Planning for the worst
Unfortunately, according to Timothy J. Ward, at the time of writing a partner based in Tefen USA’s Washington, D.C., office, “Because day-to-day operations for emergency departments (ED) are so overwhelming, I’m sad to say that we don’t have enough focus on disaster planning and it will only continue spiraling in the wrong direction.”
Furthermore, writes Ernest Sternberg, professor, Department of Urban and Regional Planning, University of Buffalo, New York, in a medical journal article entitled, “Planning for Resilience in Hospital Internal Disaster”, “Concerns about healthcare facilities are multiplied in the current period as the numbers of hazards may have increased because of the extreme weather conditions thought to arise from global climate change, the increasing urban concentration of population, the use of more types of hazardous materials in industrial production, new possibilities for civil unrest, and the emergence of new infectious agents, as well as threats from radiological, chemical, and biological weapons.
“As of the first years of the 21st century in the U.S., despite the consternation about potential terrorist use of weapons of mass destruction, preparedness in
healthcare facilities has been uneven,” observes Sternberg.
Similarly, Ward estimates that only about 1 in 10 hospitals are willing and ready to invest the necessary resources for such contingency planning. But for those in the prudent minority, Ward’s healthcare consulting experience supports several recommendations:
“The first thing we do,” says Ward, “is build a computer simulation model of day-to-day patient flow. Then we model a dozen scenarios of extraordinary events.” Those scenarios include natural disasters, biological, chemical, and radiological events; they’re categorized as “small” (involving 12 to 20 injured victims), “medium” (100 to 250 new patients), and “large” (involving up to 1,000 patients).
The next step, says Ward, is to ensure that the appropriate policies, staffing levels, internal resources, and necessary building environment are in place to support such contingencies. For example, at what point during any of these crises should the hospital change its normal protocols, i.e., cancel elective or regular surgery, call in extra staff, or transfer patients out to other hospitals?
Craig A. Goolsby, MD, staff physician, Department of Emergency Medicine, University of California at Los Angeles/Olive View-UCLA Medical Center advises in an article published on
eMedicine that a hospital disaster plan should include protocols and policies that meet the following needs:
• Recognition and notification
• Assessment of hospital capabilities
• Personnel recall
• Establishment of a facility control center
• Maintenance of accurate records
• Public relations
• Equipment resupply
More specifically, Sternberg suggests, “The first and most consistent feature of crisis is that it poses new challenges to which staff must respond by contacting persons (personnel designated to have authority in varied shifts, janitors with certain keys), acquiring specific kinds of information (as from a hazmat information center) or obtaining emergency supplies (flashlights, insulated gloves, etc.)—actions they do not routinely take. It can be reliably anticipated, therefore, that during crisis, we will need a simple, updated, reference manual on responsible personnel, contact numbers, and supply locations.”
The first line of defense architecturally, says Ward, is having a solid detection system in place to alert hospital personnel of patients who have been exposed to biological, chemical, or radiological elements. Available biological detector technology choices include biological integrated detection systems or hand-held immunoassays for anthrax detection. For chemical detection, a chemical biological mass spectrometer, an automatic chemical agent alarm and the Avir chemical agent remote sensor are all good systems. On the radiological level, the Geiger-Mueller tube and civil defense radiation survey meter can be very useful tools.
Following detection, the appropriate security technology and measures need to be established to prevent unsupervised entry of contaminated victims. In cases where decontamination before entering the facility is possible, the appropriate space and stations should be organized on hospital grounds.
Important elements to incorporate into these decontamination stations are overhead protection, procedures for handling of personal property, the ability to contain all used decontamination solutions for later disposition, ADA compliance, and security/access control.
If both detection and security fail despite these measures, Ward warns that sections of the ED may have to be taken off-line and decontaminated. Consequently, if the department is organized in sections—each section typically consisting of 8 to 12 exam rooms and a trauma room—then it becomes much easier to keep emergency care operational as a whole while one section is taken down, cleaned up, and then put back online.
During this process, one critical aspect of segmenting the ED is how the mechanical systems are set up. As Ward says, “It’s all about air flow.” For example, air flow must be designed to flow in one direction, with filtered air constantly pumped into “clean” areas and out of “dirty” areas. Waiting rooms are usually considered to be “dirty” and are thus good locations for air exhausts. Special consideration might be needed for rooms used to treat airborne infectious diseases.
In addition, a policy needs to be put in place to determine at what point the pneumatic tube system that delivers samples to the lab needs to be turned off to minimize the potential of spreading airborne agents throughout the hospital. (Preferably this is zoned so that the pneumatic tube system may continue to be used outside the ED. Also, a point-of-care lab for the most frequently used tests serving a large ED of 50,000 visits per year or more would be worth considering, in part because it greatly facilitates patient treatment during day-to-day operations, but also to minimize the need for the pneumatic tube system during contingencies.
Yet another important detail is identifying the largest open spaces within the facility, i.e., a cafeteria, and making sure that it is set up with the appropriate infrastructure—namely electrical and medical gas outlets—to support the temporary emergency addition of additional beds to continue treatment of patients who have been stabilized in the ED. Ward notes that computer modeling can determine the number of these contingency beds needed for particular levels of disaster, and the “beds” can be cots, possibly stacked two or three high on stanchions to accommodate large numbers, with electrical outlets and medical gases located in the ceiling nearby. Other contingency provisions in the cafeteria would include HVAC accommodations, toilets and showers for patients, storage for equipment and medical supplies, and some thought given as to where food will be prepared and distributed now that the cafeteria is repurposed.
Similarly, space within the hospital should also be estimated and designated to house healthy people—the worried well—who think that they might have been exposed to some sort of disaster consequences after they were medically cleared through the ED.
Although the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) does, to some extent, require hospitals to plan for disasters, Ward observes that “it would certainly help to have a more systematic federal program and regulation in place.” On a regional level, it is also very important for area hospitals to network together in an accurate and efficient manner—for example, having the means to continuously monitor and quickly assess in real time which facilities are overwhelmed and which are capable of taking in overflow patients from a disaster event.
Ward says that monitoring and coordinating hospital capacity on a regional level is clearly the responsibility of state departments of public health. A few states are starting to move tentatively in this direction.
Sternberg, for his part, recommends what he considers to be an especially thorough and well-organized checklist on mass-casualty disasters called the Mass Casualty Disaster Plan Checklist: A Template for Healthcare Facilities, written by the Association for Professionals in Infectious Control and Epidemiology, and available for reference at www.api.org.
At the same time, Erik Auf der Heide MD, MPH, FACEP, Agency for Toxic Substances & Disease Registry, U.S. Dept. Health & Human Services, in his book, Disaster Response: Principles of Preparation and Coordination, warns against what he calls the “paper-plan syndrome.” Sternberg explains that this is “the belief that disaster preparedness can be achieved simply through the filing of a written plan.” Auf der Heide strongly cautions that such plans prove more useful in practice when they are relied upon “not as documents to be suddenly consulted in an emergency, but as forms of training complemented with additional forms of preparedness.”
Ward claims that disaster preparedness is simply not being addressed proactively enough: “You would expect that after 9/11, we would have really jumped on this, and that, in 2008, we would be a lot farther ahead, but my sense is we’re not.” It will take strong, responsible government and healthcare industry and design leaders to adequately prepare the nation’s medical care system for those disasters that are, unfortunately, bound to occur.
Barbara Horwitz-Bennett is a frequent contributor to publications and organizations dealing with building and construction. Timothy J. Ward, at the time of writing, was a Partner with Tefen USA, based in Washington, D.C. For further information, phone 240.888.5589, e-mail
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