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April 2017Volume 25 Issue No. 4

Briefings on Hospital Safety

Fake doc roams Boston hospitalIncident at hospital where surgeon was killed renews security debate

Emergency Planning: Hurricanes and tornadoes

It’s storm season. Now’s the time to get your facility ready to face winds and waters of Mother Nature.

HICS planning scenario

This handy planning guide will help you prepare your hurricane response.

Are you prepared for the new CMS EP rule?

Hospitals must implement the new CMS emergency preparedness rule in November.

Healthcare Security Alert

A recent conference digs into pandemic preparedness in the U.S.

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When a man upset over the death of his mother walked into a Boston hospital in January 2015 and killed the doctor who had treated her, it sent shockwaves through the healthcare safety community as an impor-tant lesson was learned about how susceptible hospitals are to security breaches.

Or so we thought, until a woman was discovered in September 2015 wandering through a Boston hospital posing as a doctor.

In the earlier particular case, Stephen Pasceri, 55, of Millbury, Massachu-setts, walked into the Carl J. and Ruth Shapiro Cardiovascular Center at Brigham and Women’s Hospital on January 20, 2015, and specifically asked for the doctor, Michael J. Davidson. When the two stepped into an exam room to speak, colleagues reported hearing loud voices and then two shots fired as Pasceri shot and killed Davidson and them himself.

The shooting spurred Brigham and Women’s Hospital, as well as other Boston hospitals, to conduct their own security assessments and increase drills, and it inspired others across the U.S. to consider increasing secu-

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2 |Briefings on Hospital Safety April 2017

Briefings on Hospital Safety (ISSN: 1076-5972 [print]; 1535-6817 [online]) is published monthly by HCPro, a division of BLR®. Subscription rate: Regular $355/year or $639/two years; back issues are available at $25 each. • Briefings on Hospital Safety, 100 Winners Circle, Suite 300, Brentwood, TN 37027. • Copyright © 2017 HCPro, a division of BLR®. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, outside the subscriber’s facility without prior written consent of HCPro, a division of BLR., or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872. For renewal or subscription information, call customer service at 800-650-6787, fax 800-785-9212, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BHS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

BHS STAFF MEMBERS EDITORIAL ADVISORY BOARDBarbara Bisset, PhD, MS, MPH, RNExecutive DirectorEmergency Services Institute/WakeMed Raleigh, North Carolina

Joseph Cocciardi, PhD, MS, CSP, CIHExecutive DirectorCocciardi & Associates Mechanicsburg, Pennsylvania

Leo J. DeBobes, MA (OS&H), CSP, CHCM, CPEA, CHEP, CHSP, CSC, EMTAssistant Administrator, Emergency Management/ Regulatory ComplianceStony Brook University Medical Center Stony Brook, New York

Elizabeth Di Giacomo-Geffers, RN, MPH, CSHAHealthcare ConsultantDi Giacomo-Geffers and Associates Orange County, California

Zachary Goldfarb, EMT-P, CHSP, CEM, CHEPPresidentIncident Management Solutions, Inc. East Meadow, New York

Ray W. Moughalian, BS, CHFRMPrincipalSaf-T-Man Methuen, Massachusetts

John L. Murray Jr., CHMM, CSP, CIHSafety DirectorBaystate Health Springfield, Massachusetts

Paul Penn, MS, CHEM, CHSPEnMagine/HAZMAT for Healthcare Diamond Springs, California

Lisa B. Pryse Terry, CHPA, CPPODS Security Solutions Richmond, Virginia

Dalton Sawyer, MS, CHEPDirector, Emergency Preparedness and Continu-ity PlanningUNC Health Care Chapel Hill, North Carolina

Steve SchultzCorp. E&O Safety DirectorCape Fear Valley Health System Fayetteville, North Carolina

Barry D. Watkins, MBA, MHA, CHSPSenior EC SpecialistCorporate Safety Carolinas HealthCare System Charlotte, North Carolina

Kenneth S. Weinberg, PhD, MScPresidentSafdoc Systems, LLC Stoughton, Massachusetts

Thomas A. Smith, CHPA, CPPPresidentHealthcare Security Consultants, Inc. Chapel Hill, North Carolina

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

connections to an attending doctor.

At some point, physicians caught on and she was escorted off the property. Meanwhile, hospital officials posted her photograph near operating rooms and alerted other hospitals in Boston. The next day, she showed up for rounds in a conference room at Massachusetts General Hospital and was told to leave. Astonishingly, when she left, she was followed by Brigham officials to Children’s Hospital Boston, where she tried to do the same thing—she was intercepted and turned away, the Globe reported.

“Ms. Wang was an observer. She did not touch, treat, or provide care to a single patient,’’ Brigham and Women’s spokesman Erin McDonough told the Globe, though security video reportedly shows that Wang gained access to five operating rooms over two days.

The fact that Wang was able to not only gain access to the hospital, but do it several times without anyone noticing and become a part of the medical treatment community raises some serious questions about hospital security. At the very least, many hospitals—city hospitals can be busy places where hundreds or thousands of people come and go—control access to

rity measures such as visitor pat-downs, security patrols, and metal detectors.

It’s one thing to be able to detect and stop an intruder before they walk into the doors of a hospital and cause trouble, but what happens when the intruder not only gains access, but blends in and spends some time there—potentially even treating patients?

That scary scenario is exactly what happened to Brigham and Women’s nine months later, when it was discovered in September 2015 that a “fake doc” had for several days roamed the halls of the hospital unchallenged, dressed in scrubs, asking questions at a lecture, attending patient rounds, and observing operation—even helping transport a patient to the recovery unit, according to a February report in the Boston Globe.

So what happened? According to the Globe, Cheryl Wang, 42, and a former surgical resident who had been dismissed from a program in Mount Sinai St. Luke’s Hospital in New York City, and had been reported to New York’s state disciplinary board, somehow blended in with the circulating mass of medical personnel, slipping into restricted areas and suggesting she had

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Contributing EditorSteven MacArthurSafety Consultant The Greeley Company Danvers, Massachusetts

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patient treatment areas, operating rooms, and other sensitive areas using security features such as electronic ID badges. But these systems are not without their faults—and they are susceptible to human factors.

In this case, Wang took advantage of this busy envi-ronment, hedging her bets that she wouldn’t be noticed as an outsider among the many other doctors, nurses, and residents at the hospital every day. It’s called “tailgating,” a problem that security experts have warned against for years. In this practice, hospital staff hold ID badges against the electronic card reader to gain access to surgery suites, and then groups of people hold the door for one another, not questioning that someone dressed in the same medical garb might not belong there.

According to the Globe article, Wang regularly was seen following fellow employees during shift changes, and was able to sneak into sensitive areas.

“This individual looked and acted like she belonged in our institution. She was wearing our scrubs, knew her way around, understood the hospital culture and terminology, and was familiar with people’s names,’’ McDonough told the Globe in a written statement. “Because of this, we let our guard down. We know that in addition to best practice security measures, the safety and security of our hospital requires the vigilance of everyone who works here. All involved are fully committed to providing a secure [operating room] for our patients and staff.”

For its part, Brigham and Women’s Hospital seems intent on not allowing a repeat incident, and officials have reassessed the facility’s security protocols, according to the Globe. The hospital has changed protocols for allowing observers into operating rooms, and physicians sponsoring a visitor are now required to verify with a student’s educational institution that the student “is in good standing,’’ which is apparently something they never did with Wang. In fact, the report said that Wang was able to forge recommendation letters that helped her win permission to shadow a Brigham surgeon for two days in September. She was apparently able to return several months later in scrubs

with the hospital’s logo that she reportedly obtained during her September visit.

What are hospitals doing?

Obviously, the problem of intruders (even those that seem to be legally there) getting into hospitals is a perennial problem, and healthcare safety officials are constantly grappling with the debate of just how secure hospitals should be. On the one hand, hospitals are supposed to be healing places where sick and injured people come to get better, so security officials (and administrators) are hesitant to install too many deterrents that will make the facility seem unfriendly.

At the same time, an increasing number of violent incidents and intruders in hospitals have left facilities scratching their heads trying to come up with the perfect mix of security measures that could help keep the same problem from happening as did at Brigham and Women’s.

As an example, let’s look at some of the measures that Parrish Medical Center in Titusville, Florida, took after an armed man entered the hospital on July 17, 2016 and shot and killed patient Cynthia Zingsheim, 92, and healthcare aide Carrie Rouzer, 36, for no apparent reason. The facility now maintains a law enforcement presence and enhanced security at public entrances, restricts public access to the main entrance and emergency department by requesting identification, and conducts random bag checks.

Security officers are now armed with additional protective equipment and gear and are receiving more training. The health system also is considering installing metal detectors and other equipment to identify prohibited items.

In addition, law enforcement officials say the hospital’s active shooter plan, and brave security guards who confronted and held the assailant until police arrived, were two of the major factors that helped keep the incident from escalating to a worse mass shooting.

The ID badge that helped Wang get into Brigham and Women’s has grown from being just a piece of identification, and is increasingly being used as a




security tool in hospitals. With encrypted electronic chips, GPS, and proximity sensor technology becoming increasingly reliable and affordable, hospitals are looking for ways to cut down on the number of badges that staff need to carry. An all-in-one solution allows staff members not only to identify themselves, but also

to swipe in for their shifts, pay for meals through a debit card system, gain access to restricted areas, and provide security personnel with an electronic “footprint” to track where in the hospital they have been, if needed—a feature that may have been helpful to track Wang in her comings and goings at the hospital. H

Emergency Planning: Tornadoes and hurricanesIt’s storm season. Now’s the time to get your facility ready to face the power of Mother Nature

Editor’s note: This is the last in a series of stories that will address common planning concerns when it comes to certain types of emergencies that can strike a hospi-tal facility.

It’s spring time in the U.S., and with the return of warmer weather in most places, the mind turns to pleasant sunny days, lighter jackets, and at worst, spring rain showers from a weather perspective.

But from a meteorological standpoint, Mother Nature is just getting ramped up. In the U.S., tornadoes become more frequent in many parts of the Midwest as cold air in the northern half of the country meets warmer, more humid air in the southern half, creating the perfect soup for thunderstorms that can spawn brutally destructive tornadoes.

In parts of the country such as Florida, the Gulf Coast, and the Atlantic seaboard where tornadoes aren’t so prevalent, preparations begin for hurricane season, which begins in June and runs through November.

Both of these types of storms bring with them their own distinct dangers of wind and water, and while one type is usually small, quick, and violent while the other is large, and can span days over one spot, hospitals must be ready to deal with them both and to stay open to help both existing patients and incoming victims.

One would think after many years of having open hospitals in the U.S., that preparation for these storms would be second nature—and a direct strike is something that is almost statistically unfathomable. But one needs only to look at New Orleans in 2005, and

Joplin, Missouri in 2011, to know how unprepared hospitals can be.

Hurricane Katrina hit the New Orleans area on August 29, 2005 as a Category 3 storm, which may not have been a big problem for the city’s medical facilities in normal circumstances, but when 53 of the city’s protective system of levees failed, almost 80% of New Orleans was left under water, sending citizens scrambling to the roofs of their houses to escape the floodwaters. Several hospitals were left stranded, with no evacuation plans, a lack of doctors (or the inability to get staff to and from work), and failed utilities that ultimately led to many deaths of patients whose life support systems failed. The storm’s aftermath led to many emergency preparation overhauls, and changed the way healthcare organizations plan and drill for disasters.

“Hurricane Katrina was an indescribable event that forced the hospital and the community to deal with issues that were not planned for,” recalls Ken McDowell, CHSP, CHEP, safety officer for Memorial Hospital at Gulfport in Gulfport, Mississippi, an area that was especially hit hard by the hurricane.

Direct hit from a tornado

On the afternoon of May 22, 2011, an EF-5 tornado with winds approaching 300 miles per hour slammed into the city of Joplin, Missouri and roared head on into St. John’s Hospital. In the aftermath of the tornado, 161 people died, including six at the hospital itself. The roof of the building was blown off, leaving





those inside exposed to the elements. Cars in the parking lot were thrown into the hospital’s front foyer waiting room, and shards of glass sprayed patients and staff as just about every exterior window shattered. Communication was completely shut down, and an electrical generator and HVAC system on top of the hospital was tossed off and rendered useless.

Four years later, the city opened the brand new $450 million, 900,000 square-foot “tornado-proof” facility designed to withstand another direct hit. Utilities are hidden in a reinforced concrete utility bunker buried underground. Exterior walls are made with reinforced masonry and precast concrete panels designed to bow in and out to withstand pressure changes in a tornado, and the roof is built in layers—a concrete roof covered with a waterproof membrane designed to keep the roof from tearing off and exposing those inside to the elements. Special windows were made to withstand winds up to 250 miles per hour in the hospital’s most critical areas.

Clearly, man is no match for Mother Nature’s fury, but we’ve shown the ability to rebuild and learn some pretty important lessons out of experience. So how can you get ready for this year’s onslaught of wicked weather? The preparations for both types of storms are quite similar.

Our safety experts, along with those who literally weathered the two storms in Joplin and New Orleans helped us come up with some tips and advice to get you started in your preparations. Also, check out p. 7 for a training scenario you can use for your next drill.

Assess your vulnerability. It’s been said many times, many ways. The only way you can get a clear picture of the hazards that could potentially strike your hospital (and more importantly, whether or not you’re ready to deal with them) is to do a hazard vulnerability assessment. If you haven’t done one yet, you’re already out of compliance with CMS and The Joint Commission (it’s a requirement). This is the document that measures the disasters that are likely to hit your community. (Is there a freight train line that carries hazardous chemicals that run through town? Is your hospital in the flood zone for a system of levees? Are you located in Tornado Alley?)

From here, you can tailor your response possibilities, and your drills that will help practice those responses. This is important, because it will help you determine where your weaknesses are. Is your facility prone to flooding? This might be good to know if your area is prone to hurricanes, because now is the time to mitigate that problem with a system of dikes, or to stock up on sandbags, or to practice your evacuation procedures. New York City hospitals learned this the hard way when Hurricane Sandy unexpectedly flooded the basements of older buildings, forcing the evacuations of many patients to other facilities.

Protect your utility infrastructure. This is your lifeblood. Without power, lights, heating, and other important utilities, you will literally be in the dark. If there’s one thing that hospitals that have weathered huge storms have learned, it’s that wind and floodwaters will find the weaknesses in your building’s infrastructure and creep into, or blow away, your utilities. After generators and utility connections were blown either out of or off the old Joplin hospital, architects placed all of the hospital’s generators, boilers, chillers, gas, and oxygen in the underground bunker, and twin electrical feeds will ensure a redundancy should one stop working.

“We do not know of another facility that has been built with tornado and wind protection as this new facility,” says John Farnen, executive director for strategic projects for Mercy Health Systems, St. Louis, Missouri, who helped design the new Mercy Joplin Hospital.

In what has been called an example of upside-down construction, many hospitals are being built or retrofitted with the main primary electrical services located in the rooftop and powered by a fuel pump that is secured in a flood-proof vault with a 150,000-gallon tank and reserve fuel stored on-site. Many emergency fuel tanks are stored in hospital basements or bottom floors. During Hurricane Sandy in New York City, many generators were worthless because floodwaters either contaminated emergency fuel stores, or destroyed the tanks. As a result, some hospitals, such as the newly built Spaulding Rehabilitation Hospital in Boston, are being built with ballasted fuel tanks that can float in floodwaters.




the center of the hospital away from windows and outside walls. In the aftermath, patients had to be evacuated down stairwells that had collapsed, ceilings that were falling down, and lights that weren’t working. Your hospital may have a system in place for doing something similar, but if you haven’t practiced getting people out of the building, your staff won’t know how to handle it when they are truly under the gun. At least once a year, and preferably much more often, hold a real-life drill that simulates deteriorating conditions and forces your staff to make decisions based on changing variables.

Invest in updated communication technology. You can have the best communication equipment money can buy, but if the power goes out, what then? It’s a rule of emergency management that if you can’t communicate with the outside world, you are on your own, and that’s exactly what happened to many hospitals after Katrina struck. When the power went out staff members tried to use cell phones, but downed towers from the wind and overcrowded circuits rendered cell phones useless. There were a few satellite phones available, but to use the phones, staff had to go to the roof of the hospital to search for a signal. Today, cell networks are much more reliable and cell phones are much more dependable. Still, cell towers won’t withstand a 300-mile-per-hour wind, and when your staff is trying to coordinate a mass evacuation down several flights of stairs after a tornado, they aren’t likely to pick up their cell phones to communicate. You may have to rely on shouted commands or codes, handwritten notes, or a system of walkie-talkies. Have those contingencies ready.

“We have installed a first responder radio system and a ham operators system in the new facility for communication with other emergency agencies in case we should ever lose everything again,” Farnen says. “We have more redundancies for utilities including UPS (uninterruptible power supply) backup on all life support equipment.”

Yes, regulators now require your hospital to test communications systems often, and have multiple backup systems available in the event of a crisis. But the best-tested systems still can fail. After the tornado

“The weather events of the prior decade drove our decisions, and time has proven us correct,” says Spaulding Director of Communications Timothy Sullivan.

Some facilities are being built so that even if the first floor was completely flooded, critical care could still take place as usual in upper floors. At Spaulding, even the hospital’s parking garage is designed 19 feet above current flood levels, and the entranceway is designed with a special uphill “lip” that will cause water to pool, rather than rush down into the underground parking garage.

Foster mutual-aid relationships. Hospitals need to learn to work together to help out in an emergency. Before Hurricane Katrina, hospitals in New Orleans didn’t have “memorandums of understanding” with other hospitals that let other hospitals accept their patients should the need arise. Now, it’s considered best practice in your emergency plans to have deals with other hospitals. Hospitals in the same community now routinely train to not only sustain themselves in an emergency, but with other facilities to be ready to help out with supplies or patient care if needed. A similar agreement went into effect in Joplin after the twister, when Freeman Hospital, six blocks away and untouched, took in more than 100 of the most critical of patients who had been evacuated from St. John’s, but also about 1,700 patients that had walked into the emergency room off the streets. Emergency surgeons performed 22 lifesaving operations in the first hour after the twister struck.

“We had to resort to very primitive measures that day,” says Paula F. Baker, president and CEO of Freeman Health System in Joplin. “We had doctors and nurses who literally crawled out of their own homes that had been destroyed to come here and help. You couldn’t get through the streets here, so they walked and did whatever they could to get here.”

You need to drill, constantly. Practice makes perfect. Unfortunately, hospitals don’t practice enough. When a disaster strikes, hospital staff response needs to be a well-oiled machine. Take, for instance, the tornado in Joplin. When the tornado hit, staff members only had about five to 10 minutes to prepare. Only minutes remained to move patients to rooms and hallways in





in Joplin, patients were being transferred to Freeman with no patient records, since all communications by phone or computers were down. Security cameras didn’t work, and the only way to get a cell phone signal in some cases was to go to the roof of the hospital. The only way of knowing why the patient was being transferred, or what their medical history consisted of was by reading handwritten notes attached to the patient.

“Nothing could have prepared us for that,” says Baker. “We were working with every disadvantage against us.”

Have an evacuation plan, and know when to leave. One of the hardest decisions staff members of a hospital can make is the decision to evacuate. It’s an incredibly difficult undertaking that takes a massive mobilization of resources, time, and a ballet of making sure life-support systems are available to help keep critically ill patients alive. It’s not to be taken lightly. At the same time, it’s possible to wait too long to the point where it’s too late—and that’s a problem that struck facilities in New Orleans. Hospitals had always trained to stay open, and by the time the last option became the only option, the floodwaters had already risen too deep. Some will fault the government, which waited much too long to issue an effective evacuation order for the city, but it’s

those timely decisions that make the difference between being able to get ambulances and buses in to help evacuate critical patients or to hole up at the hospitals waiting until helicopters were available to assist. At the same time, you are trying to make sure your staff can safely make it into work to help keep your facility operational. (It’s also a good idea to make sure your hospital has a plan to house staff members in case they need to stay for a prolonged period of time. If you know a bad storm is on the way, you may want to consider converting a conference room, for instance, into a hotel with cots where they can stay for a few days in case conditions are bad for travel.)

It’s a good idea to write your emergency plans with the forethought that at some point, someone may have to decide to evacuate. The idea is to know ahead of time who will stay and who will go, and at what threshold it is time to make that decision. If weather conditions are deteriorating rapidly, or transportation arrangements can’t be guaranteed, or resupply lines might be compromised, those decisions need to be made earlier so they never come as a surprise. Hospitals in the New York City area had ambulance companies on standby long before Hurricane Sandy ever hit, just in case they were needed. H

Natural Disaster - Major Hurricane

External Scenario 10

NATURAL DISASTER – MAJOR HURRICANE

SCENARIO

Page 1 of 16 August 2006

The National Weather Services predicts that a Category 5 Hurricane will hit the coast of your city, with sustained winds at 160 miles per hour and a storm surge greater than 20 feet above flood stage. City, county and state officials issue mandatory evacuations of the coastal and low lying areas. As the storm approaches, rain is heavy and low-lying escape routes are flooded, making evacuation more difficult. Your hospital is located approximately 10 miles from the coast, the hospital is on high ground and the facility is hardened to withstand a major hurricane. While you do not plan to evacuate, you limit admissions, discharge appropriate patients and cancel elective surgeries, procedures and treatments. Source: California Emergency Medical Services Authority







INCIDENT PLANNING GUIDE


Does your Emergency Management Plan Address the following issues? Mitigation & Preparedness

1. Does your hospital reside in a safe location (higher ground) to maintain operations during the hurricane and flooding?

2. Does your hospital regularly monitor pre-event weather forecasts and projections?

3. Does your hospital participate in pre-event local response planning with emergency management officials, including meetings/conference calls to plan and share status?

4.

Does your facility have a plan to initiate pre-event facility hardening actions: protect windows; secure outside loose items; test back up generators; bring in supplemental supplies of essential items (food, water, medications, lighting); protect basement high risk areas; relocate at-risk items to higher levels; evacuate research animals/facility; secure surveillance cameras; prepare staff sleep/rehab areas; activate amateur radio operators; top off fuel tanks, etc.?

5. Does your hospital have contingency staff utilization and support plans?

6. Does your hospital have a plan to reduce census with cooperating inland and unaffected hospitals?

7. Does your facility have a plan to accommodate pregnant women who report to facility before and during the storm?

8. Does your facility have an established list of medical staff specialties and backup/relief staff that will need to be in the hospital to continue care during the storm?

9. Does your facility plan to provide child care for staff so that they can report to and remain on duty?

10. Does your facility have a list of non-essential staff that may be used in alternate roles?

11. Does your facility have a plan to distribute radios, auxiliary phones, and flashlights to appropriate people and hospital areas?

12. Does your facility have a plan to maintain water and sanitation systems during the storm, including providing personal hygiene/sanitation supplies (i.e., hand wipes, portable toilets, potable water)?

13. Does your hospital have a process to determine daily clinical and non-clinical services to be continued or modified before and during the storm?

14. Does your facility have a plan to accommodate community boarders that includes services provided, a designated area(s) and triggers for activation and deactivation of the boarding?

15. Does your hospital have a surge capacity plan that includes triggers and criteria for activation?

16. Does your hospital have a security plan to manage the patient surge and facility security before, during and after the storm?

17. Does your hospital have criteria and plans to evacuate the facility (partial/complete) for different category storms?

Source: California Emergency Medical Services Authority










18. Does your hospital have a plan for alternate care sites including set up, equipment, staffing and signage?

19. Does your facility have MOUs with inland hotels/motels, supply vendors, alternate care site venues, and transportation providers to provided needed services before, during or after the storm?

20. Does your facility have MOUs with fuel suppliers to ensure a supply of fuel for emergency generators and vehicles?

21. Does your facility have a plan to modify staffing and hours of work?

22. Does your facility have plans to maintain infrastructure during and after the storm including power, water, sewer, medical gases, facility repair, etc.?

23. Does your hospital identify and/or have MOUs with contractors that can perform repairs after the storm?

24. Does your hospital have a process to consider relocating hazardous materials/chemical agents to prevent contamination in case of flooding?

Response & Recovery

1. Does your hospital have procedures to perform damage assessment (interior and exterior), report damage to the HCC and initiate appropriate repairs during and after the storm?

2. Does your hospital have a plan to supplement staffing?

3. Does the facility have a plan to transport staff and their families living in potentially flooded areas or without transportation to the hospital to ensure staffing?

4. Does the hospital have a procedure to inventory equipment, supplies and medications?

5. Does your hospital have a plan and back up (redundant) systems to maintain communications with the local EOC and other officials during and after the storm?

6. Does your hospital have a process to evaluate the need for further evacuation (partial/complete) of areas of the hospital as a result of structural damage or flooding during the storm?

7. Does your hospital evacuation/relocation plan include notification of family members when patients are moved to other facilities?

8. Does your hospital have a plan to manage an increase in numbers of people presenting to the facility for non-medical, general assistance (food, medicine, diapers)?

9. Does your hospital have procedures to regularly evaluate infrastructure and operational needs and implement appropriate actions to meet the needs?

10. Does your hospital have a fatality management plan that integrates with law enforcement, medical examiner/coroner?

11. Does your hospital have a plan to house staff and their families that cannot return to or lose their homes in the storm?









12. Does the facility have protocols to notify local public health of patient status and medical/health problems presenting by types of illness or injury?

13. Does your hospital have a protocol to monitor severity of damage and progress of repairs?

14. Does your hospital have a process to monitor contractor services (work quality, costs, etc.)?

15. Does your hospital have procedures to monitor environmental issues, water safety, and biohazardous waste disposal during and after the storm, for an extended period?

16. Does your hospital have a plan to maintain essential contract services (e.g., trash pick up, food service delivery, linen and laundry, etc.)?

17. Does your hospital have a plan to provide rest/sleep, nutrition, and hydration to staff before, during and after the event?

18. Does your hospital have a plan to repatriate evacuated patients and staff?

19. Does the facility have criteria and decision-making processes to prioritize service restoration activities?

20. Does your hospital have protocols and criteria for restoring normal non-essential service operations (e.g., gift shop)?

21. Does your hospital have procedures to ensure equipment, medications and supplies are reordered to replace stock supplies?

22. Does your hospital have procedures to return borrowed equipment after proper cleaning and supplies?

23. Does your hospital have a process to recognize and acknowledge appreciation to staff, patients, solicited and unsolicited volunteers, and local, state and federal personnel sent to help?







Emergency management: Are you prepared for the new CMS rule?

Editor’s note: The following is based on a recent HCPro webinar featuring independent safety consultant Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, and health safety professional Thomas Huser, MS, CHSP, CHEP. The presentation offered tips for successful implementation of the new CMS emergency management rule. (An archive of the presentation, titled “The New CMS Emergency Management Rule: Tips for Successful Implementation,” is available at www.hcmarketplace.com/cms-emergency-management).

Hospitals must implement the new CMS emergency preparedness rule by November 16, meaning many have significant hurdles to surmount in the coming months ahead of that looming deadline.

Since officials have made clear they do not intend to offer an extension, experts say healthcare facilities should plan to invest the time and resources necessary to comply on time—a feat that will require hospitals and systems to collaborate not only within their own walls but also with their communities more broadly.

“This is going to be now the cost of doing business. There are no additional funds that we anticipate to make this happen,” said Marge McFarlane, PhD, MT (ASCP), CHSP, CHFM, CJCP, HEM, MEP, CHEP, an independent safety consultant and principal of Superior Performance LLC in Eau Claire, Wisconsin.

The final rule was published last September, before President Donald Trump won his bid for the White House. So the new administration, which has taken aim at reversing several regulations imposed under Trump’s predecessor, Barack Obama, could delay implementation or consider altering the rule’s provisions. But it remains unclear whether doing so will be a priority.

While the rule spans 186 pages in the Federal Register, Thomas Huser, MS, CHSP, CHEP, said during the webinar that healthcare safety professionals should

focus on three key portions: the summary of major provisions (p. 63861), regulatory impact analysis (p. 64008), and individual Conditions of Participation (p. 64012).

The policy—which requires hospitals to conduct risk analyses, draft emergency preparedness plans, establish emergency communications plans, conduct staff training, and test their plans—imposes different rules for each facility type.

“What makes the document so lengthy—and advantageous—is that it really breaks down the individual requirements for each of the different 17 groups that are covered by the rule,” McFarlane said.

Mental health centers and end-stage renal disease (ESRD) treatment facilities, for instance, are not bound by all the same standards as critical access hospitals (CAH) and other facilities, but the new rule anticipates that each will have a part to play in emergency situations.

“Because we live under the threat of mass casualties occurring at anytime and anywhere with consequences that may be different than the day-to-day occurrences, the healthcare system must be prepared to respond to these events by working as a team or community system,” CMS officials wrote in the Federal Register, discussing benefits of the final rule.

As its motivation, the rule cites a number of natural and man-made disasters, including the 9/11 terrorist attacks, subsequent anthrax mailings, hurricanes, flooding, tornadoes, and an influenza pandemic. It aims to take past lessons from these and other real-world events and combine them with today’s best practices.

McFarlane said that level of preparation means planning for multiple overlapping emergency situations.

“You cannot predict that there will not be cascading




disasters, meaning one thing has happened and then another thing happens, and then possibly another,” McFarlane said, citing Hurricane Katrina as an example. “The disasters cascade when you least expect them.”

Consider the long-term illnesses of people in your local community, including conditions like diabetes. If the pharmacy closes due to a disaster, where will those patients go for insulin and other ongoing treatment needs? Even after the initial shock of a disaster, hospitals could be flooded with a second and third wave of patients whose need for care is related only tangentially to the inciting event, McFarlane said. Building relationships with other health providers in the area ahead of a disaster is key.

“Everybody needs to be on the same page with the most current information, which is very difficult to do in the heat of battle,” McFarlane said.

Tips for compliance

The new rule requires that hospitals conduct a full-scale community-based hazard vulnerability assessment. But it does not specify what constitutes “community”—introducing some flexibility that Huser said seems to be intentional.

“Community can be different depending on where you are, who you are, and what kind of resources are available,” Huser said. He offered a list of practical steps each facility should take to apply the new rule to its own local community:

1. Outline the requirements specific to your facility, then conduct a gap analysis. Those currently complying with the Joint Commission standards are likely 90% of the way toward complying with the new CMS rule, Huser said. But the new rule includes several additions and more specific definitions that warrant review.

2. Create a timeline that lists the steps needed to close each gap. Translating a gap analysis into a to-do list, with deadlines, facilitates effective communication with leadership and enables

you to gauge whether you are on track to comply in time, Huser said. “How are we progressing? Here’s where we’re falling behind. Here’s how we need some additional assistance.”

3. Devise a plan of attack and a cost estimate that you can present to leaders. CMS has tables to help you estimate costs of implementation. For hospitals and those required to do full-scale exercises, “that’s going to be a real budget killer for some locations” due to overtime and materials, Huser said. “So prepare your leadership now.”

4. Prepare a budget proposal for the first year of compliance. If your fiscal year is just coming up, start planning it now. For those already well into their fiscal year, start looking for what compliance will cost so you can ask for waivers.

5. Join a healthcare coalition if you are not already participating in one. “You’ll be able to make friends, have resources, talk to people that you may not even know existed previously,” said Huser, who takes part in a central Indiana coalition.

6. Avoid reinventing the wheel whenever possible. Again, that’s where a coalition can come in handy because others have likely faced the same challenges you will face.

7. Determine which approach best suits your needs. Should you work as a system, an individual, or in combination?

8. Review the free resources published by CMS online: www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergprep/index.html

Possible challenges

Figuring out how to prioritize the time and resources needed to adequately prepare for a complex emergency is the biggest obstacle to success, McFarlane said.


http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergprep/index.html






“It’s not that emergency management isn’t really important—it’s just that patient safety is important, and patient throughput is important, and performance improvement is important, and accreditation readiness is important, and all of those other things,” she added.

Other obstacles to preparedness include staff turnover and a “lack of mindfulness,” which she described as a preoccupation with failure. Then there are the nuts and bolts of emergency management. Planners need resources to plan, and they need to ensure that their suppliers will have resources in the event of an emergency.

So hospitals should check to ensure that their suppliers of emergency fuel or bottled water can deliver the goods they promised and meet their other emergency contracts, McFarlane said. If one supplier promises two nearby hospitals the same shipment

of supplies, then a disaster affects both hospitals, that’s a problem.

“The other thing that I have found is uncooperative local authorities,” she said.

Local government leaders or even hospital bosses have their own priorities, and those can inhibit emergency preparedness, especially for less-likely emergency scenarios. You will not have the authority to implement all the changes or training you think you need, so your job is to explain why devoting resources now into planning for unlikely future emergencies is a worthwhile investment, McFarlane said. One way to make the case, she added, is to talk about planning in terms of “business continuity.”

“That is how you can sell this,” McFarlane said. “You can get back to regular business if you do the right planning ahead of time.” H

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If history is bound to repeat itself, then the newly elected Trump administration will undoubtedly face a disease outbreak at a level similar to that of its predecessors.

The only two questions that public health officials have are: How bad will it be, and how prepared is the country for the next pandemic?

For Anthony Fauci, director of the National Insti-tute of Allergy and Infectious Diseases—who has advised five different presidents on issues pertaining to infectious disease outbreaks and testified before congressional committees approximately 250 times—the looming threat of a major disease outbreak is almost a certainty.

“History tells us we will definitely get surprised in the next few years,” he said during a keynote address at “Pandemic Preparedness in the Next Administration,” a discussion hosted by the Center for Global Health Science and Security at George-town University Medical Center, in partnership with the Harvard Global Health Institute.

In a Health Affairs article published after the conference, Fauci reviewed the outbreaks that occurred under each of the last five presidents, dating back to the beginning of the HIV/AIDS epidemic under President Ronald Reagan to the modern-day concerns tied to Ebola and Zika under President Obama.

“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance,” he wrote. “We have learned from the past decades that it is important to have strong global surveillance sys-tems; transparency and honest communication with the public; strong public health and healthcare infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid develop-ment of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund.”

Other global health experts echoed his predictions and added their own concerns.

“It’s quite reasonable we’ll see a large-scale pan-demic in our lifetime,” said Rebecca Katz, co-direc-tor of the Center for Global Health Science and Security at Georgetown University Medical Center, during the event, underscoring the progress made at the local level to strengthen preparedness and integrate data to improve decision-making.

But Ashish Jha, MD, MPH, director of the Har-vard Global Health Institute and K.T. Li professor of health policy at the Harvard T.H. Chan School of Public Health, argued that as a country, the U.S. is

Preparing for the next pandemic: Key issues facing the next administrationExperts stress importance of community preparedness, funding, and support from the new administration

HEALTHCARE SECURITY ALERT


http://ghss.georgetown.edu/

http://ghss.georgetown.edu/

https://gumc.georgetown.edu/

https://gumc.georgetown.edu/

http://globalhealth.harvard.edu/





still largely unprepared for an infectious outbreak, even after recent scares associated with Zika and Ebola.

“I would argue—still today—in many ways we are not ready for the next big pandemic, which is going to come at some point,” Jha said during opening remarks. “So, the question is how do we get ready? How do we help our government play a more efficient role in preparing the American public and the globe in preventing the next big pandemic?”

For many, the answer boils down to the approach initiated by the country’s incoming administration, the funding mechanisms associated with pandemic response and—perhaps more importantly—the efforts initiated at the community level.

The new administration’s perspective

As with any transition between presidential admin-istrations, there are bound to be some policy changes that can trickle down to the public health sector and impact preparedness efforts.

But several former high level public health officials have expressed concern about President Donald Trump’s foreign policy stance, particularly his isolationist rhetoric that they say doesn’t bode well for global health initiatives or pandemic prepared-ness in general.

During the Ebola outbreak in 2014, Trump roundly criticized the Obama administration on Twitter for allowing infected clinicians that were treating Ebola patients overseas to return to the U.S. for treatment. Trump called President Obama a “psycho” and “incompetent” for not stopping incoming flights from West Africa.

“The U.S. cannot allow EBOLA infected people back. People that go to faraway places to help out are great—but must suffer the consequences!” Trump tweeted.

Experts say this perspective does not align with the response necessary to combat a large-scale pandemic.

“The idea that somehow the United States can cut itself off from the rest of the world; that we can build a wall—physically or metaphorically—high enough to keep out pathogens, to keep out disease, to protect the American people from disease, and that would make the world a safer place, is so badly misguided,” said Ronald Klain, the former Ebola response coordinator for the Obama Administra-tion at the Georgetown conference.

“There is no isolationist policy that will protect us from disease,” he added.

Former CDC director Tom Frieden, MD, has also highlighted the importance of preparing for a disease outbreak, telling the Washington Post that his biggest fear has always been an influenza pan-demic. He added that making the necessary invest-ments in global health and pandemic preparedness is a long-held presidential tradition.

“The Bush administration made important invest-ments in public health, global public health, and in influenza preparedness, and in the Obama adminis-tration, we have built on those,” he said. “It’s a baton that gets passed. Preparedness is really important.”

Global policies have significant sway when it comes to addressing pandemic preparedness on a broader level. In a recent study published in The BMJ, researchers found a “remarkable consensus” regard-ing what went wrong during the Ebola response, but very little has been done to close those gaps.

“Ebola, and more recently Zika and Yellow Fever, have demonstrated that we do not yet have a reliable or robust global system for preventing, detecting, and responding to disease outbreaks,” the authors wrote.




Almost unanimously, researchers and public health officials have also called for lawmakers to change the way the government funds pandemic response efforts. The government can pull from an emer-gency fund when a devastating natural disaster hits, but no such fund exists for a disease outbreak. This issue was brought to public light during the Zika outbreak last summer, when Congress ultimately agreed to release $1.1 billion in funding after a significant delay.

“We all know that’s a terrible way to do business and that does not leave us in a very safe place,” said Amy Pope, the former deputy homeland security advisor and deputy assistant to the president on the National Security Council during a panel discussion.

GAO outlines federal preparedness gaps

Two recent reports released by the Government Accountability Office (GAO) have addressed gaps in federal pandemic preparedness activities.

The first (www.gao.gov/assets/690/681962.pdf), released in January, addressed federal personnel reassignment and called for improved coordination between federal agencies tasked with authorizing that reassignment during emergencies. The Pan-demic and All-Hazards Preparedness Reauthoriza-tion Act of 2013 (PAHPRA), authorizes the Department of Health and Human Services (HHS) to reassign personnel in all states, but officials at HHS were “generally unaware of the reassignment authority.” Officials at the Office of the Assistant Secretary for Preparedness and Response (ASPR) told GAO that they did not conduct targeted outreach to HHS agencies to inform them of the reassignment process or requirements.

The GAO recommended that ASPR conduct outreach to HHS agencies, including expected time frames for approving reassignment requests, and

develop a plan to evaluate after-action reports from states.

“Conducting outreach to HHS agencies and offices on ASPR’s reassignment requests, review processes, and time frames would be consistent with federal internal control standards for information and communication, and would improve HHS agencies’ and offices’ awareness of expected roles, thereby preventing potential delays in decision making in the event of a public health emergency,” the GAO wrote.

The second report (www.gao.gov/products/GAO-17-150), published in February, addressed existing coordination mechanisms between the Department of Defense (DOD), HHS, and the Department of Homeland Security (DHS). The GAO determined that HHS and DHS “have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-con-strained environment in which capabilities like those provided by DOD are limited.”

The agency noted that each agency has mechanisms in place to respond to a pandemic, but all three could improve coordination efforts with one another when resources are limited, particularly as HHS and DHS are updating existing plans.

Community coalitions are the future

Although hospitals, public health officials, and emergency preparedness experts can draw on lessons learned from previous outbreaks like Ebola, Zika, and H1N1, the fact that no two diseases are alike makes it difficult to plan for the next pan-demic. It’s hard to know how to respond when no one knows what the disease will do and how it will travel between populations.

“There’s no playbook that fits the emerging infec-tious disease outbreak,” Pope said.






She and Jha highlighted the efforts of community coalitions, which have emerged as a critical emer-gency preparedness approach over the last several years. Those coalitions have made a noticeable impact during disasters such as the Boston Mara-thon bombing, the train derailment in Philadelphia, and the Orlando nightclub shooting.

“That’s the model for the future,” she said. “Using this vast healthcare system, that is in some cases very well-funded, and figuring out how to tap into those resources so we’re not using one individual local hospital to be our barrier against whatever is coming next in the U.S.”

The ASPR has repeatedly highlighted the benefits of community coalitions when responding to disasters of any kind.

That kind of community planning will be particu-larly beneficial for hospitals creating pandemic response plans that can adequately handle a poten-tial surge of infected patients, Klain said.

“We don’t need 20 hospitals in Houston to be ready to deal with Ebola or infectious disease, but we do need one,” he said. “Figuring out what that one hospital is, how well it’s prepared, how people are drilling, and how people are funneled throughout the community are important things.”


Which states are the most prepared for a pandemic?

A recent report from Trust for America’s Health (TFAH) found

that state preparedness for diseases, disasters, and bioterror-

ism varies widely across the country. As a whole, however,

states are “often caught off guard when a new threat arises,”

such as Zika or Ebola.

Twenty-six states and Washington D.C. scored a six or lower

on 10 indicators of public health preparedness, according to

the report. In a press call announcing the report, Rich Ham-

burg, interim president and CEO at TFAH, described an incon-

sistent approach to emergency response in which state

governments are forced to quickly respond to an incident, but

then just as quickly move on once the event is over.

“We aren’t adequately maintaining a strong and steady defense

and the result is we consistently see health emergencies dis-

rupting, derailing and diverting resources from other ongoing

priorities and efforts from across government, in addition to

leaving Americans at unnecessary risk,” he said.

Hamburg also noted that states have faced heavy funding cuts

over the past 15 years, from $940 million in fiscal year (FY)

2002 to $660 million in FY 2016. This, coupled with a lack of

biosurveillance and insufficient research and development for

new vaccines, has left some states woefully underprepared.

Among the recommendations issued by TFAH was the need

for more involvement from federal leadership—including the

White House—a more stable source of funding, emphasizing

local coalitions and prioritizing vaccination among children

and adults.

The most-prepared states:

• Massachusetts

• Washington

• North Carolina

• California

• Connecticut

The least prepared states:

• Alaska

• Idaho

• Iowa

• New Jersey

• Tennessee

• Virginia

• Nevada

• Wyoming





Planning for a pandemic

Prepandemic/interpandemic period

During the prepandemic/interpandemic period, do the following:

• Confirm that you have adequate, current personal disability insurance

• Acquaint yourself with current clinical information regarding the recognition, treatment, and preven-tion of transmission of influenza

• Educate all staff members about pandemic influenza

• Ensure that your family will be looked after in a pandemic so that you can continue to work

• Provide an annual influenza vaccination to all office staff members each fall

• Provide an annual influenza vaccination to all eligible patients each fall

• Provide one dose of polysaccharide pneumococcal vaccine to all eligible patients (those over age 65 and those with chronic health problems)

• Provide a conjugate pneumococcal vaccine series to infants

Prepandemic/pandemic period

During the prepandemic/pandemic period, do the following:• Reinforce good hygiene practices among staff members and patients

• Post signs advising patients to check in with reception upon arrival

• Separate the reception staff from patients with Plexiglas, or ensure a distance of at least 3 feet be-tween reception and patients

• Post cough/sneeze etiquette stations in the waiting area

• Provide liquid soap and paper towels in patient washrooms and at staff sinks

• Provide the staff with small bottles of alcohol-based hand sanitizer

• Monitor staff illness and make sure staff members with influenza-like illness remain off work

• Develop a contingency plan to address staff shortages; consider the use of volunteers

Pandemic period

During the pandemic period, do the following:• Ensure enhanced hygiene practices and social distancing to prevent the spread of pandemic influenza.

• Assign a staff member to coordinate pandemic planning and to monitor public health advisories.

• Maintain copies of pandemic educational material and “self-care guides” for patients. These are avail-able from the Centers for Disease Control and Prevention (CDC).

• Telephone-triage all patient requests for visits.






• Postpone all nonessential visits, such as routine checkups.

• If possible, schedule all patients with influenza-like illness during designated time slots.

• If possible, provide a separate entrance and waiting area for patients with influenza-like illness, or separate patients with influenza-like illness by 3 feet from others in the waiting room.

• Remove all magazines, books, and toys from the waiting area.

• Eliminate or decrease the use of shared items by patients, such as pens, clipboards, and phones.

• Minimize the amount of time spent in the waiting room by patients with influenza-like illness.

• If possible, designate one exam room for all patients with influenza-like illness.

• Assign a staff member who has recovered from pandemic influenza to care for patients with influenza-like illness.

• Plan for the disposition of all patients with influenza-like illness:

• Home with “self-care guide” (preprinted guidelines are available from the CDC)

• Home with home care (know of services that are available prior to an outbreak)

• Referral to alternate care site (keep aware of what sites are available on an ongoing basis)

• Clean waiting areas, exam rooms used by patients with influenza-like illness, and frequently touched surfaces, such as doorknobs, at least twice daily and when visibly soiled.

• Ensure that cleaners are active against viruses. Avoid vacuuming and dry dusting; “damp” dust only.

• Maintain at least one week’s supply of soap, paper towels, hand sanitizer, cleaning supplies, and surgical masks ahead of an outbreak.

CDC’s pandemic scale

Interpandemic phaseNew virus in animals, no human cases

Low risk of human cases 1

Higher risk of human cases 2

Pandemic alertNew virus causes human cases

No or very limited human-to-human transmission 3

Evidence of increased human-to-human transmission 4

Evidence of significant human-to-human transmission 5

Pandemic Efficient and sustained human-to-human transmission 6

Source: Adapted from the Infection Control Manual for the Physicians Office, HCPro.

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