|Arthur R. Bartosch, BS, CBET|
On a crisp autumn day last October, Westchester Medical Center in Valhalla, NY, was bracing for a full-blown pandemic influenza catastrophe. Physicians and nurses scrambled to ready beds, while biomeds rushed to set up enough portable blood pressure machines and ventilators in a makeshift triage area to await a steady stream of patients that could top 200% of the hospital’s usual emergency capacity.
But the patients never arrived. Fortunately, the scenario, one all too believable, was simply a preplanned, mock exercise—a “what if” picture designed to shore up the hospital’s emergency response and test interdepartmental collaboration in the event of an area-wide H1N1 epidemic or similar emergency.
Developing and executing coordinated emergency response plans to unexpected events, such as an influenza pandemic, is the responsibility of every hospital, and, increasingly, that of biomedical/clinical engineering departments as well. A biomedical/clinical engineering department’s unique knowledge of equipment and inventory can help hospitals fine-tune response plans, meet new emergency management standards, and promote greater cooperation among departments.
“Planning on paper is a strategy; actual implementation is a reactive measure,” says Arthur R. Bartosch, BS, CBET, director for biomedical engineering services at Westchester Medical Center. “But it’s when you perform that reactive measure that you realize where your strengths and weaknesses are.”
Preparing for the Worst
Readying hospitals for emergencies is certainly nothing new. The Joint Commission (TJC) has been evaluating emergency response in regard to its emergency standards since at least 2000. In the aftermath of Hurricane Katrina, which tested the limits of hospitals’ emergency-preparedness and disaster-readiness plans, TJC is now making hospitals everywhere take a fresh look at their own plans. In 2008, the agency completely rewrote its expectations for emergency management. In 2009, these emergency standards became a stand-alone chapter in the TJC accreditation manual.
The Emergency Management standards include six critical areas health care facilities should take into account when drafting emergency plans: communications, resources and assets, safety and security, staff responsibilities, utilities, and patient and clinical support activities.
The new resources and assets standards are likely to spark the most interest among clinical/biomedical engineers. Among other things, the category concerns the new regulations requiring every hospital to be able to maintain self-sufficiency in all areas, including equipment maintenance, for up to 96 hours in the event of an emergency.
“When Katrina happened, there were hospitals that were essentially an island unto themselves for at least 96 hours,” says George Mills, senior engineer for the standards interpretation group at TJC. “The 96 hours came from the fact that FEMA needs 72 hours to respond to an event and 24 hours before they can set up to assist. So, from a clinical equipment point of view, if you have equipment fail, you’re not going to be able to get equipment shipped in until then.”
Part of planning for such a resource-stretching undertaking involves referencing a list already familiar to biomeds: the hospital’s equipment inventory. According to Mills, biomedical/clinical engineering departments should have a very robust inventory of where equipment is located in the organization, so that “if they need to move equipment from one area to another as a backup strategy, they know how to make that happen.”
If self-sufficiency plans prove untenable during the emergency, hospitals must also have a detailed plan for evacuation that should include provisions on how to best move critical care equipment during the evacuation. “Maybe the strategy will be that when I’m taking patients from the upper floors and bringing them down to the loading dock, I’m throwing a C-arm and some other movable equipment in the elevator and bringing it up to the upper floor and offloading it up into the unit,” Mills says. “It’s going to take manpower, and it’s going to take knowing where this equipment is to do this quickly and effectively. You want to be able to safeguard those assets.”
The proper response to situations such as these will likely vary in every hospital, but Mills contends that a hospital’s consideration of these situations is a necessary part of preparing for the worst. “If organizations preassess the potential risks, then they can anticipate resolution,” he says. “If the event does actually occur, then they can implement the resolution strategy quicker and restore patient service faster.”
Mills also suggests keeping an intradepartmental equipment management strategy in place for quickly putting backup equipment into use in case of failure. Beyond being a good idea, equipment backup plans are also mandated by TJC’s Environment of Care (EC) standard EC.02.04.01, EP 6, which states: “The hospital has written procedures to follow when medical equipment fails, including using emergency clinical interventions and backup equipment.”
At Westchester Medical, Bartosch not only adheres to these standards, he does one better—using equipment to help guard against any eventuality. The hospital stores backup ventilators for New York State right on the premises, and Bartosch keeps a cache of assorted backup equipment on hand just in case. “I don’t sell my old monitoring systems,” he says. “I keep a dozen or two dozen fully configured with cables and lead wires, ready to go. If a disaster occurs, I can roll up 10 monitors and put them in a room. No one’s telling me to do that.”
But setting up equipment is just one area biomeds need to be comfortable with in the event their hospital finds itself overwhelmed in the face of catastrophe, and Mills stresses the interplay of all six TJC emergency themes. For example, nurse call systems, he says, likely fall under biomeds’ discretion, but they are also a vital link in intrahospital communication systems, and if down in an emergency, they can significantly affect response times when they are most valuable. Other focus areas in the standards also require biomed input and cooperation, such as safety and security, which could refer to maintaining clean, operable equipment while in use during an emergency.
As might be expected, learning how to connect with other departments in an emergency, from IT to nursing, requires a certain amount of hospitalwide liaising before disaster strikes. A special emergency task force often writes preparation plans for the hospital, and for biomeds, reserving a seat at this table should be a top priority, as operations managers do not always solicit input. “It’s not an intentional thing,” Mills says. “They just don’t think about it.”
Since biomeds can provide crucial contributions to emergency plans in regards to inventory, equipment reliability, backup, and keeping equipment serviceable during and after the event, they should not be afraid to directly approach coordinators with suggestions or ideas. “I would sit down and share some concerns with them and ask how I can get actively involved with the operations plan and kind of elbow my way into that team,” Mills says.
Good communication with plan coordinators will also help biomeds learn exactly what their hospitals’ expectations for them are. In an emergency, that could even mean stepping outside of a biomed’s day-to-day duties to do what needs to be done. “In any sort of disaster or emergency, it’s all hands on deck,” Bartosch says, who in the past year alone has experienced a loss of water emergency, a compressed air emergency, and a flooded neonatal unit at his hospital. “We need to be flexible in our roles.”
According to Mills, some caution and preplanning should be put into preparing for the unexpected. “We never expect biomeds to go outside of their skill sets,” he says, and cautions that biomeds who step too far out of their traditional duties, even in an emergency, risk introducing new risks and variables into the operating procedures. “You want to make sure you’re not expecting a level 1 tech to be repairing radiology equipment, or something outside of his or her skill sets,” he explains. “It’s an emergency, but we still have to have protocols.” The advice may seem overly pragmatic or idealistic, but Mills understands that emergencies cannot all be paint-by-numbers jobs. “With that being said, you do what you need to do within your skill set to get things done.”
Drilling it In
As a way to test the implementation of on-paper procedures, TJC standards also require facilities to perform at least two emergency exercises per year. Here, too, Mills sees opportunities for biomeds to challenge their level of preparedness by suggesting that exercise coordinators broaden the scope of the event. “Let’s say the exercise is going to be a school bus accident where the emergency department (ED) is going to have to accommodate 60 people, when the ED can typically only accommodate 12,” he says. “But let’s also throw into that mix some equipment that’s going to fail in the ED, and see how quickly it’s going to take to respond to that failed equipment. I think it could be very eye-opening to the organization.”
Exercises also provide hospitals with an opportunity to evaluate their performance and make improvements. After the pandemic flu drill at Westchester Medical Center, hospital staff involved in the exercise held a powwow to discuss what worked and what changes could be made for the future. “There were a couple things, like finding outlets for the equipment and running phone lines to the right places, that until we actually put the physical structures in place, we didn’t think about,” says Garret Doering, the hospital’s director of emergency management. “But the end result—by the time we straightened out some of the unforeseen difficulties—was that we were very confident that we did what we wanted to do.”
Through proper communication, a careful review of relevant standards, and a solid knowledge of equipment inventory, biomeds can help ready their hospitals for any eventuality. On one point both Mills and Bartosch echo similar advice: Biomeds must be proactive in their approach. “No biomed department should be waiting for someone to be coming to tell you how to be preparing for an emergency,” Bartosch says. “You are the keepers of the inventory, you are intimate with the instrumentation, and you need to know your backup plan.”
Stephen Noonoo is the associate editor of 24×7. Contact him at .