Lauren Ford Introduction When an employee first enters hospital employment, they may not consider the plan the hospital has in place for dealing with disasters. Years ago, employees rarely even knew about the disaster preparedness plans in their hospital. However, in the past decade situations have changed, and employees are more aware of the procedures that exist for dealing with disasters. After the September 11, 2001 tragedy in New York City, the Hurricane Katrina disaster in New Orleans on August 29, 2005, and the bioterrorism scares involving anthrax and smallpox in the last seven years, hospitals have been forced to reevaluate the effectiveness of their current disaster preparedness plans. They must assess whether the current plans will actually work in the event of an emergency, and the administration must decide what changes must be made in order to make the plans more successful. Should these changes and alterations be left up to the hospital itself, or should the government take a more central role in all disaster preparations? These questions must be answered before our hospitals are put to the real test by a true national disaster. We will later discuss several approaches to solving the issue of disaster preparation, and evaluate which will be the best option for hospitals to adopt.
History What exactly is a disaster preparedness program? According to the volume, Developing a Hospital Emergency Preparedness Program, part of the Management and Compliance Series, written by Gregg Beatty (1987), “the emergency preparedness program has the primary function of preparing the hospital to respond effectively and quickly to emergencies that occur within the community or within the hospital itself” (p. 5). Beatty (1987) also states that “although each hospital and community is unique, a standard set of requirements forms the core of all emergency preparedness planning” (p. 5). JCAHO requires that each hospital follow thirteen standard steps in planning its emergency preparedness program (2005, para. 4). While this is a good beginning to ensure that each hospital has a standard program in place, it is not enough to ensure that each hospital has a plan suited to their community. In the past, hospitals have relied on a standard emergency program to use for any disaster. However, due to the aforementioned recent disasters, it has become clear that each hospital needs to tailor its program to its specific region and make changes according to each disaster event. Each plan should differ depending on the type of disaster; for example, a hurricane needs a different set of procedures than a bioterrorism attack of anthrax. Hospitals need to revise their plans to account for the different types of disasters that could easily arise any day.
Background According to the Center for Disease Control (CDC), 92.3% of hospitals have revised their emergency plans since September 11, 2001 (2005, Table 1, p. 7). Hospitals have changed their plans since the terrorist attack on the World Trade Center, but it is not enough. Massive disasters had to strike our country before hospitals realized that their current emergency plans might be insufficient. Consider what happened to Charity Hospital in New Orleans when Hurricane Katrina devastated the city. According to the Annals of Emergency Medicine (2006), Charity Hospital had practiced for a disaster of this sort:
It took more than five days to evacuate Charity, the city's largest public hospital and a last refuge for the indigent. That Charity saw no flood casualties stands as a testament to Halton and other disaster officials, who drilled for this scenario with a prophetic model—a slow-moving, category-3 hurricane overwhelming New Orleans' levee system (para. 3).
Charity Hospital was lucky considering the damage Hurricane Katrina caused. However, Hermann Memorial Hospital in Houston was not so fortunate when Hurricane Allison hit in June 2001, flooding most of the city. According to the Annals of Emergency Medicine (2006), “the hospital lost electricity and its back-up power source. It had no running water, sewer services or reliable communications. Surrounding streets were flooded. By mid-morning Saturday, after the rain ended, hospital officials decided to evacuate 540 patients” (para. 5). Although they had an emergency plan, they did not anticipate the extent of damage that was possible if the city flooded. These two hospitals both had plans in place, but one can see the difference in the thoroughness and execution of their plan. By looking at these next approaches to altering the disaster preparedness process, we can decide how to better the process and increase the effectiveness of planning for disasters.
Approaches Disaster preparedness for hospitals and communities is not new. Hospitals have always been required to have an emergency plan to follow should a disaster occur. However, many employees of hospitals are not aware of the procedures to follow should an emergency occur. As noted earlier, JCAHO provides thirteen steps for hospitals to follow in planning their disaster programs, but they do not give any thorough suggestions of training the hospital and the community to work together should an emergency arise. They also do not provide ways to distinguish disaster plans based on the type of emergency. Hospitals must consider all of the stakeholders when planning their disaster preparedness plans and in turn consider how those plans would affect stakeholders. How will each plan affect the providers, the patients, the employees, and the community? Providers must be taken into account because they are the ones who provide the emergency care when a disaster hits. The plan must not hinder their ability to treat those injured by the disaster while caring for their existing patients. Also, employees need to be informed of their role during an emergency. Without communication, employees may not know what they should do. Lastly, the community must be considered when planning for emergencies. Without the community, the hospital will not be able to handle the disaster. They must work closely with the power company, the police, and the fire department. Knowing how they will communicate with one another in an emergency will make the process of disaster relief smoother. After understanding the role of each stakeholder and how would work together, we can examine three different approaches for development of a more effective disaster plan for hospitals.
Approach 1: Government Developed Base Plans In the first approach that to make hospital disaster preparedness plans more effective, the government could first develop modifiable base plans for each type of disaster. The initial step calls for the creation of a department that will be in charge of model plan development. This agency will then divide each disaster type into categories, such as natural disasters, bioterrorism attacks, and terrorism attacks. They can then form disaster plans for each subcategory. There will be a different plan for tornados and hurricanes; likewise, the plan for anthrax will be different from that of smallpox. There would also be plans for national disasters.
Once the model plans are completed, they will be sent to all hospitals in the country. Every hospital will modify these plans to suit their geographic region and community. Then, the hospitals will train their employees to follow each type of disaster plan. They will also have routine “mock disaster training” with other departments throughout their community to ensure that each division understands what to do in an emergency.
Having plans tailored to different types of disasters can ensure that hospitals are well prepared for any type of emergency. By being prepared, facilities can decrease the miscommunication and confusion during a real disaster. Consider what was said by Donna Pritchard, former Director of Nursing for New York Downtown Hospital. Pritchard worked there when the September 11, 2001 tragedy happened. She had just arrived at work the morning of the attack and recalls:
"I walked into the hospital covered in dust, and my eyes were burning. Patients were streaming in, and no one knew what was happening. Was our building safe? We lost power and went on the emergency generator. Steam and phone service went down. We didn't know what was going to happen next, and our critical thinking skills were put to the test” (Stanton, 2007, para. 3-4).
Pritchard stated that this disaster emphasized how important clear communication is among the community involved in disaster relief. She said that it is imperative that employees of the hospital understand the disaster procedures and are trained in what to do should a disaster strike.
Some hospitals may not agree with the government’s enforcement of standardized disaster plans. Currently, the plans will not be mandatory. The government is simply assisting hospitals in disaster planning. Politically, this could start an argument over the new department. It will be difficult to ensure that a mix of people from all areas of disaster relief are included in this department, as well as enough from hospital administration. We fulfill an ethical obligation in preparing for these disasters by creating plans that can be modified for individual facilities. While there may be objections to involving the government, the benefits outweigh the drawbacks and make this approach an attractive option.
It will be difficult for the new department to create model plans for each disaster, because we cannot predict every possible event. The department will have to work their hardest to cover the many scenarios. By having model plans that each hospital can tailor, the administration can ensure that their employees are adequately prepared. Ensuring that providers and other employees of the hospital know what to do will cut down on the confusion that normally occurs during an emergency situation, which will also benefit patients because they will still receive the required care. By training employees and practicing with the community for a disaster, communication will be clear, which is key during a disaster. While this approach may have weaknesses in creating a new department, it is overall a strength because the hospitals and community will be prepared for any disaster.
Approach 2: Disaster Plan Consulting Committee Another approach to consider in making hospital disaster preparedness plans more effective is to create a new governmental agency for disaster preparation. The agency will have individuals from all areas of healthcare, as well as members from emergency personnel and those in public services. By creating one agency, it will ensure that there is representation from each area involved in a disaster. The agency will handle all disaster issues, including consulting, advising on necessary changes, advocating training guidelines, and reviewing compliance with mandates the agency provides.
The agency can hire people to visit hospitals and evaluate current disaster preparedness plans. If a hospital needs assistance in making their plans more effective, the agency will send someone to their organization to help them adjust their current plan. The agency will also mandate that all hospitals receiving federal funds must cooperate with the agency in updating their emergency plans periodically, or face losing their governmental funding. However, it will be difficult for a new agency to enforce these rules. JCAHO currently requires hospitals to meet certain standards in emergency planning. They conduct on-site surveys in which “our surveyors review these plans as well as the results of the staff drills” (2001, para. 6).
Politically, it will be difficult to create this agency without protest. Hospitals may argue that creating this agency will take away their power. Hospitals do not want to report to more agencies, and they may view these new requirements as more of a hindrance than a help. Legally, it will also be difficult to force hospitals to comply. Because the funding is not coming from this agency, they cannot take away funding from a hospital. Bringing people from all different areas of disaster relief together, may also cause problems as each area may view its own as the most important, making compromise difficult. Although it will be difficult to get passed, considering a disaster preparedness agency to handle all of the disaster issues is an approach to which we should give further thought.
One big weakness of this approach is that it will be difficult to get those in charge of federal funding to work with the agency. Pulling a hospital’s funding for non-compliance will be challenging, as the agency is not in charge of federal funding. Another weakness will be reviewing all hospital disaster plans around the country. Because our country is so large, it will be hard to ensure that all hospitals are complying with the JCAHO standards. However, having employees work as consultants for hospitals struggling with forming an effective disaster preparedness plan is a strength. The consultants are not criticizing the hospital for their troubles in forming a plan; they are simply there to help develop one.
Having standards for hospitals to meet in their disaster plan will help banish the apathy that some hospitals have toward disaster preparedness. Many hospitals currently feel that creating a plan is too costly compared to the probability of a disaster. In Disaster Response: Principles of Preparation and Coordination, written by Dr. Auf der Heide (1989), the chapter, “The Apathy Factor,” states that “preparedness for moderately sized disasters may be more realistic and achieve greater acceptance by those who must pay for and carry out the preparations” (p. 7). This approach is warranted if these standards ensure that more hospitals will create effective plans and not worry about the cost in the short run. In the long run, it is more than worth the cost.
Everyone will benefit if an agency requires that all disaster plans meet certain specifications. Providers will be aware of their role and how to manage trauma patients with their existing patients. Patients will benefit because their providers will not forget about them during an emergency. The employees of the hospital will all be aware of what their part is during a disaster, and that will ensure that the hospital keeps running smoothly. The community will benefit if the hospital has adequate disaster plans. As long as the hospital and community prepare, all will benefit immensely from this approach. However, if the hospital does not involve the community when reviewing its procedures, everyone will be affected. When planning, the community must be considered, and involved in practicing, or the communication will be lacking, making everyone lose. This approach has an equal number of strengths and weaknesses. To be implemented, it will need work to make it a plausible solution for disaster preparedness.
Approach 3: Train Top Personnel in Planning A third approach in this issue involves training the top hospital personnel how to plan a disaster preparedness program. Each hospital would choose top personnel from each department (such as administration, nurses, and physicians) and form a committee. Those individuals would work together to create disaster plans for their hospital for each type of disaster that might occur. Once the group has finished creating the disaster plans, they would create a training schedule, detailing how to train the employees and how to involve the community during the training. The group will then create an evacuation plan, beginning with non-emergency patients. Those who are not absolutely needed in the hospital, including employees and patients’ families, will be evacuated as early as possible.
Once all the disaster, training, and evacuation plans are complete, the personnel return to their departments and train their respective employees on the new procedures, and the community individuals would do the same. In the article, “Evaluation of Hospital-Based Disaster Education”, Matthew Powers (2007) covers an important point, saying that “coordination between first responders and hospital staff is problematic when there is a lack of coordinated training” (para. 12). When each personnel involved is in charge of training their employees, it ensures that each member of the hospital staff receives the same disaster training and that they receive it from one who has communicated with all departments. It will keep communication open and confusion low. Those in the community will also be aware of the procedures the hospital is planning during an emergency so they can assist.
By training all employees of the hospitals and the community which will be involved, we fulfill our ethical obligation to keep people safe. Creating a disaster plan is not difficult, but involving the community and keeping open communication creates many challenges. By working together and agreeing on preparations, we are improving the relationship between important entities that will be involved in a disaster. From a political standpoint, the community will be strengthened by preparing together for a possible disaster. The stronger a community is, the easier it is to work together in times of need. This preparation will ensure that when a disaster strikes, everyone is ready.
Practicing with the community for the disaster plans is a significant strength for this approach because it guarantees that everyone is involved and understands what to do should a disaster happen. Keeping communication clear is one of the most important things in the event of an emergency. By training for each disaster with other groups in the community, everyone involved will know how to act if an emergency occurs. Beatty (1987) states “people must be involved at every level and part of the hospital organization. They must have, or develop, a sense of ownership of the program that comes only from participation” (pg. 7). He repeatedly stresses the importance of training the staff for disasters and involving the community in practicing all procedures. Practicing the procedures is extremely important.
Providers will greatly benefit from this approach because they will be involved firsthand in the creation of all disaster plans. They will give important input on what physicians need during a disaster in order to balance their original patients with emergency patients. Once again, when the providers are able to balance the sudden influx of injured patients, existing patients will still be taken care of during an emergency. The employees will greatly benefit because they will be directly trained from someone involved in the development of the disaster plan and not from someone who was simply given the training manual. Because the community is directly involved in the training and practice drill processes, this will benefit both the hospital and the community. They will have done all they can to prepare for any disaster and will have broken down the communication barrier.
Disaster preparedness for hospitals is just that- it is for the hospitals. The first two approaches cover a national angle in solving this problem, but the third approach focuses on the hospital and the community. As this approach will be implemented at the local level rather than the national level, it has more strengths then weaknesses and will be easier to carry out. Disaster preparedness issues should be dealt with at the local level, in one’s own hospital. Tackling this problem from the national level will cause more problems than not. Consider the first approach again. It has too great of a weakness in creating an agency to develop model plans. Developing model plans may sound like a good idea at first, until one thinks about the differences between communities, geographic regions, and constraints. It is not worth the time or money to create the model plans when they will more than likely have to be rewritten to cover the differences in hospitals and communities.
The second approach is also widespread. Creating an agency to monitor every hospital’s disaster plans is too large of a task. It will only anger the hospitals, because some plans will work well in one area but not in another. Unless already living in an area, one would not know what it needs for a disaster plan. Threatening to pull federal funding is simply a bad idea; hospitals will get defensive and angry when they are being reviewed for fear of losing funding. Because the agency is not in control of funding, there is no way to regulate it.
The third approach is the best chance for success because it maintains the planning and development process at a local level. Each hospital will be in charge of its own disaster plans and training. By using top personnel from every department to create the disaster plans, it ensures that all areas receive equal thought when developing the procedures. Beatty (1987) agrees, stating “To obtain their suggestions and to increase their understanding, members of the hospital staff should be made an active part of the emergency preparedness team whenever possible” (pg. 11). All areas should be given equal opportunity to voice opinions when forming the plan. Having each personnel member in charge of training their employees also helps in training, because they were involved in creating the plan.
Developing an evacuation plan is equally as important as having disaster procedures. After 9/11 and Hurricane Allison, JCAHO (Annals of Emergency Medicine, 2006) began “requiring hospitals to have evacuation plans and other means of coping with disasters” (para. 15). Having a way to evacuate patients in an emergency is so very important because it minimizes the risk of harm; the fewer patients present when a disaster strikes, the fewer casualties there are. An adequate evacuation plan must accompany one’s disaster preparedness plan. Lastly, a hospital practicing with the community is crucial. Ensuring that everyone involved during a disaster understands what to do keeps confusion to a minimum. It will improve communication and cooperation between everyone involved, and the hospital will fare better because of it.
Conclusion As discussed throughout this paper, disaster preparedness has been brought to the public eye in the past decade. After disasters such as 9/11, Hurricane Katrina, and the anthrax scare, hospitals have realized that their disaster plans may be lacking. They have begun to revise their plans to cover more types of disasters but have stumbled upon a number of roadblocks. Are they creating a plan that will be effective in a real emergency? Should the government help form these plans? These questions need answers, and after reviewing the approaches discusses in this paper, the best approach is to tackle this problem at the local level.
By involving all departments and outside organizations in disaster preparation, we ensure that all voices are heard. Training and practicing the disaster procedures with the community keeps communication open and prepares everyone for a disaster. By doing the utmost to prepare for a disaster, we guarantee that if one strikes, we will be able to handle whatever happens. Keeping preparations at a local level allows every opportunity to strengthen our relationship with the greater community. By working together, we will ensure that we can restore our community to its original state. The most important thing is to remember the importance of practice; as without it, even the best disaster plans will fail.
References Beatty, Gregg C. (1987). Developing a Hospital Emergency Preparedness Program. Management and Compliance Series. Vol. 2. Chicago: American Hospital Association.
Berger, Eric. (2006). “Maintaining Order in Chaos.” Charity Hospital and Disaster Preparedness. Annals of Emergency Medicine. Vol. 47, Issue 1, pp. 53-56.
Berger, Eric. (2006). “The Lessons of Hurricane Allison.” Charity Hospital and Disaster Preparedness. Annals of Emergency Medicine. Vol. 47, Issue 1, pp. 53-56.
“Executive Summary- Standing Together: An Emergency Planning Guide for America’s Communities.” (2005). Retrieved November 9, 2007, from http://www.jointcommission.org/NewsRoom/
Heide, Dr. Auf der. (1989). “The Apathy Factor.” Disaster Response: Principles of Preparation and Coordination. St. Louis: CV Mosby.
O'Leary, Dennis. Joint Commission on Accreditation of Healthcare Organizations. (2001). Review of Federal Bioterrorism Preparedness. Washington DC: Subcommittee on Oversight And Investigations House Committee on Energy and Commerce. Retrieved on November 11, 2007, from http://www.jointcommission.org/NewsRoom/
Powers, Matthew F. (2007). “Evaluation of Hospital- based Disaster Education.” ScienceDirect. Vol. 33, Issue 1, pp.79-82.
Niska, Richard W. & Burt, Catharine W. (2005). Bioterrorism and Mass Casualty Preparedness in Hospitals. Advance Data from Vital and Health Statistics, September 27, 2005, Num. 364, pp. 1-15. Retrieved November 9, 2007, from http://www.cdc.gov/nchs/data/ad/ad364.pdf.
Stanton, Carina. (2007). Disaster Preparedness: resources are there, but planning, staff training are keys to success. Retrieved November 10, 2007, from http://www.aorn.org/AORNNews/Disaster/.
Lauren Ford is from Athens, Alabama. She is a senior majoring in Health Care Management, with a minor in Italian and plans to graduate in May of 2008. She is a member of the Delta Zeta sorority, the Health Care Management Society, and is a Student Associate in the American College of Health Care Executives. Other organizations she is a member of include Blue Key, Cardinal Key, Omicron Delta Kappa, Order of Omega, Phi Eta Sigma, and Upsilon Phi Delta Honor Societies.