In the U.S. model, there has historically been a disparity between what building codes require that emergency generators support and the hospital’s electrical power requirements for patient care. The codes are designed to address life safety issues and protect occupants in the event of a power failure, fire, or other emergency. The level of electrical generator support is limited to that required to permit the occupants to safely exit the building. The code does not recognize the need to provide power for operating autoclaves, laboratory and radiology equipment, and other devices necessary for hospital function during a disaster. The members of the EMC should know what equipment and what locations receive power from emergency generators in the event of a power failure, how long the fuel supply will last when the generators are running, and how long they will run if the fuel must be shared with the boilers. Further action may be necessary to ensure these additional essential components receive emergency power. Another approach to minimize the threat of power disruption is to provide normal electrical service to the facility from two different utility substations.
Time of year can also increase the fuel consumption needs of boilers as well as pose other challenges. During a blackout in a New England winter, a small community hospital initially received emergency power from its generators. The hospital had an above-ground fuel storage tank and had forgotten to connect the immersion heater to the generator circuitry. After several hours the fuel cooled, became more viscous, and resulted in a generator shutdown.
In August 2003, a considerable portion of the northeast United States experienced a blackout, at first thought to be caused by a terrorist attack but later found to be caused by faulty equipment in Ohio. Hospitals throughout the region were forced to use emergency power – supplied by generators. As had been reported in previous disasters, several institutions experienced failure of this critical equipment and lost power. This illustrates the importance of the EMC needing to identify and maintain equipment and locations that receive emergency power from the generators.
The requirements of The Joint Commission mandating tests of the emergency generators should be considered the absolute minimum for testing the generators. Diesel engines need to be run at, or near, full load of the engine rating and not just the connected electrical load, for approximately 15% of the run time. They need a heavy load for most of the time remaining in the test. There are islands in the Caribbean that use the same type of generators as U.S. hospitals. These units may run for months without shutdown. It is what these generators are built to do if properly exercised and maintained. U.S. hospitals do not exercise them enough and then are challenged when they cease to run. Other good practices include changing oil as recommended by the manufacturer, and changing the generator coolant at least every other year, or more frequently if recommended by the manufacturer. Only distilled water should be used to mix with the antifreeze to prevent mineral buildup and resultant loss of cooling capacity of the radiator. Batteries should be replaced every three years as a good practice, and at each oil change a sample should be sent for an independent analysis. The fuel in the tanks should be reconditioned annually by running it through a staged series of water separators and filters. Fuel should be analyzed on site until it reaches the specified clarity and quality. Further, a manual dipstick, coated with water indicator paste, should be performed weekly on each tank, rather than relying on a gauge that could be faulty.
The transfer switch that locks out commercial power and allows generated power to the hospital is a link in the chain of proper functioning. For this reason, the transfer switch needs to be periodically inspected and connections tested. If the switch fails, there will be no power to the hospital from the generators. In areas subject to earthquake, there have been instances where tremors caused emergency generators to fail. This problem can be prevented with proper mounts.28
An additional concern created by use of supplemental standby power is the extent to which the laboratory and radiology can operate their equipment relying on this source. Furnishing generator power to these departments is insufficient. Some devices have unique requirements relating to electrical current flow and personnel must know whether the cyclical fluctuation of the generator will cause delicate equipment to malfunction or fail completely. Such conditions must be anticipated pre-event and addressed collaboratively between EMC and plant operations representatives.
Because generators and transfer switches can malfunction even after proper maintenance, the hospital should have an ample supply of flashlights, battery-powered lights, headlamps, and batteries as a safeguard against generator failure. Illumination sources using light-emitting diodes (LED) conserve battery power and should be considered.
Natural gas is a common fuel and may power the hospital’s air conditioning system, boilers, hot water, cooking ranges, ovens, and generators. Although natural gas is more reliable during storms than overhead electrical lines, it is extremely vulnerable to earthquakes and mudslides.
Heating, Ventilating, and Air Conditioning
In compliance with ventilation codes, a hospital in the United States can draw in more pounds of air per day than pounds of water. The typical hospital will have multiple handling units that pass the incoming air through mechanical or electronic filters, heat or cool the air, humidify or dehumidify the air, and send it to the various areas of the hospital. This air does not linger in the building and is removed by exhaust fans. Hospitals have high energy costs due to compliance with these building codes. Little recirculation is permitted as an infection control measure, and a large number of air exchanges per hour are required. If the hospital does not have adequate emergency generator capacity, there will be a shutdown of this system and also air conditioning. If the air conditioning chillers are fueled by natural gas, the loss of this supply will also shut down the units. During and after Hurricane Katrina, many hospitals in the affected area experienced temperatures of over 37°C, creating a significant hardship for patients and staff. Certain types of equipment cannot function in that temperature range. Because the applicable codes do not require emergency generator power to HVAC equipment, the prudent facility spends the extra money and purchases larger-capacity generators after a thorough analysis of emergency electrical needs. This pre-event strategy can protect the multiple services not addressed by regulatory codes that are required to operate the hospital and provide patient care. Whatever the type of disaster, planners must understand that loss of power or other utilities can severely limit patient care capacity.
The hospital’s HVAC system can become a safety hazard in the event of a chemical spill. Transportation and industrial accidents can release chemicals that are carried through the air. If a hospital is downwind of a chemical plume, it will quickly draw the chemical into the building by the air-handling units, and this may in turn sicken or even kill staff and patients. The EMC, as an all-hazard planning committee, must be cognizant of this possibility and plan accordingly.
The first consideration is the location of the air intakes for the hospital. Because many chemicals are heavier than air, ground level air intakes are particularly susceptible to drawing in contamination. Some hospitals have intakes mounted on the side of the building, which is better, especially if they are 4.6 meters or more above the ground. The best location is on the roof; however, even rooftop units do not guarantee that the hospital cannot become contaminated. Due to the risk of terrorism, hospital planners must be mindful of the need for security of these air-handling intakes. Additional information about protecting the building and its occupants is found in Guidance for Protecting Building Environments from Airborne Chemical, Biological or Radiological Attacks.28,29
To protect the facility from such an event, the EMC must develop a plan to lock all external entrances to the hospital and to guard them. The engineering department must rehearse the shutdown of all air-handling units to prevent the chemical or smoke from entering into the building. Also, security officers should be taught this procedure to assist the engineer on duty or in case the engineer becomes incapacitated. If evacuation of the facility is not appropriate, using this shelter-in-place strategy to protect patients is the best option.
Water
Water is an absolute necessity to keep the hospital functioning. The EMC should determine whether the utility company feeds water to the hospital from two directions. This is a safeguard in the event of a water main break. Another option is to have a continuous loop that surrounds the hospital property. Some hospitals have storage tanks that are constantly refreshed by a main water line. An supplementary water tank for fire protection is also a prudent investment. Additional strategies for water supply include bottled water, arrangements with water-hauling companies, and pre-event agreements with the community emergency management agency for assistance. In the case of slow-onset events such as hurricanes, the hospital can fill water bladders if they have them. These can be purchased in a variety of sizes. Bladders are also useful for on-site storage of delivered water if a means of extracting the water is available.
The EMC must also develop a water-rationing plan including alternate means of disposing of human waste. To avoid further loss of limited supplies, patient and employee commodes can be lined with plastic bags. Following use, several ounces of chlorine bleach can be added and then the contents can be double bagged. A standby contract for portable toilets can be helpful, especially for hospital personnel and visitors. Planners must determine how the facility will dispose of human waste.
Some hospitals have wells on their campuses. In these cases, the EMC must ensure the pumps are connected to the emergency generator. Wells, however, can be damaged or destroyed by earthquakes and some other types of disasters so contingency plans must be in place.
Damage Control
Healthcare facilities can be damaged in a disaster; however, they are expected to remain functional and remain open for patient care. For the protection of patients and personnel, the facility should have a damage control plan. The damage control plan should be developed jointly by the plant operations personnel and the EMC. The plan outlines a methodology whereby reports are received at a central point such as the hospital EOC from the various departments regarding damage their area has experienced. At the same time, management staff should dispatch employees to conduct a rapid needs assessment of every floor and department. These employees then report their findings to the EOC. A person/position designated in the Damage Control Plan then reviews the damage list and determines the emergency repair priorities in consultation with the IC and chief of the Operations Section. The work of the damage control team can be greatly facilitated if the following equipment is contained in a storage area on site: floor plans, rolls of plastic and lathing strips for covering windows, spools of wire, sprinkler plugs, hand tools, gasoline-powered rescue saws with blades for steel and concrete, dewatering pumps, portable oxy-acetylene torches, flashlights, headlamps, portable flood lights, sheets of exterior plywood, saws, pry bars, and materials for controlling chemical spills. Large-sized facilities should consider creating several such storage areas. The hospital must aim toward self-sufficiency for at least the first 72 hours and not expect external assistance from emergency response agencies because these groups are fully committed in a disaster and their capabilities are frequently exceeded.
Supplies
From a preparedness standpoint, a weakness in the hospital industry is the just-in-time inventory system. Although such systems improve cash flow and are efficient during routine operations, they are unreliable in a disaster, especially one that covers a large geographical area such as Hurricane Katrina. Because a just-in-time system depends heavily on truck transportation, this can become problematic due to obstruction of transportation corridors after a disaster.
The AHA’s Association for Healthcare Resource and Materials Management (AHRMM) in concert with the Health Industry Group Purchasing Association and the Health Industry Distribution Association created a preparedness document.29 This publication consists of a core and pediatric inventory and then adds specific items needed for managing the effects of terrorist attacks with chemical, radiological, explosive, nuclear, or biological weapons. The document also contains recommendations for staff PPE. Laboratory and radiological supply needs are not included. The Minnesota Department of Health’s website contains a more refined list.30
As previously cited in the section on History of Healthcare Disaster Planning and Preparedness, the United States no longer has the massive reserves of medical and surgical supplies of past years. In addition, reliance on the military medical service is somewhat problematic. Their first commitment is to national defense; therefore they have limited resources to participate in civilian disaster response. The reduction of combat support hospitals and other field medical units as well as diminished military medical supply inventories also limits their ability to respond.
The EMC should carefully consider the cited lists, determine desired inventory levels, and decide whether the hospital can afford to increase supply levels of frequently used items. Additionally, the materials management department can craft pre-event purchase orders, arranging contracts with suppliers for emergency shipments and mutual aid agreements with neighboring hospitals or as part of a multi-hospital system. These arrangements should part of community-wide planning to avoid multiple facilities in the region depending on the same supplier. Standby agreements should also be established with medical suppliers outside the immediate area in case local suppliers are unable to deliver the requested inventory.
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