Disaster planning exercises prepare ASCs to care for patients and assist communities

Ambulatory surgery centers (ASCs) are taking a new look at the question of disaster response. Staff are not always informed about what emergencies might occur, or what they should do in response to the most likely scenarios.

Likewise, many local emergency management agencies are not even aware of the ASCs in their midst, much less able to understand the types of aid and service those ASCs could provide in a disaster.

Even if disaster never strikes—an unwise bet given recent history—updated conditions for coverage mandate having a plan for emergency response.

Noncompliance with CFR 416.41(c): Disaster Preparedness Plan, has increasingly caught the attention of surveyors. In fact, the Arizona Department of Health Services reported noncompliance was one of the top 10 deficiencies in that state in the period July 2011 to June 2012.

The Centers for Medicare & Medicaid Services (CMS) includes this three-part standard in its survey guidance:

The ASC must maintain a written disaster preparedness plan that provides for the emergency care of patients, staff, and others in the facility in the event of fire, natural disaster, functional failure of equipment, or other unexpected events or circumstances that are likely to threaten the health and safety of those in the ASC.
The ASC coordinates the plan with state and local authorities, as appropriate.
The ASC conducts drills, at least annually, to test the plan’s effectiveness. The ASC must complete a written evaluation of each drill and promptly implement any corrections to the plan.

Despite heroic efforts seen at some ASCs in the face of actual disasters—from generator failures to tornadoes to physical attacks—industry veterans and consultants report that ASCs as a group are less likely to have formal response plans than their hospital and long-term care counterparts.

“They’re not very prepared,” concludes William Moorhead, JD, president of All Clear Emergency Management Group in Raleigh, North Carolina. He advises his ASC clients to begin the process by listing their vulnerabilities.

“List the hazards, and then ask how they could affect you,” Moorhead says. “For example, a wildfire nearby means exposure to smoke. So ask why each hazard is a concern.”

Think beyond public disasters like weather, terrorism, and disease outbreaks, counsels Laurie Roderiques, RN, CASC, LNC, with Healthcare Consulting Specialists in Merrimack, New Hampshire. For an ASC, local emergencies could include cardiac and respiratory events, malignant hyperthermia, toxic exposure, and power failure.

William Moorhead, JD

Laurie Roderiques, RN, CASC, LNC

Moorhead, who advises churches, schools, and other organizations as well as healthcare facilities, says preparedness involves more than having an action plan for the moment disaster strikes. Rather, he says, there is a cycle, with stages that overlap: mitigation, preparedness, response, and recovery.

Mitigation includes risk assessment and prevention efforts. For example, if there is vulnerability to floods, avoid storing supplies on floors or in basements where water could rise. Then, even while protecting people during a flood, begin taking steps to recover and resume operations.

First prepare the ASC, Moorhead says, then look outward to the community, starting with other healthcare facilities that might have resources to share. For example, if surgery is in progress and medical gases are lost, where is the nearest facility that could help? If patients must be relocated, where will they go?

After determining the nature and extent of risks, obtain state and local emergency planning regulations, and identify local emergency managers who will be contact persons for coordination efforts. Ask suppliers how they would respond to distribution interruptions or the need for additional supplies in a crisis.

Become familiar with the building construction and life safety systems. Review the organization chart, and assign responsibilities and communication networks among staff.

It’s important to build in redundancy so that more than one manager is prepared to step in during a crisis. Make sure two or three people are trained in various skills—such as operating the generator—to avoid gaps in case of loss of any personnel.

One ASC manager notes that during a wildfire, the facility was not damaged but several employees lost their homes and needed some time off from work. “Know where your staff live and their circumstances,” she says.

CMS also publishes on its website a detailed checklist for healthcare facilities to help assess risk, design a plan, and conduct drills (www.CMS.gov). States and counties are responsible for disaster plans, and state organizations can be helpful in clarifying rules and identifying resources.

The Colorado Ambulatory Surgery Center Association (CASCA) has published a detailed checklist with websites and telephone numbers. Its main provisions, however, apply to any ASC.

Among the things to consider:

vulnerabilities and threats—physical hazards as well as the business impact of various events
capabilities and resources—staff skills, such as multiple languages or experience with previous disasters; vendors and distributors; and insurance providers who can assist in resuming operations quickly
evacuation routes and assembly locations
emergency response roles for staff and appointment of an emergency coordinator
regular review and updates of emergency contact lists for all staff and physicians, police, and fire responders
support for employees affected by a crisis, such as counseling, child care, and flexible work hours
business resumption strategy, such as an alternative location, adequacy of insurance, and list of critical equipment
staff training and emergency drills
protection of technology and business data, including secure backup of medical records
emergency communication devices such as cell phones or radios.

A facility’s governing board should approve the emergency plan annually and whenever changes are made, and the approval should be documented. Just as critical, according to Roderiques, is to actually follow the plan: “Remember to always follow your organization’s written policies and procedures regarding emergency preparedness,” she says.

Instructions should be specific. One ASC that Roderiques worked with developed the following response to a fire alarm:

“If there is a fire alarm in the building, patients in the ASC will be moved to one of the safe compartment areas in either the prep area or the recovery area. Protect in place until the Fire Department issues the order to evacuate the third floor. No new procedures should begin, nor should more patients be prepped, until the alarm has been cleared.”

Another ASC includes this instruction for evacuation:

“In the event of evacuation, designated meeting places are on the north and south side of the building, depending on the location of the emergency and the best stairwell to use for evacuation. On the north side of the building, the meeting place is behind the mailbox in the Social Security office parking lot.”

Roderiques recommends developing standard codes to communicate emergency situations to staff and response personnel. An example would be:

Amber—missing patient or other person
Red—fire
Blue—cardiac arrest or other medical emergency
Gray—violent or combative person
Silver—hostage situation
Black—bomb threat
White—emerging threat, information to follow.

The final plan should provide a hierarchy of responsibility, with one person (or position) who manages the entire operation and is informed of all events and activities. At the same time, departments at lower levels must share information to coordinate efforts.

Moorhead recommends having an “incident command system” that is often used in larger organizations but could provide a starting point for an ASC to designate lines of responsibility and communication. A single emergency management officer, the “incident commander,” has overall responsibility for four main sections: operations, planning, logistics, and finance/administration.

For example, the planning section looks ahead and could include documentation, resources, and technical specialists. Logistics might have two subdivisions, for support (supplies and facilities) and services (medical, food supply, and communications). Administration would cover financial areas such as tracking hours worked, compensation, and procurement.

The incident commander would see that the various sections communicated their progress and requirements. For example, the operations group would manage patient care. The planning group would monitor operations and determine what medical supplies would be needed. Logistics would manage how they would be ordered and delivered, and finance/administration would see that the supplies are paid for.

To accomplish this, each section would have to know what the others were doing. Although ASCs normally have systems in place to share responsibilities, in a crisis, it is easy for communications to break down.

A tabletop drill is the first step in designing a live exercise. Participants set objectives for what will be tested, and then they create an emergency scenario—approaching wildfires, for example. They discuss likely hazards, such as smoke interfering with HVAC systems and staff shortages if employee dwellings are affected. Using the plan, they list procedures they will follow.

Later, participants review the written procedures and decide if improvements are needed.

In June 2015, The Surgery Center at Lutheran in Wheat Ridge, Colorado, conducted a tabletop exercise with Moorhead and 10 visiting healthcare professionals in the local area to test its emergency plan.

Doing the drill showed people that it was neither as complicated nor as time-consuming as expected, Moorhead says.

In addition to periodic discussions about emergency procedures, ASCs should stage physical drills at least quarterly, according to Roderiques.

One way to approach a drill is to focus on a small section of the plan, such as fire evacuation or setting up an isolation area. Fire departments can help organize drills.

Drills should be unannounced to all but the administrator or medical director, who then should direct the response.

Roderiques notes that ASC staff must be adaptable to different roles, yet no one should overstep their skill levels; patient care should be left to nurses, for example.

“This sounds logical,” she says, “but in a crisis, not everybody thinks level-headedly. The purpose of the drill is to make reactions second nature, so people don’t panic.”

Don’t just discuss responses, she adds, but go through the physical motions, such as evacuation of the building and meeting in assigned locations.

Finally, document and evaluate the activities, and develop ways to improve.

With a well-tested plan in place, it is time to reach out to the community. Roderiques notes that the CMS guidance mentions coordination with state and local agencies “as appropriate,” which is open to interpretation.

She recalls that, while serving as director of an ASC in New Hampshire, she contacted the local fire chief to offer help in case of emergency. The chief, who was also the town’s emergency manager, replied in a letter that the community plan “does not require the use of your facility or your staff’s participation.”

Although the town turned down her offer, Roderiques says the effort was worthwhile, because the letter documents the ASC’s compliance with the CMS standard.

The fire chief’s reaction, whatever its basis, is not unusual. Many observers, including clinicians and disaster response personnel, say ASCs are among the least prepared and least likely to be considered as resources. “In practical application during a large-scale event, it is frustrating,” Moorhead admits.

In some states, however, a new way is emerging by which ASCs can begin to participate with community and hospital responders. Thanks to federal grants, states are forming healthcare coalitions aimed at gathering and allocating emergency resources.

One state that has been active in that movement is Colorado. The state’s Department of Public Health and Environment (CDPHE) in 2010 issued a memorandum of understanding to establish a healthcare coalition. As usual, it addresses only hospitals, citing “a voluntary agreement among Colorado hospitals.”

CASCA executive director Christopher Skagen, JD, has been attending coalition meetings for the past 5 years, making the case that ASCs should participate. “ASCs have an identity problem with the public and other healthcare providers,” he notes. Yet even though they are smaller than hospitals, ASCs can provide clinicians, a sterile environment, and surgical supplies that may be scarce in a major emergency. “An ASC can be another tool in the toolbox,” he says.

Christopher Skagan, JD

Christopher Skagan, JD

In states with less-organized coalitions, ASCs need to take the initiative, he says. “They need to show up, and make other respondents aware of their existence and capabilities.”

Working closely with Skagen is Lyle Moore Jr, MPH, the resiliency officer at CDPHE, who helps to rebuild communities following disasters and shows them how to respond more effectively to future disasters. Moore says he is trying to include ambulatory, long-term care, and mental health providers in the coalition.

“If a hospital is inundated, they can turn to other hospitals, but they could also turn to different health providers,” he says. “We want that whole community together.”

For ASCs that want to participate, he advises contacting the public health department, rather than local fire or police officials. Health department officials will know who the emergency manager is, and they can help the ASC contact any healthcare coalitions in the area.

Then, he says, work with local—city or county—responders to coordinate plans. “All emergencies are local, at first,” he notes. ✥

References
Centers for Medicare & Medicaid Services. Emergency preparedness checklist recommended tool for effective health care facility planning. www.cms.gov.

Centers for Medicare & Medicaid Services. State operations manual appendix L— Guidance for surveyors: Ambulatory surgical centers. www.cms.gov.

Moorhead W. Emergency management for ambulatory surgical centers. 2015 CASCA Conference.

Roderiques L. Emergency preparedness in the ASC. 2015 ASCA Conference.