Sunday night's explosion at a power plant in Middletown, CT, brought with it hospital disaster response repercussions.
The explosion—believed to have been caused by some sort of natural gas leak or purge—occurred at the Kleen Energy Plant, which was under construction at the time and not operating, according to office of Middletown Mayor Sebastian N. Giuliano. Contractors were conducting various tests at the site when the explosion rocked the area.
Middlesex Hospital, a 275-bed community hospital in Middletown, was quickly put on alert about a potential mass casualty event, says Jim Hite, the facility's emergency planner and director of safety and security.
The medical center uses the Hospital Incident Command System, more commonly known as HICS (pronounced "hicks"). HICS is a popular incident management setup that uses a series of job action sheets to define staff roles during an emergency response. The job action sheets list specific duties for staff members to observe.
"We all have our established functions and our job action worksheets," says Peg Arico, Middlesex Hospital's manager of public relations and communications. By teaching clinician and support workers the structure of HICS, they have the ability to use it for any type of incident response, Hite says. "Staff training really paid off," he says regarding the success of response efforts.
During off-shifts and weekends, the nursing supervisor on duty at Middlesex Hospital is the designated incident commander. That approach was important because the plant explosion occurred on a Sunday morning during Super Bowl weekend, when many top administrators weren't at the hospital.
While the facility's e-mail and phone alert system reached out to off-duty managers and staff, the nursing supervisor huddled with other nurses, security officers, and hospitalists to plot out immediate actions in response to the explosion, Hite says. For example:
Hospitalists began determining which patients could be rapidly discharged in order to free up beds
OR staff began preparing the post-anesthesia care unit to open up beds
Security officers were posted at every hospital entrance in anticipation that concerned visitors and reporters would congregate at the facility seeking information about victims
In the end, the hospital treated about two dozen people from the explosion scene, but initial projections indicated 60 to 100 potential victims. It also wasn't immediately clear what caused the explosion.
"At the time, we didn't know if there were chemicals involved," Hite says. Although a field morgue was set up at the power plant, Hite knew the hospital might be asked to store corpses. The facility's morgue capacity is 10 bodies, but the building has a utility hookup that allows refrigerated trucks to connect to hospital systems at the loading dock.
Had it been needed, the hospital could have had a refrigerated trailer at the hospital within a couple of hours to handle overflow cadavers, Hite says. As it turned out, there were five deaths in the explosion.
Another useful arrangement that Hite mentioned: The hospital's EMS manager kept tabs on what was happening in at the power plant from a paramedic on the scene. The EMS manager, in turn, acted as the liaison between the hospital's emergency operations center and the response scene, without the need to interact with busy police and fire officials, Hite said.
The settlement of a lawsuit stemming from a patient's death in the aftermath of Hurricane Katrina has left more questions than answers for now, particularly given that similar cases are on the horizon.
Though emergency management was a focal point in the case—in particular, the fact a fuel pump was flooded over during Katrina, which stopped a generator from running—the bigger concern is one of assets, said Anna Grizzle, an attorney at Bass, Berry, & Sims PLC in Nashville.
"Katrina represents an example, for hospitals, of the constant struggle to allocate resources," said Grizzle, who represents healthcare companies in operational and compliance matters.
The settlement between the family of deceased patient Althea LaCoste and Pendleton Methodist Hospital, LLC, in New Orleans came last week in the midst of a jury trial, according to The Times-Picayune newspaper.
To what extent do you plan?
Because of the settlement, a matter yet to be resolved is how much a hospital must invest in preparing for nearly inconceivable disaster scenarios.
The Joint Commission's emergency management standards require hospital planners to identify and rank potential disasters that could affect the facility, and then take actions to mitigate those risks that have the greatest likelihood of either occurring or affecting hospital operations.
"[New Orleans] being below sea level, a hurricane is a possibility and flooding is a possibility," Grizzle said. "I don't think anyone knew the levies would break or that the entire city of New Orleans would be flooded. I don't think that would have ranked very high in possibility for any disaster analysis."
Previously filed court records indicated the family believed LaCoste died following Katrina because the hospital allegedly failed to design its emergency power infrastructure to withstand flood waters and allegedly failed to have an adequate plan in place to transfer patients.
Pendleton Methodist suffered terrible damage from flood waters and never reopened. LaCoste required a mechanical ventilator when she was admitted to Pendleton Methodist on August 28, 2005. During Katrina's rising waters, the hospital lost regular and emergency generator power, which caused various pieces of medical equipment to shut down, according to court records.
The hospital had two generators: one near the ground floor and one on the roof of the building. LaCoste's family argued that if the hospital had invested in a $10,000 submersible fuel pump, the roof generator might have kept operating, according to a The Times-Picayune.
Hospital lawyers said the facility was not negligent and that the emergency power system met or exceeded electrical codes, The Times-Picayune reported.
General negligence awards aren't capped
In an earlier ruling before the trial started, the Louisiana Supreme Court rejected an attempt by Pendleton Methodist to limit the potential award to $500,000, which is Louisiana's cap for medical negligence, Grizzle said.
The state has no cap for general negligence, which the LaCoste case was tried under.
"The court is saying, at least here, that more should have been done" by the hospital, Grizzle said of the earlier Supreme Court ruling.
Whether other jurisdictions in the country look to this ruling for guidance or let it remain as part of the unique circumstances of Katrina will be an important point for hospital CEOs and planners to follow, she added.
It's possible that courts and juries could look at the LaCoste lawsuit and others that are coming and apply them broadly to more common disaster scenarios.
There is a lot of focus on patient safety, emergency management, and other hot-button issues, but needle-related injuries still present significant regulatory risks for hospitals.
For at least the 10th year in row, the latest OSHA statistics show that the agency's bloodborne pathogens standard was the most cited in general acute care hospitals in fiscal year 2009. The standard requires a variety of measures to prevent exposures to blood and other potentially infectious bodily fluids, including steps to avoid needlesticks and an exposure control plan.
Evidence from the ECRI Institute—a respected healthcare research firm in Plymouth Meeting, PA—reinforces the occupational dangers of needle injuries. The firm's list of the 10 most hazardous medical technologies, includes warnings about needlesticks and other sharps injuries.
Among the recommendations from the ECRI Institute is to ensure that staff members don't make assumptions that a needle or other sharp instrument is shielded just because a safety mechanism appears activated.
Under the bloodborne pathogens standard, OSHA requires hospitals to provide engineering and work practice controls to minimize employee exposures to blood. Engineering controls include sharps disposal containers, self-sheathing needles, needleless systems, and other safety needle technologies.
There is a considerable amount of superficial compliance with the bloodborne pathogens standard that can get hospitals into trouble, says Bradford Hammock, a partner with law firm Jackson Lewis LLP, in Reston, VA, where he heads the workplace safety compliance practice group. Hammock, who writes the "OSHA Law Blog," is formerly OSHA's lead counsel for safety standards.
One problem Hammock sees is that some hospital safety professionals just cut-and-paste their required exposure control plans from OSHA's Web site without instead tweaking them to their hospitals' conditions. That shortcut means facilities haven't fully met OSHA's expectations, he says.
OSHA officials have previously told HealthLeaders Media's sister newsletter, Briefings on Hospital Safety, about the risk of using prefilled syringes for injected medication. Although pharmaceutical companies distribute some drugs in such devices to help nurses administer more precise doses to patients, the prefilled syringes at times are less safe than syringes that can be filled and offer safety controls.
Although the earthquake in Haiti has resulted in extreme emergency response situations that may never be repeated in this country, U.S. hospitals can nonetheless take away points that might prompt revisions to their emergency contingency plans.
There are several universal aspects of the quake response to consider:
Communications. It's become mundane to say that communications systems will go down in any emergency, but Haiti's circumstances have strictly reinforced that notion, as there are likely areas of the country with zero modern communication devices operating right now. Although satellite phones are a good option in such cases, that equipment is expensive for American hospitals. Human messengers are a last-ditch effort that U.S. healthcare facilities should build into their emergency operations plans in case communications equipment fails completely.
Morgues. The aftermath of Hurricane Katrina didn't see death tolls approach anything close to the estimated casualties in Haiti. U.S. hospital emergency planners probably can't reasonably design for tens of thousands of deaths after a disaster, but even several hundred deaths in a community would overrun morgues. Furthermore, the idea of burying the dead in mass graves may not be accepted by the American public. If your plans don't already account for large-scale body counts, contact owners of climate-controlled buildings, such as ice rinks and refrigeration warehouses, to find out how they may be able to help with temporary morgue set-ups.
Secondary triage sites. Many healthcare regulators require hospitals to establish alternative care sites if a primary location becomes untenable. Hospitals have suffered extensive damage from natural disasters in the United States, so in ways, Haiti's situation does ring true in terms of healthcare buildings being unavailable for treatment. An excellent disaster drill scenario could involve how caregivers will deal with triage should the main hospital be totally shut down.
The 96-hour period. The Joint Commission mandates that its accredited hospitals identify their capabilities to survive without outside help from the community for up to 96 hours following a disaster. If a hospital determines it couldn't last that long without help, it must establish contingency plans, such as evacuations. The grim scenes in Haiti show what can happen when days go by without outside assistance, so hospitals on U.S. soil should take the opportunity to critically review their 96-hour planning, including security measures that may be necessary to protect property and resources.
Freeing up beds for victims. Patients from Haiti have been air-lifted to hospitals in the United States for treatment. Regardless of whether such casualties come from a foreign country or a domestic disaster, this contingency requires far-flung medical centers to rapidly free up beds. Hospital emergency plans should address the criteria and time frame involved in discharging patients to make room for incoming casualties.
The Joint Commission's focus on Life Safety Code® compliance doesn't look to be subsiding, as evidenced by fire safety provisions topping the latest list of most-cited standards in hospitals.
However, there are some simple strategies CEOs can ask their safety committees or facilities departments to look into that may help hospitals stay in better compliance.
During surveys in the first half of 2009, the top-cited standard was LS.02.01.20 (45% of hospitals receiving citations), according to the November 2009 Joint Commission Perspectives. That standard requires you to properly maintain egress routes.
Although The Joint Commission doesn't specify what concerns under LS.02.01.20 were the most troublesome, one of the likely culprits is corridor clutter, said Steven MacArthur, safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA.
Watch for items obstructing corridors
Corridor exit paths must be free of obstructions, including unattended items that are not considered in use. This issue nags hospitals across the country.
CEOs should find out how often staff members on units are educated about corridor storage rules. Generally, wheeled items can only remain unattended in corridors for up to 30 minutes before surveyors will consider them in storage. There are two notable exceptions:
Crash carts can remain in corridors at all times because they must be available for immediate emergency use.
Isolation carts can stay in corridors outside of active isolation patient rooms at all times (once the room is empty, the cart must be relocated), which is an important provision during the H1N1 swine flu pandemic.
CEOs should also have their safety professionals verify whether fire response plans spell out where to relocate wheeled items when a fire alarm is activated, as corridors may need to be cleared for evacuations or incoming firefighters, said Thomas Salamone, director of environment of care and regulatory compliance at AKF Group, LLC, in Yonkers, NY.
Monitor fire doors improperly held open
In close second place on The Joint Commission's list of top citations is:
LS.02.01.10 (43% of hospitals receiving findings), which requires facilities to design and maintain building features to minimize the effects of smoke and fire.
Many citations under LS.02.01.10 come from a common problem: fire doors that don't properly latch closed, said Claude Baker, CFPS, fire and life safety officer at the University of Chicago Medical Center.
An easy-to-spot snafu occurs when staff members prop open fire doors with wedges or chocks, which defeat the purpose of requiring the doors to self-close or close upon activation of a fire alarm.
CEOs should ask safety committees to identify problem areas where this bad habit crops up and offer refresher education for employees if necessary, Baker said.
CEOs, emergency planners, and facility directors should be monitoring the upcoming results of a trial in New Orleans, which has the potential to alter the way hospitals plan for disasters.
The family of deceased patient Althea LaCoste is suing Pendleton Methodist Hospital, LLC, in New Orleans, saying that LaCoste died in the aftermath of Hurricane Katrina because the facility allegedly failed to design its emergency power infrastructure to withstand flood waters and allegedly failed to have an adequate plan in place to transfer patients, according to prior court documents available online.
The hospital suffered terrible damage from flood waters and never reopened. LaCoste required a mechanical ventilator when she was admitted to Pendleton Methodist on August 28, 2005. During Katrina's rising waters, the hospital lost regular and emergency generator power, which caused various medical equipment to shut down, according to court records.
The hospital had two generators: one near the ground floor and one on the roof of the building. LaCoste's family argues that if the hospital had invested in a $10,000 submersible fuel pump, the roof generator might have kept operating, according to a January 4 article in The Times-Picayune of New Orleans.
Hospital lawyers said in court documents that Katrina's aftermath was unforeseeable, that the facility was not negligent, and that the emergency power system met or exceeded electrical codes, The Times-Picayune reported.
Generally, medical facilities put emergency generators in the basement because it's easier to install and they don't take up valuable, income-earning space on patient care floors.
Any outcry to retroactively move generators to higher floors to avoid flooding is a complicated edict. Such steps involve rewiring entire buildings and changing power distribution networks.
There are other options to protect basement-level equipment, such as installing flood doors to protect a low-lying building's perimeter.
Joint Commission warnings to heed
In September 2006, The Joint Commission published a Sentinel Event Alert that put additional focus on emergency generator performance.
The main messages of the Sentinel Event Alert, which remains in effect today, include the following:
All hospitals must have an emergency power testing program that includes generator load testing and emergency power supply system maintenance
Healthcare facilities should strive to exceed minimum National Fire Protection Association requirements for emergency power
Hospitals must conduct thorough hazard vulnerability analyses of their utility systems
The alert recommends that facilities ensure “engineering staff communicate the capabilities and limitations of the emergency power supply system to the organization's management and clinical leaders.”
A wind storm knocked out power to the hospital that month, which activated a surge protector and generator. But the surge protector only had enough battery power to last two hours.
Additionally, areas of the hospital that provide essential medical services weren't attached to the generator, which the CEO didn't know about. Engineers at the hospital had allegedly assured the CEO in the past that the generator had enough capacity to handle the facility's needs.
There have been other post-disaster critiques that have pointed to infrastructure flaws and incomplete staff member education as potential risks in future emergencies.
For example, following a severe ice storm in December 2008, Heywood Hospital in Gardner, MA, stayed on generator power for 48 hours. Hospital managers noted that some ICU areas had no power to bathrooms or vending machines, yet the Christmas lights remained on, according to HCPro's Briefings on Hospital Safety.
That irony indicated a lack of understanding about which electrical outlets emergency power will supply.
In a development that might be attractive to other hospitals and bargaining units, the California Nurses Association (CNA) has worked pandemic flu preparation into its new labor agreement with Catholic Healthcare West (CHW).
While the agreement doesn't delve into vaccinations—mandatory or otherwise—it covers personal protective equipment and promotes communication between union rank-and-file members and hospital management via a joint task force charged with limiting the spread of seasonal and H1N1 swine flu.
The settlement involves 13,000 registered nurses in 32 CHW facilities in California and Nevada who are represented by CNA and its affiliate, the National Nurses Organizing Committee.
The top three issues the pact aimed to resolve are probably endemic to many hospital's response plans. Sacramento nurse Richard Sandness, RN, one of the CNA members who sat at the bargaining table, pointed to the following pain points the union and health system will be working together to eliminate:
N95 respirator inventories. When a patient with confirmed or suspected H1N1 presents to the hospital, caregivers need to have N95s available per the latest recommendations from the Centers for Disease Control and Prevention. The pact between the CNA and CHW addresses how staff members who need N95s can get them right away.
Exposure notification. Nurses need to know if they're potentially facing H1N1 exposures.
Patient screening and tracking. Patients coming down with—or getting over—H1N1 may show up at the hospital for treatment of other medical issues. Uncovering these cases and tracking them through the hospital is key to controlling flu's spread.
Not just for H1N1 response
The upside of making a union-friendly plan—which can cover other diseases beyond the flu—is that it gets staff members involved more deeply in emergency preparation and response. While management can put together a plan, the union can poll the nurses to make sure they understand it and can execute it.
"It's management's responsibility to provide the proper safety equipment, but on the other end, are we getting it when it runs out in the department? Does everyone know where the proper safety equipment is?" Sandman said. "We're working on it on both sides."
The agreement codifies guidelines CHW had been following, said Jill Dryer, a spokesperson for the health system.
"The agreement covers measures that CHW already has in place, including information and training for direct caregivers as well as the provision of personal protective equipment, including N95 respirator masks and clothing," Dryer said. "We are pleased to now have the CNA's full collaboration in furthering our efforts."
