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294 HEALTH DEVICES 34 (9), September 2005 2005 ECRI. Member hospitals may reproduce this page for internal distr ibution only.

GuidanceArticle

The Emergency Management Plan

Summary. Healthcare facilities have emergency manage-

ment plans (EMPs) in place to respond to both natural

disasters, such as earthquakes and floods, and man-made

disasters, such as terrorist acts and transportation acci-

dents. The devastation and massive disruptions caused by

Hurricanes Katrina and Rita in New Orleans and nu-

merous other communities along the U.S. Gulf Coast

are sad reminders of just how critical such plans can be.

In the wake of these storms, healthcare facilities in all

parts of the world will undoubtedly be examining their

EMPs to assess whether they are prepared to handle simi-

lar large-scale disasters. To help with this effort, we pres-

ent below an overview of the hospitals role in handling

major disasters and a discussion of how to ensure that ahealthcare facility has an effective EMP. (Note that much

of the information presented here has been excerpted from

our September-October 2001 Guidance Article on emer-

gency preparedness.*)

Responding to aLarge-Scale Disaster

A Broad Role for Hospitals

Disasters can have many forms. They may be of natural

origin (geological or weather-related) or have man-made

causes (including terrorism, armed conflicts, and techno-

logical disasters). They may be strictly internal, such as

bomb threats and hazardous spills, or external, affecting an

entire region. There may be advance warning, as for a hur-

ricane or blizzard, or there may be no warning at all. Hos-

pitals must be prepared for any of these types of disasters

at almost any time.

During disasters, especially when there are mass casu-

alties, a hospital is required to operate simultaneously on

many levels:1. as an individual organization,

2. as a component of the communitys healthcare system,

and

3. as a part of the community as a whole.

Hospital involvement will depend on the cause of the

incident (e.g., explosion, chemical or biological exposure)

and could include such roles as prevention, hazardous

agent identification, and/or treatment. Hospitals will need

to be able to respond to the emergency while at the same

time continuing to treat their current patients and protect

their staff as needed.

Beyond this, in a large disaster especially one in-

volving mass casualties the resources of a communitys

entire healthcare system (including all the physicians

offices, hospitals, and the general resources of the commu-

nity) may be required, possibly for an extended period.

Hospitals will need to work closely with government

primarily the local government to meet communityneeds. They will need to coordinate with the police and

fire departments; with officials responsible for transporta-

tion, utilities, schools, and public health; and also with

churches, news organizations, telephone and other com-

munication companies, volunteer organizations (such as

the Red Cross and Salvation Army), and restaurants and

food suppliers.

Being ready for such a role is daunting. Most hospitals

typically prepare for and respond to short, intense

disasters. They tend to be less ready for mass casualty in-

cidents, especially those that require numerous healthcare

facilities to respond simultaneously. Understandably,

large-scale disasters are much harder to prepare for. But de-

spite the huge effort involved, hospitals need to be just as

prepared for a mass casualty event as for any other patient

care scenario.

The Key to an EffectiveResponse

The Emergency Management Plan

The emergency management plan (EMP) should be cre-

ated by a committee consisting of representatives of medi-

cal staff, administrators, risk management, security, safety,

telecommunications, engineering, admissions, pharmacy,

support services, public relations, nursing, materials man-

agement, and the emergency department. The committee

should also seek input from representatives of outside

agencies such as the local civil preparedness office, the* ECRI. Emergency preparedness for hospitals: an overview.Health

Devices 2001 Sep-Oct;30(9-10):365-9.

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media, the Red Cross, the police and fire departments, and

gas, electrical, and other utility companies. If representa-

tives of these organizations cannot serve on the committee,

a draft of the EMP should be sent to them for their review.

Each facility should also have emergency management

officers, who should be familiar with their counterpartsor contacts in other community or federal emergency re-

sponse agencies and be able to identify one main contact

and a backup contact in each of the organizations. The

committee should also coordinate its efforts with other

nearby healthcare facilities to determine who can take care

of issues such as patient overload.

DEVELOPING THE EMP

The first step in creating an EMP, as with developing any

hazard policy, is identifying the levels and types of disas-

ter risks. Assessing risks involves a number of tasks, in-

cluding: identifying the probability that a disastrous event

might occur during a certain period of time; estimating the

impact or the degree of loss that could result from a disas-

ter, including injury to people or damage to buildings,

utilities, services, or infrastructures; determining the mea-

sures that could reduce the risk; and taking the appropriate

action to reduce the threat or risk after an appropriate

cost/benefit analysis.

With this accomplished, the next step is to devise the

EMP itself. The Joint Commission on Accreditation of

Healthcare Organizations (JCAHO), in its emergency

management standard EC.4.10, states that the EMP shouldprovide processes for the following:*

Identifying specific procedures to be implemented in

response to a variety of disasters or emergencies

Initiating response and recovery phases of the plan (in-

cluding a description of how, when, and by whom it is

to be initiated)

Defining and, when appropriate, integrating the hospi-

tals role with community-wide emergency response

agencies, including setting priorities for emergency

management and linking the hospitals and commu-

nitys command structures

Cooperative planning with nearby healthcare

organizations

Notifying external authorities of emergencies and noti-

fying personnel when emergency response measures

are initiated

Assigning available personnel in emergencies to coverall necessary staff positions

Managing patient, staff, and staff-family support activi-

ties, as well as critical supplies, security, and media

interaction

Evacuating the entire facility when the environment

cannot support adequate patient care and treatment

Establishing an alternate care site and planning for pa-

tient transport, transfer of necessities, patient tracking,

and communication with the site

Identifying alternative means of meeting essential

building utility needs, backup internal and external

communication systems, facilities for radioactive or

chemical isolation and decontamination, and alternate

roles and responsibilities of personnel

In separate standards, JCAHO also requires that facili-

ties establish a staff orientation and education program for

the emergency management plan (HR.2.20), that they con-

duct drills to test the plan (EC.4.20), and that they monitor

performance and annually evaluate the plans objectives,

scope, performance, and effectiveness (EC.9.10).

REVIEWING AND TESTING THE PLAN

The EMP should be routinely reviewed to ensure that it

adequately addresses all likely situations, that staff are ad-

equately trained, that emergency communication systems

are operational, and that necessary supplies are on hand. In

addition, it must be tested twice a year through emergency

drills. (For more on this topic, see Designing, Executing,

and Evaluating Disaster Drills on page 300.)

When conducting drills, it is important to challenge the

entire system, not just a few components. That is, dont

simulate a train accident simply by sending your emer-

gency department a large number of injured people.

Rather, involve admissions (patient processing), laboratory

services (lab tests), security (crowd control), pharmacy

(medications), materials management (supplies such as

bandages, saline, and gloves), etc., in the drill to fully de-

termine whether you are ready for such an incident.

COMMON SHORTCOMINGS OF EMPs

According to the panel at the 2000 AHA Invitational Fo-

rum on Hospital Preparedness for Mass Casualties, there

2005 ECRI. Member hospitals may reproduce this page for internal distribution only. HEALTH DEVICES 34 (9), September 2005 295

GuidanceArticle

* Note that this is only a summary of some of the key requirements of

standard EC.4.10. For the full text of this standard, see: Joint Commission

on Accreditation of Healthcare Organizations (JCAHO).Comprehensive

accreditation manual for hospitals (CAMH). Update 3. EC.4.10.

Oakbrook Terrace (IL): JCAHO; 2005 Aug.

JCAHOs 2005 Hospital Accreditation Standards related to emergency

planning are also currently available online at www.jcaho.org/news+room/

press+kits/ems/05_hap_stds.htm.

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are four common EMP shortcomings that will bring ev-

erything to a halt if not adequately addressed.*

Community-wide preparedness. Without adequate

widespread planning, an individual hospital will be unable

to deal with a disaster affecting the entire community.

Communities must develop relationships with the organi-zations that they would work with during a mass casualty

incident, both governmental and private, and hospitals

need to be a part of this process. This includes coordinat-

ing patient care with other healthcare facilities.

Planning has traditionally overlooked scenarios in

which the hospital itself experiences a disaster that com-

pletely disrupts its operations. Hospital planners should

prepare for the possibility that they might have to evacuate

or quarantine their patients or reroute incoming patients to

other facilities. Its also important to agree on a common

communication protocol to be used during disasters; other-

wise, organizations using different communication meth-

ods may not be able to make contact immediately.

Staff readiness. Hospitals faced with a disaster need to

be sure they can obtain enough personnel to meet their

emergency needs while continuing to maintain regular

patient services. These people must be trained beforehand,

since there probably wont be time for intensive training

during the disaster.

But having enough people to deal with the disaster isnt

the only issue; personnel must also be able to continue to

function under conditions of extraordinary stress longhours, poor or absent communications, and concern about

family and friends. Support services including access to

vaccines and mental health counseling will be needed

to help staff meet the demands placed on them.

Communications. During a disaster, communications be-

come chaotic, and accurate information is at a premium.

The communication structure to be used during a disaster

must be carefully set out in advance. For example, ordi-

nary communication methods, particularly wired and cel-

lular telephone services, often become overloaded, so

redundant backup systems need to be available both insideand outside the facility. Also, to avoid a situation in which

different facilities issue different and possibly conflicting

public statements, a single community spokesperson

should be designated. This person will serve as a conduit

for information from the healthcare network to the

community.

Public policy. There needs to be a broader recognition of

the role that government at all levels must play in helping

hospitals and other community organizations deal with

disasters.

296 HEALTH DEVICES 34 (9), September 2005 2005 ECRI. Member hospitals may reproduce this page for internal distr ibution only.

GuidanceArticle

* American Hospital Association. Hospital preparedness for mass casual-

ties: final report [online]. Summary of an invitational forum convened on

2000 Mar 8-9. Published 2000 Aug [cited 2001 Oct 8]. Available from

Internet: www.hospitalconnect.com/ahapolicyforum/resources/disaster.

html.

Examples of Disaster Scenarios

Understandably, the widespread devastation that can be

caused by storms such as Hurricanes Katrina and Rita is fore-

most in peoples minds right now. However, hurricanes are not

the only kind of disaster for which healthcare facilities must

prepare. Following are just a few examples of disaster scenar-

ios that could challenge a healthcare system:

An earthquake causes a loss of all utilities and some struc-

tural damage to the facility.

An airplane crashes in a nearby field, and victims are walk-ing into the emergency department (ED).

A farmers truck overturns and spills organophosphate near

the center of town; dozens of people are affected.

Several people present to the ED with symptoms of highly

contagious disease.

A nearby forest fire combined with weather conditions

causes respiratory distress to residents who present to the

ED along with injured firefighters.

The water supply fails or becomes contaminated.

A healthcare worker spills a radioactive isotope on a pa-

tient room floor.

Insects, rats, or other rodents infest the facility.

Hackers break into the facilitys computer system,

disrupting scheduling, records, and communications.

An oxygen leak rapidly depletes the hospitals oxygen

supply. An escaped felon takes hostages in the waiting area.

A fungus or other organism is being spread by the heating,

ventilating, and air-conditioning system.

Seating collapses at a local stadium, causing injuries to

several hundred people.

A car bomb is reported in the facility parking garage.

A freight train derails near town, resulting in fire and a toxic

gas leak.