Patient Safety Tip of the Week
November 1, 2016
CMS Emergency Preparedness Rule
Most of us who have long worked in hospitals are aware of many contingencies in place for certain emergencies. For instance, we know that there are backup electrical generators for power outages and that there are periodic drills to test that the backup generator is working correctly. But not all healthcare venues have such systems. Several years ago we participated in a discussion about what happens in dialysis facilities when there is a power outage. It turns out that in many states there is no requirement that dialysis facilities even have backup power sources. So it becomes even more important that all such facilities have comprehensive plans for what to do in such emergencies. Moreover, hospitals are also vulnerable to emergencies other than just power outages, as experiences with some of the recent hurricanes and other natural disasters have demonstrated.
CMS (Centers for
Medicare & Medicaid Services) has now put forward an Emergency Preparedness
Regulation (CMS
2016a). This regulation goes into effect on November 16, 2016 and all
affected facilities and providers must comply and implement all requirements
one year after the effective date, on November 16, 2017. The final rule “Emergency Preparedness Requirements for
Medicare and Medicaid Participating Providers and Suppliers” was posted in the
Federal Register on September 16, 2016 (CMS
2016b). But the latter is almost 200 pages and difficult to read so we
think you’ll get the most use from the CMS
2016a website and its links.
The new rule applies
to all
17 CMS provider and supplier types, though the exact requirements vary by
provider/supplier type as outlined in tabular
form on the CMS website. And ASPR TRACIE (Office of the Assistant Secretary
for Preparedness & Response. Technical Resources Assistance Center
Information Exchange) provides resources and samples to help facilities comply
with the new rule (ASPR TRACIE
2016). There are 4 basic elements for each provider type to consider:
- Emergency Plan
- Policies and Procedures
- Communication Plan
- Training and Testing
Emergency plans must take into account not only the facility level but also the
community and regional or even statewide level. They need to include a risk
assessment and consideration of hazards likely to occur in the geographic area,
care-related emergencies, equipment and power failures, interruption in
communications (including cyberattacks), and full or partial loss of the
facility or supplies. The emergency plan is to be reviewed and updated at least
annually.
While there should
be an all-hazard plan (fires, bioterrorism, tornadoes, floods,
pandemics, etc.), the facility/organization needs to also consider
contingencies for emergencies more likely in their geographic area (eg. are they vulnerable to earthquakes? hurricanes? etc.)
Consider also that indirect hazards affecting the community but not the
facility directly may still interrupt services, supplies or staffing. The specific
vulnerabilities of the facility for each identified hazard should be
analyzed to determine the actions to be taken. Key staff responsible for
executing the plan must be identified, as well as overall staffing
requirements and defined staff responsibilities. That would include
designating critical staff, providing for other staff and volunteer coverage.
You also need to consider staff needs, including transportation and sheltering
critical staff members’ family. The plan should include identification and
maintenance of sufficient supplies and equipment to sustain operations and
deliver care and services for 3-10 days, based on each facility’s assessment of
their hazard vulnerabilities. Consider how you will communicate with staff,
families, patients, and the outside world not only during, but also before and
after, the emergency. And you need to have arrangements with your suppliers and
vendors to ensure you can increase supplies or provisions in the event you have
a surge in capacity as the result of an emergency event.
Your emergency plan,
policies and procedures should attempt to include criteria for declaration of
the various types of emergency and also for declaration that the emergency
condition is over.
The emergency plan should
also contain a “shelter in place” plan (for example, for a storm, active
shooter incidents, etc.) and an evacuation plan. We recommend that you
have two locations designated as “command centers” or “control
centers”. Most hospitals use a designated conference room or board room for
their internal command center. However, for emergencies necessitating
evacuation of the facility you should have an external command center (eg. nearby building) designated. Both sites should have
methods of communicating by multiple means (land phone lines, cell phones,
walkie-talkies, keeping in mind they must be kept fully charged at all times),
backup power supplies, lists of phone numbers for all key internal and external
personnel/agencies, and maps of the facilities and grounds.
The ASPR TRACIE
(Office of the Assistant Secretary for Preparedness & Response. Technical
Resources Assistance Center Information Exchange) website has sample emergency
plans and templates among its many valuable resources (ASPR TRACIE 2016). The ASPR
TRACIE resources are terrific and cover the needs for a variety of facility
types. For example, it provides links to over 50 articles, plan templates and
other resources for dialysis centers with multiple lessons learned from mass
power outages, hurricanes, earthquakes, tsunamis, floods, and water
contamination alerts.
You’ll find
particularly useful the Emergency
Preparedness Checklist downloadable from the CMS Emergency Preparedness
Rule website. This allows you to track where you stand on all the tasks
necessary to meet the requirements of the new rule.
CMS is looking for
the following elements in an Evacuation Plan:
- Identification of person responsible for implementing the facility
evacuation plan (even if no outside evacuation order is given)
- Multiple pre-determined evacuation locations (contract or agreement)
with a “like” facility have been established, with suitable space,
utilities, security and sanitary
facilities for individuals receiving care, staff and others using the location, with at least one facility
being 50 miles away. A back-up may be necessary if the first one is unable
to accept evacuees.
- Evacuation routes and alternative routes have been identified, and
the proper authorities have been notified. Maps are available and specified
travel time has been established.
- Adequate food supply and logistical support for transporting food is
described.
- The amounts of water to be transported and logistical support is
described (1 gal/person).
- The logistics to transport medications is described, including
ensuring their protection under the control of a registered nurse.
- Procedures for protecting and transporting resident/patient medical
records.
- The list of items to accompany residents/patients is described.
- Identify how persons receiving care, their families, staff and
others will be notified of the evacuation and communication methods that
will be used during and after the evacuation
- Identify staff responsibilities and how individuals will be cared
for during evacuation and the back-up plan if there isn’t sufficient
staff.
- Procedures are described to ensure residents/patients dependent on
wheelchairs and/or other assistive devices are transported so their
equipment will be protected and their personal needs met during transit
(e.g., incontinent supplies for long periods, transfer boards and other
assistive devices).
- A description of how other critical supplies and equipment will be
transported is included.
- Determine a method to account for all individuals during and after
the evacuation
- Procedures are described to ensure staff accompany evacuating
residents.
- Procedures are described if a patient/resident becomes ill or dies
in route.
- Mental health and grief counselors are available at reception points
to talk with and counsel evacuees.
- Procedures are described if a patient/resident turns up missing
during an evacuation:
- Notify the patient/resident’s family
- Notify local law enforcement
- Notify Nursing Home Administration and staff
- Ensure that patient/resident identification wristband (or equivalent
identification) must be intact on all residents.
- Describe the process to be utilized to track the arrival of each
resident at the destination.
- It is described whether staff’s family can shelter at the facility
and evacuate.
When you must
perform a facility evacuation for something like a fire, you need to include in
your plan the sites where you will congregate and do a patient and staff count.
In the event of an evacuation, you also need to determine how residents will be
identified and ensure the appropriate identifying information will be
transferred with each resident (eg. name, date of
birth, social security number, photograph, etc). But
you also should make sure that information regarding diagnosis, current
medications, diet are provided as well as information about health insurance,
family/caregiver contact, advance directives, etc. Your plan should include how
this information will be secured and transported (e.g., laminated documents,
water proof pouch around resident’s neck, water proof wrist tag, etc.).
And part of your
evacuation plan should be a Facility Reentry Plan. That should detail
who will authorize reentry to the facility after an evacuation, the procedures
for inspecting the facility, how it will be determined when it is safe to
return to the facility after an evacuation, and how patients will travel back
to the facility.
Facility transfer agreements are typically done among regional facilities. The CMS site has a link to
a Facility
Transfer Agreement Example. But your emergency plan should include not only
what to do if there is an emergency in your facility or region but also
contingencies for remote disasters. For example, hospitals as far away as
western New York needed to have plans to handle excess capacity if patients in
the New York City area or New Jersey were forced to evacuate during Hurricane
Sandy. Border towns and cities may also need to include cooperation with
facilities across the border in, for example, a neighboring Canadian province.
The CMS Emergency
Preparedness Checklist also has a nice section on suggested principles of
care for relocated patients/residents, including addressing their fears,
anxieties, and psychological needs. It also reminds you to make sure that any
vendors or volunteers who will help transport residents and those who receive
them at shelters and other facilities are trained on the needs of the chronic,
cognitively impaired and frail population and are knowledgeable on the methods
to help minimize transfer trauma.
The Communication
Plan must include a system to contact staff, including patients’
physicians, other necessary persons, and also comply with Federal and State
Laws. It should be well-coordinated within the facility, across health care
providers, and with state and local public health departments and emergency
management agencies. Your communication plan should also include phone numbers
for families to call.
Communication with
community facilities and resources is not a one-time event. Hospitals typically
hold drills with other community resources at least annually in the form of a “disaster
drill”. Those are usually coordinated by some form of regional planning and
emergency response agency. But we also encourage hospitals and other healthcare
facilities to meet with and drill with their local fire department (see our
October 21, 2014 Patient Safety Tip of the Week “The
Fire Department and Your Hospital”) and police department (for active
shooter drills, absconds, kidnappings, etc.). There are certain aspects of facilities
that those first responders must be familiar with, such as the dangers inherent
in MRI suites.
While it may not be
formally required by CMS, one of the emergencies you must be prepared for is
that of a missing patient. We refer you to our April 7, 2015 Patient Safety Tip
of the Week “Missing
Patients and Death” for details on what you need to do in the case of a
missing patient, including how to announce the problem, set up a command
center, perform grid search, alert appropriate authorities (and family), and
what to do when you find the patient.
The other emergency you need a plan for is infant abduction. We refer you to our Patient Safety Tips of the Week for December 20, 2011 “Infant Abduction” and September 4, 2012 “More Infant Abductions” for details.
Critical to emergency preparedness is training and drills. Everyone who works in your facility needs to be knowledgeable about your emergency preparedness plan(s). While most often staff are educated about the plan(s) during initial orientation, you must re-educate them at least annually and reinforce it with periodic drills. Unfortunately, the staff that tend to slip through the cracks are those temporary hires or per diem floating staff that are only at your facility for short periods. The same applies to housestaff that may rotate through your facility for only short periods.
The only way to be truly prepared for emergencies is to practice ahead of time. This is done through drills. Our readers have heard us harp on the need for drills for surgical fires, elopements, absconds, missing patients, infant abductions, fires and others. So here we just want to remind you of two things about drills. First is that we are often disappointed with the lack of detail and formal assessment about the drills. You should always have designated observers who are recording important aspects of the drill and then have a formal evaluation with appropriate constituents. Second is a reminder that certain emergencies might be piggybacked (eg. an elopement or an infant abduction occurring when a fire alarm is triggered). So we recommend that periodically you include both types of drill at the same time (eg. initiate an infant abduction drill during a fire drill).
CMS also stresses that your training also needs to address psychological and emotional aspects on caregivers, families, residents, and the community at large. And your plan needs to consider more mundane issues like mechanisms for patients to make claims for personal effects lost during the emergency.
Just as you need to
conduct a review of all your emergency drills, you need to at least annually
review your Emergency Preparedness Plan(s). Such review should include
lessons learned from your drill reviews, any actual emergencies, newly
identified threats or hazards, and any new regulations or infrastructure
changes.
Lastly, let’s get
real – no one could possible remember all the things they need to do for
each type of emergency. Even as a hospital medical director, I had to keep
with me checklists of what my responsibilities were for each type of emergency.
There are a couple ways to do it. You can’t fit much more than the “RACE”
acronym for fires on the back of your facility ID badge. Lots of facilities
have notebooks or packets of letter-sized paper with instructions. No one will
carry those around! So there are other options. One is to have thin packets
of small laminated cards with instructions for each emergency/drill so that
each individual could have a tailored set that could fit on a key ring
and fit in one’s pocket. That also provides an easy way to help those temporary
individuals who will only be at your facility for short periods. The other
method, given that almost everyone nowadays has a smartphone, is to
provide the role-specific instructions for them on their smartphone. Those
could be easily found by a PDF reader on the smartphone. But we find that
putting them in the notes section of most smartphone contact lists is
the best way to make them more easily accessible. For example, under the “last
name” or “company” field in your contact list enter “missing patient” and then
under the “notes” field enter all the steps you must follow. You can even use
the phone number fields for any key phone numbers someone might need to call (eg. one for your command center, another for the police
department, etc.). You can even customize your headings for when you have
different roles. For example, you could have them under multiple listings such
as “Fire – charge nurse” or “Fire – staff nurse” or “Fire – nurse supervisor”
for when you have roles that might change. Lastly, so you don’t have to use the
search function in your contact list, either put the entries in your
“favorites” list of phone numbers or precede each with whatever
letter/number/symbol that your particular smartphone sorts to the top of your
contact list.
Hopefully, your
facility is already in compliance with most of these requirements but the new
CMS Emergency Preparedness Rule provides additional incentive to take a look at
the gamut of your emergency preparedness activities and update them to ensure
you meet all the CMS requirements.
References:
CMS (Centers for
Medicare & Medicaid Services). Emergency Preparedness Rule. 2016
CMS (Centers for
Medicare & Medicaid Services). Emergency
Preparedness Requirements for Medicare and Medicaid Participating Providers and
Suppliers. Federal Register 2016; 81(180): 63860-64044 September 16,
2016
DHHS (US Department
of Health and Human Services). Emergency Preparedness Requirements for Medicare
and Medicaid Participating Providers and Suppliers. ASPR TRACIE (Office of the
Assistant Secretary for Preparedness & Response. Technical Resources
Assistance Center Information Exchange). Last updated October 25, 2016
https://asprtracie.hhs.gov/cmsrule
CMS (Centers for
Medicare & Medicaid Services). Facility Transfer Agreement Example.
CMS (Centers for
Medicare & Medicaid Services). Emergency Preparedness Checklist for All
Providers.
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