Download Operational Issues Checklist

EMERGENCY PREPAREDNESS: OUTLINE OF OPERATIONS ISSUES
Emily Black Grey, Esquire
Breazeale Sachse & Wilson LLP
I. COMMUNICATIONS
a.
Inside the Hospital
If the power is out or the communications network is otherwise impacted,
hospitals should consider how they will be communicating among the staff
between floors and within the hospital campus. Also, consideration should be
given to the inability of patients to press a call button in their room get assistance.
b.
Outside the Hospital
A number of potential issues make communications outside the hospital difficult
in a disaster. Those issues can include the following:
1. Power Loss. Although cell phones will work for a certain amount of time,
when there is no power to recharge them, they lose their usefulness.
Additionally, no power can mean that hospital phones do not operate. It can
also mean that radio contact with Emergency Medical Service (EMS) is
limited or unavailable.
2. Cell Towers Down. In a disaster, it is likely that towers which provide signals
for cell phones and other devices may be knocked out, making it impossible
to get a signal. Additionally, high volumes of cell phone calls can make it very
difficult to get a connection. Text messaging from cell phones is sometimes
effective when a call will not connect.
3. HAM Radio. When all telephone lines were down and cell phone towers are
out, one option that may work is using a HAM radio.
c.
Communicating Needs
When communications are difficult, and there is a limited ability to contact the
outside world, the hospital should have an established a point person who can
communicate detailed needs. Avoid the mistake of asking for “all the support we
can get.” Rather, communicate a detailed, descriptive list of items that are
required, such as specific pharmaceuticals, staffing requirements, food, water, or
fuel needs.
d.
Transfers
It may be difficult to communicate with other facilities regarding patients who
require transfer. Also consider the possibility that the municipality, state, or even
the federal government has set up a special emergency transfer program.
e.
With Staff Who Are Not Present
Hospitals will want to keep contact with staff who are not at the facility. More
information regarding this will follow.
II. POWER
In emergency situations, operations are acutely impacted by the lack of power. The
following are some precautions which can increase the chances that power will be
maintained.
a.
Backup Generators
1. Unit Placement/Elevation. It is essential that generators and chillers be
elevated so that they are not impacted by flood waters. These units should
be adequately protected from the elements and the potential impact of the
disaster (for instance, flood waters, earthquake damage, etc.).
2. Motor Control Center Placement. Even facilities that have proper placement
of generator and chiller units can run into problems if the control center (a/k/a
the “switches”) are placed or connected in an inappropriate area where wires
or the controls themselves will be underwater). This can render the
generators and chillers useless.
3. Capacity. Do the back up generators have capacity to run heat and/or air
conditioning? Hospitals should check your generators’ ratings to ensure
power for the full operations of the hospital. In extreme heat, generators
unable to handle the pull for air conditioning can cause a serious issue for
patients and physicians, particularly where patient rooms have windows that
do not open.
4. Testing. To ensure that the back up generators function appropriately, they
should be tested once a week.
b. Fuel
1. Back-up generators are useless without fuel to power them. It is
recommended that a hospital have at least seventy-two hours of fuel on
hand to operate its generators.
2. Where is the fuel maintained? Is it in underground storage tanks? If so, will
the underground storage tanks be impacted by the potential disaster?
3. Does the facility have an uninterruptable power system (UPS) in place? Often
hospitals have one back up generator and/or battery power which comes on
when the power grid fails. Many hospitals enter into contingency contracts
during hurricane season for a second generator to act as a back-up in the
event the first generator fails. If there is a predictable disaster, a contingency
contract may be a possibility.
c. Evaluation
If the hospital is unable to answer the questions above, it should obtain an
evaluation of its system and take precautions to ensure that it does not lose
power in the event of a disaster. Many operations issues are brought on by a lack
of power. Should the hospital not have a contact, Carrier Corporation can provide
this type of evaluation. A point of contact is Chuck Grey, in Carrier Commercial
Services, who has significant experience handling the power needs of hospitals
in the aftermath of Hurricane Katrina and other hurricanes. He can be reached at
(225) 678-0727.
III. DIETARY
a.
Suppliers
The hospital should consider the possibility of being cut off from the supplier of
food for an extended period of time. Consider how many days of food to keep on
hand, keeping in mind that not only patients need to be fed, but also the staff,
and family members.
b.
Serving/Cooking
If there is no power and/or a limited water supply, the hospital dietary staff should
have a plan for preparing food without power and/or natural gas. Consideration
should also be given as to how to handle serving food when water to wash the
hospital trays is not available. Disposable serving items may be a good option.
IV. ADDITIONAL PEOPLE
a.
Sheltering in Place
Often in the event of hurricanes, people shelter in place. Other facilities may
evacuate to the hospital. The hospital needs to make plans for these additional
people which include not only patients but also potentially the following:
1. Patient families.
2. Staff members and their families; consider the potential for children to
accompany staff members. Childcare plans may help ensure that the staff
members can continue to work.
3. Pets. Some of the individuals listed above could potentially bring pets with
them if it is not safe to leave the pets in their homes. The hospital should
develop a policy on this and if it chooses to accept pets, make plans for not
only feeding and housing the pets, but also for the noise created and cleaning
up after the pets and letting them out of any cages in which they may be kept.
V. MEDICATIONS AND SUPPLIES
a.
Extreme Temperature
Consider the impact of extreme heat on various medications. If there is a loss of
power what is the capacity to refrigerate medications; how they will be kept cool?
b.
Blood Products
How will these be maintained if there is a power loss? How will more blood be
obtained if supplies are cut off?
c.
If pharmaceutical suppliers are unable to reach the facility, how will medications
be handled? What about rationing?
d.
If the facility closes and evacuates, how will drugs be protected? Pharmacies
have a potential for being burglarized by drug seekers.
VI. TRANSPORTATION ISSUES
a.
Potential Issues
There are multiple potential issues that can prevent transportation including
weather, flooding, impassable roads, and violence. Even with support from
helicopters and/or EMS there is a potential that they will be prevented from
reaching the hospital by events such as riots in addition to natural disasters.
b.
Communications
Post-disaster it may be difficult to communicate with EMS and/or other facilities
or any other available transportation option regarding your needs and where
patients are going.
c.
Order of Transport
In advance, the hospital should try and develop a plan as to deciding which
patients and/or staff will be transported first.
d.
Record-keeping
In the aftermath of a significant disaster, patients may be transported all over the
country. Patients may not have a choice of where to go. Family members, who
may even be eager to come and get them or provide support, may be distraught
when they cannot get access to a patient. The hospital should develop a plan to
keep up with patients as the state and/or federal government transports them via
whatever method may be available (e.g., bus, airplane, train) from the hospital in
a disaster area.
e.
Triage
The disaster area may have an emergency process in place which overrides
Emergency Medical Treatment and Active Labor Act (EMTALA). There are
specific rules under EMTALA when a disaster/emergency is declared, and the
triage rules can be quite different.
f.
Transporting Patients
How will specialized patients be transported? For instance, how will the neonatal
intensive care unit be evacuated? What will happen with the psychiatric patients;
morbidly obese patients? If helicopters are used, what types of patients can be
combined?
g.
Moving Patients Within the Facility With No Power
It is difficult to move patients without electricity; patient beds are impacted as are
elevators and lights.
1. Where there are no elevators, consider how patients will be transported up or
down stairs. Some hospitals have been compelled to carefully slide patients
on mattresses down stairs in darkened stairwells. Some hospital staff have
carried patients up stairs on their backs.
2. Consider how the morbidly obese will be moved. In the event of a flood, how
will they be moved to higher ground? Is it feasible, where there is potential for
flooding, to get the patients to higher ground before rising water and/or power
outage becomes an issue?
3. Think about the areas of your facility where it will be dark if the power goes
out. Is there back-up lighting available?
4. Destruction to the building. Consider how patients will be moved from areas
of the building that are severely damaged. Will you be able to dig out patients
covered in rubble? If a fire erupts, how will non-ambulatory patients be
rescued when no fire department is available?
h.
Transferring Between Hospitals
1. Consider what will happen if there are no in-state facilities available to accept
transfers. Is there a corporate office with which to coordinate? If not, consider
making contacts outside of the potential disaster area in advance to have a
point of contact if everything in-state is unavailable.
2. Receiving Patients. Consider the possibility that facilities on the outskirts of
the disaster area will be receiving multiple patients from facilities within the
disaster area who may arrive with no records, no medical history, and no
ability to communicate. Consider the likelihood that you will short-staffed.
VII. STAFFING
a.
Pre-Emergency
1. Determine who will stay and who will evacuate in advance. Designate key
personnel to remain at the facility.
2. Obtain contact information. In the event that staff resides near the hospital,
they will also be in a disaster area. If your staff evacuates, where can they be
reached? Facilities can address this in advance by obtaining emergency
contact information from your staff about where they would go if they did
evacuate.
3. Training. Consider the difficulty staff will have if they are not properly trained
for a potential disaster. Consider the difficulty staff will have, for instance,
denying limited supplies in the event of rationing. Staff will be more capable
of handling these types of issues if they are trained in advance rather than
being surprised with the problem during the emergency.
b.
During and After the Disaster
1. Remember that schools are closed during a disaster. Your staff may have
childcare issues. This is something you may be able to provide at the facility
to keep your staff working.
2. Do you have a plan for disaster privileges? Shortly after the disaster, there
will likely be a large volume of volunteers ready to come in and help. What is
your policy for providing emergency credentials? If you do not have one, you
should.
3. Consider the possibility that your State Board of Medical Examiners and other
non-physician provider licensing boards may be closed due to the disaster
and that the state agencies may take special action as a result. This
information will likely be communicated via an internet posting.
For Example, after Katrina, Louisiana suspended, by executive order, the
licensure laws for out-of-state physicians. After Katrina, the Louisiana
Department of Health and Hospitals (DHH)provided guidance for emergency
nurse credentialing by giving a directive to facilities as follows:
i.
Providing documentation that an RN has a verified and current license on
every nurse.
ii. Providing documentation that the nurse is assigned to patients in an area
that the nurse feels qualified to work. Hospitals were not allowed to ask
nurses to assume care of patients in a position for which the nurse had no
previous work experience. For instance, a nurse with no experience in the
intensive care unit should not be assigned to that unit.
iii. If the nurse was licensed out of state, the DHH acknowledged that there
was not contact available with the Louisiana State Board of Nursing to
verify how they wanted it handled. In light of the disaster, if the hospital
could provide documentation of the current license status of the nurse
from the State Board of Nursing, it was acceptable to allow that nurse to
work in Louisiana as long as the assignment was in the area that they
have previous work experience and feel competent to work.
4. Consider the possibility that the state hospital licensing agency may be
closed and may be unavailable to provide any guidance.
5. Emergency Credentialing Physicians. Hospitals should first look to their own
emergency procedures in their bylaws.
In another Hurricane Katrina example, the Louisiana State Board of Medical
Examiners was closed. Hospital credentialing procedures, per the DHH
Directive, should at least include obtaining a copy of the current medical
license, a current Controlled Dangerous Substances license and picture
identification. The facilities were also instructed to document the scope of the
physician privileges and obtain written approval from their chief of staff,
medical director, or chief executive officer.
6. Note that The Joint Commission also provides guidance for disaster
privileging procedures.
c. Maintaining Contact With Your Staff
Post-disaster, using the contact information obtained pre-emergency, you should
keep in contact with your staff. It can also be helpful to establish and disseminate
a website on which hospital updates will be provided to staff in advance.
d. Payroll
Consider whether and how continue to paying employees, even if payroll
personnel is out for an extended amount of time, if power is out, or if the banks
are closed.
VIII. WATER SUPPLY
Consider what will happen if the water supply is limited. The following are some
potential operational issues.
a.
Is there sufficient drinking water for all persons at the hospital?
b.
Is there sufficient water to wash linens, plates, supplies? For sterilization?
c.
Is there water to flush the toilets? What if the sewerage is cut offor if the pumping
station is without electricity or destroyed? What happens if the sewerage backs
up into the facility?
d.
Chillers
Even with power, if there is insufficient water to operate chillers, air conditioning
will not run, which in extreme temperatures can cause multiple issues.
IX. DECEASED
Consider what to do with multiple corpses when the morgue is unavailable or full.
Will there be a designated space for this purpose? How will it be separated it from
patients? How can you best minimize the impact of this issue and properly respect the
bodies of the deceased?
X. MEDICAL RECORDS
a.
Placement
Consider the vulnerability of medical records in an area which could potentially
flood. Even if the area does not flood, consider the opportunity for mold to grow
and destroy the records.
b.
Electronic Health Records
Consider how records will be handled if the power goes out. Will staff have
sufficient access to information to take care of the patients? Are back-up forms
available in the event the electronic health records fail?
c.
With Transport
Consider how to coordinate transporting the entire patient population out with
medical records in the event that the facility has to be evacuated.
d.
HIPAA
Recognize that there may be suspension of HIPAA in a disaster situation. For
instance, after Hurricane Katrina, DHHS waived certain provisions of HIPAA in
the disaster area including the requirement to obtain a patient’s agreement to
speak with family members or friends or to honor a patient’s request to opt out of
a facility directory; the requirement to distribute a notice of privacy practices, and
the patient’s right to request privacy restrictions or confidential communications.
XI. LIABILITY ISSUES
a.
State Good Samaritan Rules
Consider whether these are available in your state and what protection they offer
for both your staff and other volunteer staff.
XII.
SURGERY ISSUES TO CONSIDER
a.
Unavailability of water.
b.
Unavailability of power.
c.
Even with power, unavailability of AC. Consider operating in extreme heat.
XIII. SAFETY
a.
Pharmaceuticals.
Post-disaster, there can be a significant concern about drug seekers violently
approaching the hospital. Consider what is required to protect your patients and
staff.
b.
Riots Outside the Hospital
Consider the potential of violence surrounding your facility. How will you protect
the facility entrances and limit access inside?
c.
Internal Issues
Consider potential mental health problems of your patients (particularly
psychiatric patients), your staff, and their family members in a crisis situation. Is
there adequate security internally to manage these issues?
XIV. OFFICE CLOSURES
Consider the possibility that multiple offices may be closed due to the disaster
including the following:
a.
Government
Including the State Board of Medical Examiners, the Department of Health &
Hospitals, the CMS Regional Office, the Board of Nursing, other non-physician
practitioner licensing boards.
b.
Providers/Suppliers
Including doctor’s offices, dialysis units (closures mean patients presenting with
need for dialysis), surgery centers, imaging facilities, blood banks,
pharmaceutical suppliers (closures mean patients coming to your hospital
needing refills of crucial medications often with only their empty medicine
bottles).
c.
Others
Counsel, banks, utilities.
d.
Facility Support
Consider that the following may fail and no one will be available to help: power,
water, phone, food, medical supplies, pharmaceuticals, PRN staff, fuel, internet,
electronic health records, dialysis, and information technology.
XV. OTHER SECONDARY ISSUES
Consider issues that may result from the disaster and impact your facility such as the
following:
a.
Gas leak
b.
Water main break
c.
Sewerage break
d.
Rampant contagious disease/infection within your facility or outside your facility
e.
Quarantine
f.
Violence/Riots
g.
Fire
XVI. RE-OPENING ISSUES
Consider the requirements that will come from your state regarding re-opening your
facility including environmental reviews and evaluations. Importantly, recognize that
CMS does not allow a change of ownership for a closed facility. Your facility must reopen if you want to sell it.