Introduction
The successful Emergency Manager attempts to leave as little as possible to chance. Creating an Emergency Response Plan for a healthcare setting is, in many respects, simply another project. As such, it is very much amenable to the processes described in detail elsewhere in this series, including applied research methodology, Root-Cause Analysis, Project Management, Lean, and Six Sigma. Each of these can have a significant impact on both the project and the quality of the result.
That being said, the practice of emergency management has its own major components, and these can provide the Emergency Manager with further assistance, by identifying those issues which must be addressed in order to create an effective and interoperable Emergency Response Plan. Understanding each of these components, and the associated issues, is essential; without careful analysis and understanding of these issues, and the advance work need to resolve them, the Emergency Manager will never really have a clear picture of what planning needs to occur. This chapter will address the basic components of emergency management, and the major issues which must be resolved prior to the creation of an Emergency Response Plan.
Learning Objectives
On completion of this chapter, the student should be able to identify the four major components of emergency management and describe how each component works. The student should be able to describe how these components influence the process of creating an Emergency Response Plan. Finally, they should be able to understand and describe how these components operate in a healthcare setting, in order to generate requirements for advance research, dialogue, and problem-solving, prior to beginning to write an Emergency Response Plan.
The Fundamentals
In all types of emergency management, and in all types of settings, there are four separate and distinct components to practice which have become universal. These four components encompass the entire range of the emergency management process from beginning to end and have been in common usage for more than 30 years now. The first of these components is mitigation1; the process whereby the Emergency Manager attempts to treat existing risk exposures effectively, so that their effects are either reduced or eliminated. This should always be the first component to any emergency management practice.
The second component is preparedness2; those activities which accept that a risk exposure is present, but which attempt to ensure in advance that the organization or community has the ability to deal with the risk exposure, should it occur. The third component is response; those activities directed at being able to deal with a risk exposure effectively and safely, when it does occur. The fourth and final component is recovery; those activities and measures which will restore the organization or community to an operating state of normal or “near normal” operations, after a risk exposure has occurred, and has been addressed. Each of these four components will be addressed separately, and in much greater detail, later in this chapter.
There is a fifth component which has been proposed in some circles; prevention, however, there is considerable debate among emergency management professionals regarding how and why this proposed component differs from the accepted mitigation component.3 The four components to practice are often depicted graphically as a cycle; however, the experienced Emergency Manager recognizes that this model is not necessarily rigid, and that opportunities to address some elements of each of the various components may often occur even while another component is occurring. To illustrate, opportunities for mitigation are often identified and put into place during both the response and recovery components, and both mitigation and preparedness planning will often occur concurrently.
Mitigation
Mitigation is the modification of a vulnerable process or location within the healthcare facility or the community, in order to either reduce the amount of risk exposure, should a hazard event occur. It may also involve the complete elimination of the possibility of occurrence for the hazard event, thereby eliminating the risk exposure completely.
In some quarters, there is an argument for a fifth component of the emergency management cycle, specifically, prevention. This, to some extent, reflects the influence of FEMA being absorbed by the U.S. Department of Homeland Security. As a result of the influence of currently dealing with terrorism, instead of simply natural and technological disasters, there is a new emphasis on “prevention” being the first of the five stages of homeland security, and on it receiving primacy over the four stages of emergency management.4
There are those who argue that prevention refers to the elimination of the event occurring, and is specifically associated with terrorism, while mitigation deals with the reduction of effects, should the event actually occur.5 However, the majority in the field, at least, thus far, continue to believe that Prevention is simply the outcome of Mitigation performed well,6 although sometimes varying by the extent to which the effects of the hazard or risk event are eliminated.
As one example, consider the hospital’s vulnerability to interruptions in the community’s electrical distribution system. Within a hospital, or indeed, in many types of healthcare facilities, uninterrupted access to electricity can be critical; there are often patients who are dependent upon technology-based life support systems which are powered by electricity. In addition, there may be patients who are undergoing critical procedures, such as surgery or childbirth. There are patients who, while not in such an immediate threat, would begin to suffer fairly quickly during a power disruption, such as those in the newborn nursery.
There are also other critical processes with the potential to be disrupted by a power outage, including the laboratories, diagnostic imaging, and the Blood Bank. Finally, there are processes which, while not immediately life-threatening, have the potential to substantially disrupt the business of the hospital, including computers, digital telephones, paging systems, food refrigerators, drug refrigerators, and in some cases, elevators. One of the most vulnerable aspects of any hospital to power interruption is the heating, ventilation, and air conditioning systems. Because of their power demands, such systems are not universally included in the emergency power “grid.” The vulnerability of a hospital to a power outage is substantial, and such outages occur on a fairly regular basis in many communities.
Figure 1.1 A hospital’s emergency generators; one of the most essential and most misunderstood items of emergency equipment in the facility
In an attempt to mitigate against such problems, most hospitals have installed emergency power generators (see Figure 1.1). These generators are designed to activate automatically, during any power disruption. Such systems are often installed at the time of construction, and only rarely revisited, apart from regular testing and inspections. The only time that many such systems are updated is when the facility is undergoing major renovations. One of the challenges with such systems is that while medical technology, and therefore, the demand for electricity, continue to grow, the emergency generator system often does not.
Many of these systems are decades old, and the initial need for such systems was seen to be the powering of a limited number of essential devices in each location, but not the entire facility. In many cases, older systems power as little as 20 percent of the facility’s daily needs, with just a few emergency power plugs (often red) on each Unit, and it is common to find systems which power only a single elevator, although the hospital may have several. In newer facilities, such systems are designed to cope with all of the power needs of the facility which were current at the time of installation, but even these only rarely fully address the needs of the building’s heating, ventilation, and air conditioning systems, which typically draw enormous amounts of power.
Potential mitigation measures include the installation of newer, more powerful, electrical generators, to replace the older systems. When a facility is extensively renovated, it may be possible to greatly expand the number and distribution of emergency power plugs on the various Units, as work progresses. Another relatively low-cost and creative way to mitigate against electrical failure is to connect the healthcare facility to two separate segments of the community’s electrical distribution grid, so that if a power failure occurs in one portion of the grid, the hospital simply takes its supply from the other point of connection.
It may also be possible to have battery “back-up” systems, or Uninterruptable Power Supplies (UPS) for essential devices, and such systems, which have been common in computer networks for, are growing in use with medical devices, as well. Indeed, it may be possible to add this feature to the specification process for a new device being purchased. Taken collectively, the items described represent a “menu” of options, and a layered approach to mitigation against power failures, with all of the options being possible, and even considered to be good ideas, with the only challenging factor being the cost of doing all of these things.
A recurring theme in the mitigation process is that of cost versus potential benefit. No one would ordinarily simply refuse to upgrade a hospital’s emergency power generators, for example, but a hospital is a dynamic organization in a constant state of growth. There are many different items which various parties within the organization believe to be a priority, and there is always a limited budget. The challenge is for the Emergency Manager to justify mitigation measures in the face of many other competing, and equally valid, priorities for the hospital’s limited resources. Some mitigation measures may be easier to “sell” than others; particularly if there is no immediate budgetary impact, or when both parties can get what they require from the transaction.
To illustrate, the Emergency Manager wants to reduce vulnerability to power failures in the hospital’s critical systems, and the Director of Critical Care Services wants to upgrade the five-year-old cardiac monitors in the Intensive Care Unit and the Recovery Room. If the Emergency Manager can persuade the hospital administration to go ahead with the purchase, but to also create a mandatory policy which adds UPS to the specification list for both this purchase and all future technology purchases, both parties win.
The Emergency Manager has achieved a change in policy which does not create any substantial new budget demand but which ensures that critical technologies have built in mitigation against vulnerability, and the Director of Critical Care has the new monitors. Such mitigation measures are easier to sell, because, on the face of it, they are not competing, and there is no “hard” budget outlay to pay for the mitigation. In the process, this type of cooperation may even begin to generate some new supporters, or even “champions,” for the emergency management process.
The challenge of mitigation is to fix as many areas of vulnerability as are feasible before any hazard event occurs. The problem is that, from the perspective of many on the management team, the Emergency Manager is still attempting to divert much-needed resources to an event which “might never happen.” In all types of mitigation efforts, a sound business case, suitably referenced and cited, will often be required, just as it is for the rest of the hospital’s proposed projects. It may be that the Emergency Manager can demonstrate that the cost of addressing the problem if it occurs will be higher than the cost of mitigation against it, but if the Emergency Manager cannot also demonstrate that the probability of occurrence is also high, they may not be successful.
When mitigation is impossible or unfeasible, the Emergency Manager must begin to consider the next stage of this process; Preparedness. Indeed, it is often wise for the Emergency Manager to consider both of these stages in parallel. An argument which accurately describes the cost of preparing for, responding to, and recovering from an event, instead of mitigating against it, can be a powerful argument indeed.
Preparedness
When a risk exposure cannot be mitigated against, the logical response is to engage in some level of preparation for its occurrence. The degree of preparedness, along with the amount of associated time and effort spent upon preparedness, will be determined by several factors. The first of these should always be the findings of the Hazard Identification and Risk Assessment (HIRA) research, described elsewhere in this work. Along with this information, the Emergency Manager will need to consider other variables, such as funding availability and staff availability for preparedness efforts. Preparedness activities include a broad range of areas, including the creation, approval, and regular updating of the organization’s Emergency Response Plan, the acquisition of appropriate resources for response to the incident, the education and training of staff, and the testing of the Plan, by means of various types of exercises. Each of these activities will be discussed in detail in subsequent chapters.
Many of the efforts directed at preparing the organization to cope with an emergency will need to be research-based.7 It is almost impossible to adequately prepare for an emergency event, without a complete understanding of the event itself, its characteristics, and the experiences of similar organizations, such as hospitals, when confronted with such an event. To illustrate, the Emergency Manager may take the HIRA information for the hospital and determine that tornados are a priority for planning. Research would then be conducted to identify similar events which affected other hospitals, preferably but not necessarily nearby.
After identifying the specific impacts on those hospitals through research, the Emergency Manager would then employ the process of Root-Cause Analysis, in order to identify the specific, underlying causes of vulnerability for the other hospitals studied. Both isolated issues and general trends in vulnerability would be identified, followed by an examination of the Emergency Manager’s own organization for the presence of similar specific vulnerabilities or vulnerability characteristics.
Figure 1.2 As Emergency Management professionalizes and requires greater academic credentials, the availability of good quality research in the field will grow, and will influence preparedness and response decisions
With this information, the Emergency Manager will be much more able to effectively determine which mitigation measures are required, any specific response resources that might be required, training required by staff, including which scenarios to use in emergency exercises, and any case-specific procedures that need to be added to the Emergency Response Plan. The results of this research will also provide hard evidence for the Emergency Manager to use in obtaining approval for preparedness activities from the senior management of the hospital (see Figure 1.2).
Once again, the HIRA information will direct and drive the research activities of the Emergency Manager, spending much more research time and effort on high probability and/or high impact events first, and following up with research on those events which are less likely or lower impact as the opportunity presents itself. Such activities can even lead from a conventional, generic Emergency Response Plan, to more detailed, case-specific annexes to the Plan. To illustrate, almost all hospitals have a generic Emergency Plan of some description, but issues such as mass casualty incidents, fires, and evacuations have sufficient probabilities of occurrence and significant impact, that specific subplans for dealing with such events are commonplace.
Armed with a completed and approved Emergency Response Plan, the Emergency Manager then focuses on the identification of specific training and response resources required in order to prepare for emergencies in general, and for specific scenarios. Partnership and advance dialogue with both the community and with partner agencies are absolutely essential to this process. The time to meet the Fire Chief is NOT when the hospital is burning! Without such ongoing dialogue, both communities and healthcare organizations tend to develop expectations of one another which are both unrealistic and somewhat distorted. This type of planning, usually based upon erroneous assumptions, can lead to poor performance during the emergency, or even to the outright failure of the Plan for either group. There are a number of specific considerations which must be considered and clarified well in advance of any emergency.
What are the expectations placed upon the organization to deal with the specific emergency, should it occur? Does the community Emergency Plan simply state that “all ill or injured persons will be taken to the hospital,” or does it contain a rational, resource-based plan for the balanced distribution of victims to several hospitals based upon clinical requirements, in order to balance the impact? It is astonishing how often communities simply do not understand the capabilities or the capacity of their local hospital, and simply assume that their hospital can handle all of the victims, because no one has ever told them differently. To illustrate, if your hospital does not have a neurosurgeon on staff, there is little point to local Emergency Medical Service (EMS) bringing victims with head injuries to your door, even in a crisis (see Figure 1.3).
Figure 1.3 Trauma Centers: Limited capacity is not always obvious to other nearby hospitals
Similarly, while communities and regions are increasingly served by hospitals with Trauma Centers, not all hospitals have such facilities, and the ones which do have a limited capacity.8 Many hospitals assume that all trauma patients will be taken to the local Trauma Center for planning purposes, not apparently realizing that the moment that the Trauma Center reaches its capacity (often about six major trauma patients arriving simultaneously), the other hospitals will be “back in the trauma business.” This becomes a point for addressing the twin issues of surge capacity and surge capability, and how they will be expected to operate within the organization’s Emergency Response Plan.9
The other aspect to this is the delivery of all patients to the local hospital and overwhelming it, particularly when there are other hospitals available within a reasonable transport range, with the resources to transport those patients available. All of these factors can play a huge role during a mass casualty incident, and how they have been addressed may represent the difference between success and failure. The only time to resolve such issues, and to clarify both expectations and procedures, is well in advance of the occurrence of an incident.
Which processes and procedures will be internal, and which will be addressed by outside agencies? To illustrate, if there is a hazardous materials incident in the community, does the hospital expect the local Fire Department to decontaminate all of the patients prior to sending them to hospital? To what extent will decontamination occur? Will the Fire Department perform gross decontamination prior to transport, with the hospital expected to perform a more detailed decontamination prior to triage and treatment? Does the Fire Department expect the hospital to provide medical support for their decontamination process, or will they use paramedics for this function? If a hazardous materials spill occurs in the hospital, will the Fire Department respond for containment and cleanup, or is the hospital expected to use a private contractor? It may well be that the hospital cannot or should not rely on others for decontamination of incoming patients, and the Emergency Manager will be required to establish a process and a procedure for this.10
Does the local Fire Department even HAVE hazmat response resources and training? In one true scenario several years ago, in a Canadian community, a patient was critically injured in an explosion which occurred during an industrial process and was also coated by an extremely toxic chemical “soup,” as a result of the explosion.11 The local Fire Department had no hazardous materials response equipment or training, and, as the man was clearly dying, paramedics rushed him to the local hospital, sickening themselves in the process. Upon arrival in the Emergency Department, the man began off-gassing toxic vapors, sickening staff and patients alike, and forcing the evacuation and closure of the Emergency Department. The now deceased patient was then moved to open air in the parking lot, where he remained for several hours, while those involved attempted to figure out how to manage his body safely. THIS is the level of disaster which can occur when advance dialogue between partner agencies does not occur!
As a further example, if the hospital requires evacuation, does the hospital have an expectation that local EMS will perform that evacuation? Is that a realistic expectation, and has EMS agreed to this? If the event is external, EMS is already dealing with the response to it, and also attempting to deal with all of the other emergencies which invariably occur in the community, even during a crisis. Even if local EMS agrees to move your most critical patients (evacuating the Intensive Care Unit, for example), it is highly unrealistic in a community with four or five ambulances to expect them to evacuate a 120-bed community hospital; other advance arrangements will almost certainly be required (see Figure 1.4).
Figure 1.4 Hospitals relying on EMS for their evacuation may be an unrealistic expectation, particularly during an existing crisis
Will EMS participation be limited to the collection of evacuees at the hospital doors, or is there an expectation that they will go to the bedside to move patients? Remember that ambulances are an extremely limited resource in most communities, and every minute that an ambulance crew uses to go to the bedside to collect the patient, is a minute in which they are not moving one of your patients to another facility. Have you ever taken the time to “benchmark” precisely how long it would take to evacuate your facility? Where will your patients be evacuated to, and have YOU made arrangements for this to occur? Have you negotiated and signed advance agreements with partner facilities for the reception of your patients during an evacuation? They are, after all, YOUR patients, and only you have the specific details of their illnesses and treatment requirements. Careful advance planning and dialogue with all partner agencies are required, and a clear decision-making process should be identified in advance.12
In 1979, in Mississauga, Canada, a freight train derailment resulted in a large-scale hazardous materials release, forcing the evacuation of more than a quarter of a million residents.13 Among these were the patients of three acute care hospitals and six long-term care facilities. In a response which could only have occurred in a socialized medicine system, a fleet of 100 ambulances was assembled, with some of these having to travel in excess of 100 miles to respond. There was no private patient transportation service at that time.
Working around the clock, in some cases for 30 consecutive hours or more, the paramedics succeeded in moving all of the hospital patients and nursing home residents, 2,600 patient movements in all, in a 24-hour period: a magnificent accomplishment. But this was not without its problems; several hundred of the patients had to be moved more than once, because they were evacuated to other hospitals or nursing homes which were subsequently evacuated themselves. Ambulances were delayed as nurses photocopied patient charts to accompany the patients; without the presence of a specific evacuation protocol, many of the nurses treated the evacuations as they would routine inter-facility transfers. The patients themselves were evacuated to locations across a broad region of the province of Ontario, and it was several days before it was known exactly where each patient was. All of these issues also resulted from a lack of advance preparedness and interagency dialogue.
What specific resources are required to appropriately address the emergency? Does your hospital require additional patient handling resources, such as stretchers and wheelchairs? Do you have a procedure in place for gathering these resources from the various locations around the hospital and bringing them to a fixed location during an emergency? Does staff know this procedure, and when was it last tested? Have you predesignated specific locations for the triage and treatment of incoming patients, or to hold patients who are being evacuated? Have you obtained approval for their use from the “owners” of these locations? Is there specific equipment which is required in each location, where does it come from, how does it get to where it’s needed, and who is responsible for the assembly of these improvised resources? When is the last time that the assembly of each was tested, in order to ensure that staff was able to perform this function without problems?
What types of staff training are required? Does management staff require training in a Command and Control model, such as the Incident Management System, Hospital Emergency Incident Command System (HEICS), or Hospital Emergency Command and Control System (HECCS)? Have all staff received training in evacuation lifts and carries? Has designated Emergency Room staff been trained in the appropriate emergency triage procedures? How frequently is such training updated, and when was it last tested? Does ordinary staff receive regular refresher training on the Emergency Response Plan and the associated procedures? Does your facility possess the qualifications and skill sets required to conduct such training in house, or will it have to be contracted out? And what is all of this going to cost? The questions are many, and the subject of preparedness in a healthcare setting, if done properly, is a complex one!
Armed with the HIRA data, answers to all of the preceding questions, and a solid grounding in advance dialogue with partner agencies, the Emergency Manager is ready to begin to create a preparedness program. This will include the creation of a new, state-of-the-art Emergency Response Plan and case-specific procedures, resource acquisition, staff training, and exercises to test the entire process. It is also important to ensure that each step in this process is well-documented, as this documentation will be invaluable during any accreditation process, or in any legal process which follows an incident.
Response
Eventually, a hazard or risk event which has not been fully mitigated against may occur. The success or failure to respond to this event will be determined in large measure by the degree to which advance mitigation occurred, and the success of preparedness programs. During the response phase of the emergency, the role of the Emergency Manager will become supportive and advisory, while others lead. The response resources, such as the Hospital Command Center or Triage or Treatment areas, which should be already identified in the Emergency Response Plan, will require assembly and activation, staffing will need to be assessed, and augmented, if required.
Many of the decisions which need to be made will be clinical, and it is likely that in a hospital, members of the senior management group, or preassigned staff (usually mid-level managers) with predesignated roles under Incident Management System (IMS) or a similar command and control model, will actually run the response. In healthcare settings, such groups are usually highly clinical in composition, although the participation of support services, such as administration, physical plant, and logistics are absolutely essential. It is not necessary for the Incident Manager to be a clinician, even in a hospital, but it is essential that good clinicians are readily available to provide advice and to interpret both clinical events and reports. In such situations, as in the community, where the Emergency Operations Center typically supports a command structure at the site of the incident, there is likely to be a specific person in charge (usually in the Emergency Room) and the role of the Hospital Command Center will be to support that person.
The response to the emergency may require fundamental changes in the normal operating procedures of the facility. Whatever one might think of institutional capabilities, emergencies are not “business as usual.” EMS may be redirected to other facilities, in order to permit the hospital to focus more exclusively on dealing with the emergency. Hospitals are boxes of finite size, and existing low priority in-patients may require “decanting” to alternate venues of care, in order to provide space for the new victims. Elective surgery may be postponed or cancelled, and in true mass casualty incidents, access to diagnostic and treatment resources, including surgery, may need to be rationed or triaged.
Many hospitals develop a patient flow arrangement in which emergency treatment occurs, and then patients are distributed to other facilities, rather than being admitted, in order to balance the impact across the entire local health network.14 “Just-in-Time” materials management arrangements are likely to fail; a situation which is understandable, when a hospital receives an entire weekly census of patients in a single afternoon. Emergency re-supply arrangements will need to be implemented. Arrangements for these measures will need to be made in advance, because if they are not, they become much more difficult to arrange in the middle of the crisis.
In such circumstances, the Emergency Manager may have numerous responsibilities. They can and should be a trusted advisor and expertise resource for the Incident Manager and the entire senior management team. They may or may not have a clinical background, but they certainly understand the context of the response to the emergency better than anyone else in the hospital. The Emergency Manager can be a valuable point of contact with the community’s response to the emergency, and to other levels of government. The Emergency Manager, as an experienced project manager, is also likely to be the most effective individual available to assist a less experienced Incident Manager (remember, this is NOT their normal job) in the development and operation of an Incident Action Plan.
An effective Emergency Manager will also monitor process flow, such as the Hospital Command Center Business Cycle meetings, and provide advice to the Incident Manager on the maintenance of this essential process, and will also monitor documentation of events, requests, and decisions made, in order to ensure that an appropriate and comprehensive record of the incident is available upon its resolution. An Emergency Manager can also provide support to the planning function, and act as a point of contact, or at least a point of introduction, for liaison with outside agencies. The Emergency Manager will also, almost always, be tasked with overseeing those background activities which support the operation of the Hospital Command Center, making it as “seamless” as possible; as always, a knowledgeable and sophisticated “generalist” instead of a specialist!
Once the response to the emergency has concluded, the focus will shift to the return to normal or “near-normal” operations. In some cases, this will be simpler than in others. If the hospital has simply received a large number of patients, recovery should be relatively straightforward. As the emergency treatment of each patient concludes, they will either be admitted for observation and follow-up care, they will be transferred to another hospital with more capacity to provide them with services, or they will be discharged to the community, with or without community care support. Staff will be rotated out of service and provided with rest periods, and then rescheduled to resume normal shift patterns. The “just-in-time” inventory, probably utterly exhausted, will be replenished and restored to normal operations. Finally, decisions will be required regarding a plan and a timetable for the restoration of normal operations, including the resumption of those services which were suspended in order to cope with the emergency.
However, if the hospital has been directly affected by the emergency, such as sustaining damage, the problem becomes much more complex. Recovery will include dealing with insurance carriers, and possibly even fundraising and public appeals for assistance. Reconstruction or extensive repair of damaged facilities may be required. Essential medical electronics and other medical devices may require replacement or reconditioning. Basic equipment, such as beds, stretcher, and wheelchairs, may require replacement. Staff who have been injured or killed may require replacement. When a hospital has been severely impacted, it can take a year or more to restore it to normal operations. If the hospital is the only such facility in the community, there is likely to be a local expectation that some reduced level of service will continue to be provided, albeit in improvised facilities. When St. John’s Hospital in Joplin, Missouri was destroyed by a direct impact by a tornado on May 22, 2011, the hospital staff continued to operate for over a year from a portable field hospital, borrowed from the Missouri National Guard, which was set up in a parking lot15!
Although the recovery effort may vary somewhat in its complexity, the role of the Emergency Manager will be central. All of those who participated in the event should be debriefed, and the results recorded for future use. An After-Action Report, summarizing the events in chronological detail, problems encountered, solutions attempted, and lessons learned, along with specific recommendations for future events, must be created. All records relating to the response to the emergency will need to be collected, collated, reviewed, and archived, ideally with the hospital’s solicitors, against the potential for a public inquiry, inquest, or other legal issues, since such documents are normally admissible as evidence in many jurisdictions. Changes will also need to be made to the existing Emergency Plan and associated case-specific procedures, based upon the problems identified and lessons learned, in order to ensure that the hospital is better prepared for the next emergency. All of these activities are an essential part of the successful recovery of the hospital or healthcare facility and are normally the duties of the Emergency Manager.
Figure 1.5 An American hospital, following a direct tornado strike
Other Mandates
Before beginning to create the Emergency Response Plan for the organization, the Emergency Manager will also need to conduct research into identifying those mandates placed on the organization from other sources. These may include standards from Accreditation bodies,16 or legislative mandates, usually from a state or provincial government. In some cases, mandates may even come from the most senior level of government, although these are less likely, in most jurisdictions. Which Accreditation body is used by the organization? Are there specific standards, or merely general guidance? How will the Emergency Response Plan be reviewed by Accreditors, when they visit?
Legislative mandates may occur in specific emergency management legislation, or they may occur in legislation intended to govern specific aspects of the healthcare system, such as long-term care facilities,17 hospitals,18 or public health providers.19,20 What does the appropriate legislation actually say? Does it consist of general guidance or specific standards? What processes and measures need to be in place in order to be in compliance with both the law and Accreditation standards? With the answers to these questions, the Emergency Manager will have a much more complete picture of the context in which the Emergency Response Plan is to be created.
Conclusion
The four major components of emergency management, specifically mitigation, preparedness, response, and recovery have provided a highly effective framework for the creation of emergency plans and other emergency management activities for more than 30 years. There is one significant reason why they have endured so well in an evolving field; they work. By understanding the issues which are generated by each for an Emergency Manager in a healthcare setting, he or she will achieve an understanding of precisely what is required of the planning process which is far more comprehensive, and therefore, more effective. An Emergency Response Plan really cannot be effective unless its creator understands, in detail, what is being planned for, and how responses to these four issues will occur. With this information used as the basis for creation, the Emergency Response Plan becomes far more than a checkmark on an Accreditor’s list; it becomes an “evergreen” document which is easy to use, easy to find information in, provides clear instructions, and makes sense. As such, it becomes the first choice for any employee in a healthcare setting to find information and instructions during a crisis.
Student Project No. 1
Select a single point of vulnerability within a single hospital and study it in detail. Using your research skills, create a list of potential options for mitigation against this point of vulnerability, outlining the probable cost of each. Rank these options, both according to cost, and according to potential impact, and select a single option for implementation, explaining your reasons for your selection. All information in the report should be suitably referenced and cited, in order to demonstrate that the appropriate research has occurred.
Student Project No. 2
Select a single type of emergency event (mass casualty incident, evacuation, etc.) and consider how each currently operates. Using research, outline five different measures which could be implemented in advance, in order to improve the management of the selected event. Describe the requirements for their implementation in advance, and rank them according to potential effectiveness. All information in the report should be suitably referenced and cited, in order to demonstrate that the appropriate research has occurred.
Test Your Knowledge
Take your time. Read each question carefully, and select the MOST CORRECT answer for each. The correct answers appear at the end of the section. If you score less than 80 percent (8 correct answers) you should reread this chapter.
1. Those activities directed at reducing or eliminating in advance the potential effects of an identified risk exposure are called:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation
2. Creating an Emergency Response Plan, training staff, and conducting emergency exercises would be examples of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation
3. Triaging incoming patients or evacuation of a healthcare facility would be examples of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation
4. Returning the healthcare facility to a level of normal or near-normal operations, following a mass casualty incident would be an example of:
(a) Preparedness
(b) Response
(c) Recovery
(d) Mitigation
5. One of the greatest challenges facing the Emergency Manager who is attempting to implement mitigation measures in a healthcare facility is the presence of:
(a) Indifference
(b) Competing Priorities
(c) Public Opinion
(d) Management Practices
6. The degree of complexity involved in a healthcare organization’s recovery process following a crisis will often be directly determined by:
(a) Decisions by the Hospital Board
(b) Requests from the community
(c) Whether the impact on the organization was direct or indirect
(d) Both A and B
7. During the emergency planning process, it is reasonable to invoke a planning assumption that during many types of emergencies:
(a) “Just-in-Time” supply processes will be overwhelmed
(b) “Just-in-Time” supply processes will continue to function
(c) Alternate supply sources will be required
(d) Both A and C
8. The evacuation of a healthcare facility works best when:
(a) EMS is used to move the patients
(b) Patients can be discharged to the community
(c) All agencies have a clear understanding of expectations, based on advance dialogue
(d) A formal Declaration of Emergency has been issued
9. An Emergency Response Plan will generally be more effective for a healthcare organization, if the Emergency Manager has conducted research to identify the:
(a) Historical weather patterns in the area
(b) History of disasters in the state/province
(c) Previous events which affected the organization
(d) Municipal by-law requirements
10. During mass casualty incidents, triage may be required, not only to sort patients according to severity on admission, but also to:
(a) Locate hospital beds
(b) Provide access to limited resources
(c) Determine the clinically appropriate order of access to limited resources
(d) Provide accurate Census information to the Hospital Command Center
Answers
1. (d ) 2. (a) 3. (b) 4. (c) 5. (b)
6. (c) 7. (d) 8. (c) 9. (c) 10. (c)
The author recommends the following exceptionally good titles as supplemental readings, which will help to enhance the student’s knowledge of those topics covered in this chapter:
Baird, M.E. 2010. “The “Phases” of Emergency Management.” Background Paper, University of Memphis, .pdf document, www.vanderbilt.edu/vector/research/emmgtphases.pdf (accessed January 20, 2014).
De Lia, D. 2007. “Hospital Capacity, Patient Flow, and Emergency Department Use in New Jersey.” Rutgers University, .pdf document, www.nj.gov/health/rhc/documents/ed_report.pdf (accessed January 22, 2014).
Harvard School of Public Health. 2013. “Hospital Decontamination Self-Assessment Tool.” Emergency Preparedness Bureau, Commonwealth of Massachusetts, .pdf file, www.hsph.harvard.edu/policy-translation-leadership-development/files/2013/01/Hospital-Decontamination-Self-Assessment-Tool-2013.pdf (accessed January 22, 2014).
US Federal Emergency Management Agency. “Emergency Manager: An Orientation to the Position.” Emergency Management Institute web-based independent study course, http://emilms.fema.gov/is1a/index.htm (accessed January 20, 2014).
Zane, R., P. Biddinger, A. Rich J. Gerber, and J. DeAngelis. 2010. “Hospital Evacuation Decision Guide.” US Department of Health and Human Services, .pdf document, http://archive.ahrq.gov/prep/hospevacguide/hospevac.pdf (accessed January 22, 2014).