With memories of 9/11 and Katrina still lingering, it is natural for you to wonder how your department would fare in a similar disaster. Emergencies such as a loss of power or flooding of a basement shop have certainly crossed your mind. But the Joint Commission would now like clinical engineering (CE) departments to think more strategically.
Joint Commission standards EC 4.10 and EC 4.20 currently require healthcare facilities to address emergency management by conducting a hazard vulnerability analysis and developing and maintaining an emergency management plan. These facilities also must conduct regular exercises to test their preparedness.
According to George Mills, senior engineer in the Joint Commission's Standards Interpretation Group, these existing standards are “somewhat one-dimensional” and don't prepare hospitals for an escalation of events.
Since 2000, the Joint Commission has visited the sites of floods, electrical utility outages, terrorist attacks, and hurricanes seeking ways to improve the standards. A year and a half ago, the group sat down to create what has turned out to be “a pretty radical change to our existing emergency management standards,” says Mills. The new standards, which will take effect in January 2008, broaden and clarify the existing rules by expanding the current requirements.
As a result of its visits to disaster sites, “the Joint Commission concluded that it is not sufficient to require healthcare organizations to plan for a single event; rather, they should be able to demonstrate sufficient flexibility to respond effectively to combinations of escalating events,” the new standards state.
During many disasters, events intensify over a period of days, weeks, or even years, Mills says. For example, Hurricane Katrina brought high winds, then flooding. Civic unrest, including looting and violence, followed the storm. Once people were evacuated, cleanup and rebuilding began and continues today. The new standards address this theme of escalation by forcing hospitals to anticipate these events and fashion appropriate responses. New standard EC 4.20, for example, requires organizations to test their emergency operations plans twice a year, with one of those drills being escalated “to evaluate how effectively the organization performs when it cannot be supported by the local community.”
Under the existing emergency management standards, “all of us were ready for the first wave,” Mills says. The devices are in stock, functioning, and can be repaired as necessary. However, if there's flooding and the CE department is in the basement, what's the next step? “Do you have contacts at other facilities or with vendors that can supply equipment? Can you move your benches to other locations, or is that even feasible?” Mills encourages all facilities to examine how quickly they can get tools on carts and out of their normal location. During the first 30 minutes of flooding in Hurricane Katrina, water was entering buildings about two inches every five minutes, leaving little time to act and even less to plan. “You don't want to be making decisions during the crisis,” Mills says.
Six Critical Areas
The Joint Commission's new emergency management standards are structured around six critical areas: communication, managing resources and assets, managing safety and security, defining and managing staff roles and responsibilities, managing utilities, and managing clinical activities. “It is important that organizations have an understanding of their capabilities in meeting these six critical functions during varying conditions when their facility's infrastructure, the community's infrastructure, or both are compromised,” the new standards state.
Exactly how these areas will impact a hospital's CE department remains to be seen, says Malcolm Ridgway, senior vice president for technology management at Master-plan in Chatsworth, CA. Their role, he says, will depend upon how the hospital formulates its emergency plan, and how individual hospitals do that “will be all over the map.”
Ridgway notes, however, that CE departments should participate in the creation of these plans, “if for no other reason than to avoid being blindsided.” Mills agrees: “Throw CE into the mix on the planning side.” When the hospital does its hazard analysis, see how many things CE can resolve, he says.
Mills sees a role for CE in almost every one of the six critical areas. Communication could include nurse call systems. In terms of managing resources and assets, CE departments should look at their memoranda of understanding (MOUs) with outside vendors. Two or more hospitals may have the same MOU with the same vendor, but that vendor might not be able to meet both hospitals' supply needs in an emergency. During emergency drills, call the vendor to see how prepared it is. “Exercise the MOUs when it's safe to do so,” says Mills. “You need to know you can count on that.”
Safety and security may not seem like an area that would affect CEs and BMETs, but if the biomed shop must relocate during an event, managers should determine whether it's safe to leave devices in an unsecured area. In examining staff roles and responsibilities, if there are more technicians than will be needed during an emergency, a hospital may want to cross train them to help in other areas of the facility. “You don't want to have people working outside their normal skill sets in an emergency situation unless they're properly trained ahead of time,” Mills says.
When looking at the management of utilities, make sure everyone in CE knows that the condition of the power is appropriate, and where they can get more power if they need it. “There needs to be a relationship between the device user and the people supplying power to the devices,” Mills notes. In managing clinical activities, think about transporting devices that are normally immobile, and what might happen to them en route. A piece of equipment might be dropped, or get out of calibration. “Your normal preventive maintenance procedures won't suffice in an emergency situation,” Mills says.
Although, as Ridgway says, there won't be a consensus on how emergency plans are drafted “until people start sharing their homework,” CE departments can play a role upfront. Most importantly, Mills notes, is anticipating any and all problems with medical devices. Answer the question “What do we need to do to be prepared?” by thinking outside the box.
Editor's Note: AAMI members can pose questions about Joint Commission standards and obtain responses by e-mailing questions to email@example.com.
Variables in Range Orders
Q: During a recent environment of care committee meeting discussing various policies, the issue of handling of range orders was discussed. Specifically, if a hospital's policy is very clear about the handling of range orders (for example, Morphine 1–2mg IV Q4–6 hours prn), is it acceptable to have two variables in an order?
A: Joint Commission standards permit medication orders to include two variables—dose and dosing interval (MM.3.20, EP 6). As you noted, the critical element here is having a clear policy. If an organization allows range orders, it must develop guidelines for interpreting them.
Using the preceding example, when should a nurse administer 1 milligram of morphine and when should he or she administer 2? Under what circumstances should the dosing interval be four hours as opposed to six? In many organizations, the policy is to begin with the lowest dose and the longest interval. Another option is to tie ranges to pain scale assessments.
Q: When was the Imed Gemini PC-1® infusion pump first introduced, and what was the last major change incorporated into this unit? How does the manufacturer provide updates to customers? What is the temperature operating range for this unit's battery?
A: For specific questions about a brand or model of medical equipment, check with the manufacturer.
Reprinted with permission of Joint Commission Resources, Inc., www.jcrinc.com.
Andrea Hall is a freelance writer based in Rockville, MD.