Emergency preparedness—Is your OR ready?

John E. Eiland

Emergency situations are a constant threat to the everyday challenges faced by US health care facilities. Only recently have these emergency situations included terrorist threats, such as radiation, biological and chemical attacks, bombings, and other major catastrophes. As a result, the importance of emergency preparedness in clinical practice settings has increased.

Perioperative services is a key component of a facility's emergency preparedness plan. The versatility of perioperative areas and the skills of perioperative staff members support many aspects of an emergency response plan. (1) Is your perioperative service ready to respond to a major disaster?

After the terrorists acts of Sept 11, 2001, heath care facilities nationwide reviewed their emergency preparedness plans and updated them as needed. The experiences of the hospitals supporting recent terrorist disaster areas have resulted in facilities enhancing their decontamination units, increasing supplies of medications used to counteract biological and chemical agents, immunizing first responders for smallpox, and strengthening disaster training programs for employees. Although almost three years have passed since the terrorist attacks on the World Trade Center and the Pentagon, health care facilities, including perioperative services, must not become complacent. The threat of an emergency situation is always present.

EMERGENCY PREPAREDNESS PLAN

A facility's emergency preparedness plan should be general but include specific responses to the types of disasters that might occur. All disasters can be categorized as either natural (eg, tornadoes, floods, hurricanes) or man-made (eg, warfare, riots, chemical or biological attacks). An organization's emergency preparedness plan might provide for a variety of natural and man-made disasters based on the facility's location and the likelihood of specific types of disasters occurring there. (2)

JOINT COMMISSION STANDARDS

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) modified its disaster preparedness standards in January 2001 to address the concepts of emergency management and community involvement in the process. The changes to the standards require accredited organizations to take an "all hazards" approach to disaster planning that reviews and analyzes all hazards that are seen as credible and serious threats to the community. (3)

After the Sept 11, 2001, terrorist attacks, JCAHO further modified its disaster preparedness standards to require health care organizations to communicate and coordinate with each other in the event of a disaster. This modification became effective Jan 1, 2003. (3)

The Joint Commission defines an emergency as

a natural or man-made event that suddenly or significantly disrupts the environment of care; disrupts care and treatment; or changes or increases demands for the organization's services. (3)

The Joint Commission's emergency preparedness standards require that health care facilities participate in at least one emergency drill per year, preferably one that is community wide. Additionally, they must address four phases of disaster management--mitigation, preparedness, response, and recovery. (3)

MITIGATION. Mitigation activities involve identifying potential emergencies that may affect a facility's operations or the demand for its services and implementing a plan to support areas in the organization that may be vulnerable. As a result, mitigation activities can reduce the severity and effects of a disaster. (3) Perioperative mitigation activities include developing policies and procedures that address potential emergencies that could occur in or around a facility. These could include policies on response to internal disasters, such as fire or power outage; external disasters, such as multi-injury vehicle accidents or multiple victims of a terrorist attack; or a chemical, biological or radiation accident.

PREPAREDNESS. Preparedness activities develop the organization's ability to manage the effects of an emergency. (3) Perioperative preparedness activities include written plans for staffing, obtaining supplies, triaging of patients, and other activities related to the specific emergency needs.

RESPONSE. Response activities are designed to control the negative effects of an emergency situation. (3) Perioperative response activities include participation in disaster drills, tabletop discussions of potential emergency events, and periodic review of the emergency preparedness plan by perioperative staff members.

RECOVERY. Recovery actions are aimed at restoring essential services and resuming normal operations of the facility. They begin almost simultaneously with response activities. (3) Perioperative recovery activities include the rescheduling of surgical procedures cancelled during the emergency, replenishing supplies, and ensuring a return to a surgical environment, if this was affected by the emergency situation.

In evaluating an organization's emergency preparedness, JCAHO surveyors assess the following during an on-site visit:

* how the organization develops, designs, implements, and improves its emergency management plan;

* how the plan prepares the organization to deal with a variety of potential emergencies; and

* whether personnel at all levels of the organization are trained in their roles and responsibilities in the plan. (3)

In addition, perioperative staff members should be prepared to share their department emergency preparedness plans, documentation of staff member orientation and education about the plan, and documentation of participation in disaster drills. With the recent focus on fire safety in the OR, documentation of fire drills in the OR also may be requested.

PERIOPERATIVE PREPAREDNESS

An emergency or disaster can occur at any time. There may be an early warning, such as in the case of hurricanes, for nadoes, or floods. There may be potential for an emergency occurring during a local event, such as the Olympics, the Super Bowl, or a visit by the President. In such situations, a health care facility should heighten its preparedness status. At other times, there may be no warning, as in the case of a mass casualty accident, terrorist attack, chemical plant explosion, or power outage. (1)

Surgical facilities are uniquely positioned to handle trauma resulting from a disaster. Although trauma centers are prepared to handle massive trauma, any community hospital in the vicinity of a disaster may receive victims requiring surgical intervention. Patients with less acute injuries may be triaged to an outpatient surgery center, or a surgery center may be asked to take overflow patients from acute care hospitals. When the Allison Flood hit Houston in June 2001, the outpatient surgery center at St Luke's Episcopal Hospital, Houston, became a 54-bed intensive care unit (ICU) for a week when the main hospital lost electrical power and water.

COMMUNICATION

A health care facility's senior manager or other designee decides when to initiate the emergency response plan. The plan should contain specific communication procedures and structures for notifying personnel when emergency response measures are initiated. Announcements may be made through pagers, a public address system, emergency telephones in the case of telephone equipment failure, or in other designated manners. Other external devices that may be used in an emergency are cellular and satellite telephones and emergency radios.

All personnel must be identifiable--name badges typically are a required part of health care workers' uniforms. To maintain a safe and secure environment, nurses and ancillary staff members must have plainly visible hospital identification. Employees should be checked into their specific work areas (eg, the OR, postanesthesia care unit [PACU], central supply).

Activities and resources in the OR and PACU must be assessed. Use of a department checklist provides structure and guidance for new or experienced managers. Managers must evaluate the facility's ability to accept additional patients requiring surgical procedures. Managers must determine the nature of the emergency, its impact on the facility's functions, and whether to cancel nonemergent surgeries and other elective procedures.

Ongoing discussion with the chief anesthesia care provider is encouraged to coordinate patient care, OR assignments, and staff member utilization. The perioperative manager's focus is on patient and employee safety issues, and he or she should communicate his or her complete assessment to the incident commander or individual in charge in a clear and succinct manner.

The PACU leader must determine the number and timing of patients expected from the OR. Will patients be able to transfer out of the PACU or will they need to remain there? The skill level of PACU nurses is a valuable asset in the event of a disaster. Postanesthesia care unit staff members may be called on to assist in other areas, such as the emergency department (ED), ICU, or triage areas.

Perioperative managers should maintain current contact information for direct patient caregivers and ancillary personnel. They must instruct staff members to submit changes of home and cellular telephone numbers, pager numbers, e-mail addresses, and emergency contact telephone numbers and redistribute the list after every update. When recall is initiated using the roster, the manager or designee must maintain a call log to record who was contacted and at what time, the expected arrival time, and relevant comments.

The perioperative manager must organize communication strategies. Staff members must be educated about the facility's disaster preparedness plan and trained to respond in the perioperative area. Time perioperative preparedness plan is integrated into the institution-wide response. The disaster plan is to be taken seriously--it is not to be left on the shelf with other manuals in the nurses' station. The manager sets the culture on the unit. He or she should discuss with staff members routine planning and improvising for extraordinary circumstances. Orientation of new staff members, continuing education, annual competency assessment, and participation in facility-wide disaster drills will keep staff members prepared. The perioperative manager must consider how to handle an event that may last several days. He or she must plan staffing schedules to ensure appropriate rest periods.

It is part of the manager's role to communicate to staff members the importance of planning. They should keep several days worth of any medication they take regularly, underwear, and other essentials at work. Those with families should make plans in advance for the care of children, older parents, and pets. For a disaster event that requires staff members to stay in the hospital beyond their assigned shifts, arrangements for sleep areas and food must be taken into consideration.

If an evacuation is necessary, perioperative managers retain responsibility for patients in their area until care has been transferred. Care must be taken to keep an accurate record of all patients. If the patients are transported to other health care facilities, communications with receiving facilities must be maintained to ensure continuity of care. It is very important to ensure that medical records accompany patients to the receiving facility. (1)

INDIVIDUAL ROLES

Duties should be assigned according to an individual's position and skills. Key roles include the following.

* Perioperative lead--This generally is the perioperative manager or designee, who is responsible for communicating with the command center and coordinating the perioperative services response.

* Scribe--Assign an individual to keep track manually of all communications and events, including names of individuals and times of events.

* Specialty coordinators--Specific staff members may be assigned to coordinate the activities and needs of certain specialties (eg, neurosurgery, orthopedic, burn, pediatrics) related to the situation. These individuals may be responsible for obtaining specific supplies, calling in specialty physicians, and assisting staff members who may not be familiar with specific service needs.

* Staff coordinator--Assign a qualified individual to keep track of staff members and their assignments. This person also would stay in contact with members of the hospital staffing pool in case the perioperative area needs additional staff members or has additional staff members who can assist in other areas of the facility. The perioperative staff coordinator also could be responsible for coordinating break periods for staff members, obtaining food and water for them, and watching them for signs of stress and fatigue.

* Anesthesia lead--This typically is the chief of anesthesia. This anesthesia care provider would assist in triaging patients and coordinating the flow of patients throughout the perioperative area.

* Surgeon lead--This typically is the chief of surgery. This surgeon works in conjunction with the perioperative manager and anesthesia lead and is a key in coordinating the assignment of surgeons, triaging patients, and keeping communication flowing among medical staff members.

SUPPLIES

An initial assessment of the supplies on hand should be performed by staff members who are familiar with the area and its supplies. Additional supplies can be requested from vendors based on the type of emergency. For example, a multivehicle accident may require additional orthopedic fixation systems or wound irrigation sets. The ED may quickly deplete the hospital's supply of suture sets, and the perioperative area may need to supplement the ED with additional supplies. The just-in-time resupply programs currently used by most health care facilities cannot be expected to sustain perioperative departments when disasters occur.

Having a procedure in place whereby suppliers automatically bring specified supplies to the facility in the event of a major disaster could address an immediate supply need until a more thorough review of needed supplies can take place. Traditional methods of placing orders may not be possible if computers and telephone lines are down.

The perioperative department must keep its vendor list, including representatives' names and telephone numbers, current. It may be difficult to get supply trucks into a disaster area; therefore, a hospital staff member should be assigned the responsibility of maintaining good communication with local authorities to ensure that supply trucks will have access to the facility. It is important to establish these arrangements before a disaster occurs. (4) To minimize access problems, some facilities provide high-volume vendor representatives who serve the perioperative area with hospital identification badges noting their vendor status.

CHARGE CAPTURE

During the crisis period of immediate emergency, care, the need to capture the supplies used and charge appropriately may be ignored, it is important to have a system in place, however, to allow staff members to accurately account for supplies used so charges can be captured as soon as possible. In a disaster situation, most costs will be reimbursed, so it is especially important to capture this information. The perioperative disaster response plan should include

* documentation for financial and record-keeping purposes;

* a system for tracking supplies borrowed from or loaned to other departments or facilities; and

* a process for documentation of damaged supplies and equipment. (1)

RECOVERY

The perioperative area should plan in advance for returning to normal service after a major emergency response. Perioperative leaders, including the anesthesia and surgeon leads, may initiate the plan for recovery soon after the start of the emergency response. Recovery considerations may include

* terminally cleaning the department;

* inspecting, testing, and repairing equipment as needed;

* validating sterilizer efficacy if a steam or power interruption occurred;

* cleaning or changing air filters, if necessary;

* restocking supplies;

* providing emotional support to staff members;

* rescheduling canceled elective surgical procedures; and

* critiquing the disaster response and improving procedures, if necessary. (1)

CONCLUSION

Although perioperative emergency preparedness plans have existed for many years, the tragic events of Sept 11, 2001, have encouraged most departments to dust off those plans and heighten health care workers' awareness of their roles in an emergency response. The time to prepare is before an event occurs, not during or after the crisis. Perioperative leaders must meet the challenge of preparing the department for a wide range of potential disasters. Staff members and others in the facility depend on perioperative leaders to take the helm in ensuring that staff members and the department are adequately prepared.

NOTES

(1.) AORN, Perioperative Disaster Preparedness Resource Manual (Denver: AORN, Inc, 2003).

(2.) "Emergency management," Joint Commission on Accreditation of Healthcare Organizations, http://www.jcaho.org/accredit ed+organizations/home+care/standards/faqs/env +safety+equip+manage/emergency+management/emergency+management.htm (accessed 30 April 2004).

(3.) "Facts about the emergency management standards," Joint Commission on Accreditation of Healthcare Organizations, http://jcaho.com/accredited+organizations /health+care+network/standards/ems+facts.htm (accessed 30 April 2004).

(4.) R Neil, "Connecting the supply line," Materials Management in Health Care 12 (July 2003) 20-24.

Examination

1. The experiences of hospital personnel supporting recent terrorist disaster areas have resulted in

1. enhancing decontamination units.

2. immunizing first responders against smallpox.

3. increasing medication supplies used to counteract biological and chemical agents.

4. strengthening employee disaster training programs.

5. increasing facility-wide supply stock levels.

a. 2 and 4

b. 1, 3, and 5

c. 1, 2, 3, and 4

d. 1, 2, 3, 4, and 5

2. All disasters can be classified into which two general categories?

1. man-made

2. civil disorders

3. natural

4. meteorological

5. terrorist

a. 1 and 3

b. 1 and 4

c. 2 and 5

d. 3 and 5

3. Activities that control the negative effects of emergency situations are considered what kind of activities?

a. mitigation

b. preparedness

c. recovery

d. response

4. Outpatient surgery centers are expected to plan for possible mass casualty situations.

a. true

b. false

5. Staff members should be kept prepared for potential emergency situations by

1. annual competency assessment.

2. continuing education.

3. new hire orientation.

4. participation in facility-wide disaster drills.

a. 1 and 3

b. 2 and 4

c. 1, 3, and 4

d. 1, 2, 3, and 4

6. Assisting in triaging patients and coordinating the flow of patients throughout the perioperative area is the responsibility of the

a. anesthesia lead.

b. perioperative lead.

c. specialty coordinators.

d. staff coordinator.

7. Just-in-time resupply programs are excellent methods to ensure sustained perioperative supply levels when a disaster occurs.

a. true

b. false

8. To minimize access problems, some facilities

a. notify local authorities at the time of the disaster that all vendors now have permission to bring supply trucks into the area.

c. provide high-volume vendor representatives with hospital identification badges noting their vendor status.

b. use the Internet as the primary communication source during the disaster to order supplies that are needed immediately.

9. The perioperative disaster response plan should

1. address financial and record-keeping documentation.

2. ensure immediate capture of supply costs.

3. establish a testing and repair process.

4. include a damaged supply and equipment reporting process.

5. include a supply and equipment tracking process.

a. 1 and 3

b. 2 and 4

c. 2, 3, and 5

d. 1, 4, and 5

10. The plan for recovery from an emergency response is initiated after the emergency has resolved to ensure that all team efforts are focused on the emergency situation.

a. true

b. false

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Learner Evaluation

Objectives

To what extent were the following objectives of this Home Study Program achieved?

1. Explain how the terrorists acts of Sept 11, 2001, affected facility emergency preparedness plans nationwide.

2. Define the phases of disaster management.

3. Explain how perioperative preparedness is pertinent to all surgical facilities.

4. Describe how key roles of individuals involved in a disaster are enhanced by educational preparedness.

5. Identify methods to ensure availability of supplies during a disaster.

Content

6. Did this article increase your knowledge of the subject matter?

7. Was the content clear and organized?

8. Did this article facilitate learning?

9. Were your individual objectives met?

10.How well did the objectives relate to the overall purpose/goal?

Test Questions/Answers

11. Were they reflective of the content?

12.Were they easy to understand?

13. Did they address important points?

Learner Input

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a. yes b. no

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a. the Journal I receive as an AORN member.

b. a Journal I obtained elsewhere.

c. the AORN web site.

d. SSM Online.

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What other topics would you like to see addressed in a future Home Study Program? Would you be interested or do you know someone who would be interested in writing an article on this topic?

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Session Number

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John E. Eiland, RN, MS, LTC, is chief, department of surgery, Blanchfield Army Community Hospital, Ft Campbell, Ky.

Donna A. Pritchard, RN, BSN, MA, CNOR, CNA, is director of nursing, perioperative services, NYU Downtown Hospital, New York.

Darlena A. Stevens, RN, MSN, CNOR, CNAA, is vice president, perioperative and woman's services, St Luke's Episcopal Hospital, Houston.

COPYRIGHT 2004 Association of Operating Room Nurses, Inc.
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