Could Your Office Cope With Disaster?

Medical practices should remember the Boy Scout motto and be prepared for a day when the unexpected happens.

Gerard Klinzing, MD, and Charles McClure, MD

Covered in FPM Quiz

Tool inside

One Wednesday, about 5:30 p.m., staff members began to notice an abnormal smell in our office suite. Soon, we could see smoke in the air. The staff was beginning to bring patients to the exam rooms for our Wednesday evening office hours. Over the next 30 minutes, smoke infiltrated an entire hallway. We couldn't find a fire, but we did finally discover that demolition workers in an adjacent office were using cutting torches to dismantle a safe. We sealed off the affected hallway with plastic and ended office hours by 7:30.

The upshot of this episode was that we were displaced from our office for almost two weeks. We had not planned adequately for such a contingency, and we were faced with many logistical problems we weren't prepared for. From trooping out for grade-school fire drills to carrying a snakebite kit and compass on a day hike in scouting, we are taught early that the best way to survive a disaster is to prepare for it. Why do we so lightly abandon these lessons in our professional lives?

It is easy to dismiss the need for disaster planning, but disasters may not be as unlikely as they seem. Last year saw tornadoes in Florida and floods in Alabama, among other places -- and every one of these disasters was an opportunity for the prepared medical office to be an asset to the community in need and not just another casualty.

And as our experience demonstrates, it's not just large-scale natural disasters that require preparedness. When was the last time your office staff practiced a fire drill (or even discussed what to do in case of fire)? While we cannot anticipate every contingency nor afford every safety precaution, it takes relatively little time and money to predict likely catastrophes and construct basic reaction plans. The ability of an office to function during an emergency will not only ensure optimal patient care and preserve the office's reputation but may also be financially life-saving. [Read what another practice learned about disaster planning when it was damaged by fire, page 33.]

Large offices operated by hospitals as outpatient clinics are subject to the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and must meet certain requirements with respect to disaster preparedness. Most offices do not operate under JCAHO requirements, however, and the literature offers little guidance for the solo physician or small practice interested in preparing for the worst. It is up to you how far your practice should go in the event of an emergency, but failure to plan ahead will ensure problems. And if you are in an isolated area or an area where private practices provide the bulk of care for the community, it may be imperative that your practice be ready to provide care in times of difficulty.

KEY POINTS: You cannot cope with every conceivable disaster, so start by deciding on the conditions that would lead you to say "uncle." It's important to involve your whole staff in planning, drills and revision of the plan Store a "portable office" off site: a collection of the materiel you would need to operate if denied access to your office. The ideal emergency drill includes patients and finishes with debriefing and evaluation.

Expect the worst

Office disasters can take many forms, but a common approach to preparation may be used for all. The steps are these:

• Identify probable crises and decide which ones you will prepare for,
• Develop basic contingency plans,
• Procure needed resources,
• Train staff with periodic drills.

When was the last time your office staff practiced a fire drill (or even discussed what to do in case of fire)?

Identifying crises. Given the range of potential crises, it's important to decide which ones you hope to be able to cope with and to identify the level of disaster at which the office will say "uncle" and simply close (see "Common disasters"). For some offices this will be nuclear war, and for others it will be severe weather.

Identifying what it would take to make you give up helps in two ways: First, it allows you to focus your preparations on disasters you can realistically expect to manage. Second, it allows you to tell your patients your limits. (To disseminate office closure policies, you can use fliers and office memos. To issue actual closing notices, you can use Internet postings, TV and radio announcements and answering-machine messages. Knowing how to avail yourself of the various options is an important part of disaster planning.)

Planning for contingencies. In creating a disaster contingency plan, you'll need to establish the following:

• Steps to take to prepare for the disaster,
• Steps to take during the disaster (and the optimal order of those steps),
• The person responsible for each step (with a backup person, if possible).

It is essential to include your staff in the development, rehearsal and modification of the plan. Successful operation in an emergency requires teamwork and flexibility in addition to a well-constructed plan. This goal is more easily reached when all members of the team provide input and take pride in the development of a plan that works. Once you have thought your way through the plan, you should be able to encapsulate it in a disaster checklist (for an example, see "Office fire checklist").

Common disasters Weather-related Snow, ice Flood Heat wave, drought Earthquake Tornado, hurricane Administrative Loss of key personnel Loss of medical or financial records Computer system failure Theft of office equipment Fire During working hours After hours Physical plant Electrical outage Telephone outage Water supply interruption; water leaking into the practice during office hours HVAC failure Community, mass casualty Infectious disease, exposure Influenza Hepatitis A Rotavirus Hazardous materials Mass casualty near the office Miscellaneous Bomb threat Robbery Abduction of a child from the office Forced closure of the office requiring relocation Mass-transit strike (patients cannot come to the office)

Procuring resources. If your office is willing to operate during a given crisis, it must identify the resources needed for work to continue. An asset in most emergencies is the "portable office." This kit should be stored somewhere away from the office in case the office is involved in the catastrophe. The kit should contain the bare medical and administrative necessities for temporary office operations (see "Off-site necessities kit").

Cross-training of staff is an essential element of the plan.

Training staff. Once you have targeted likely crises and developed plans for coping with them, you'll need a plan for drills. The goal of initial training is to discuss the plan with staff, assign responsibilities and walk through a drill without patients.

Ideally, these training sessions would be followed by an office-hours drill in which patients are included. This may not be feasible in all situations, but it is the most accurate method of assessing the reliability of your plan. In addition to the training they provide, drills test the effectiveness of your plans and show areas requiring modification. A post-exercise debriefing with input from all participants (including patients) will provide data necessary to refine the plan. To make the drill as effective as possible, use a rehearsal evaluation form based on your checklist (see "Office fire drill evaluation form," page 30). Cross-training of staff in both medical and administrative tasks is an essential element of the plan and should be included in the drill.

Office fire checklist This checklist can be downloaded as a PDF. Before a fire occurs Designate an evacuation route. Identify a location to meet after evacuation. Post the evacuation plan (including floor plan with locations of extinguishers). Periodically inspect fire-suppression and extinguishing equipment. Hold periodic fire drills. Assemble off-site necessities kit Arrange alternate office site. Store back-up copy of medical records and schedules off site. Assign responsibilities for actions during a fire: Responsibilities Names Coordinates evacuation (runs checklist) _____________ Alerts office staff and patients _____________ Calls EMS and fire department _____________ Tends to wounded _____________ Accounts for all patients and staff _____________ During a fire Remember RACE: First Remove patients, then Alarm/Alert the fire department, then Contain the fire (Close the doors), then Extinguish the fire. Ensure that patients are safely evacuated. Alert the fire department (911). Alert office staff and patients. Close office doors. Contain or extinguish the fire. Triage wounded patients and staff members. Obtain a charged cellular phone; forward calls to it. Isolate the patient record area. Access off-site medical records and schedule. Alert office staff (if off-hours).

Plan for the unexpected

We were able to scramble and find an alternate office location.

Naturally, you cannot prepare for, or even anticipate, every eventuality. Even if our office had had a remarkably complete disaster plan, we might not have thought of incorporating a plan for dealing with welding fumes. But we would at least have had a plan for coping with forced closure of the office, and we would have been that much better off.

What did end up happening was this: Employees and patients who were exposed to the fumes were instructed to report any symptoms that persisted or that arose after they left the office. Coincidentally, no appointments had been scheduled for the next morning; we used the time to contact the hospital's safety officer and risk management office. They advised us to allow no employee or patient to enter the office until an analysis for potential toxic exposure could be made.

Off-site necessities kit To be prepared for emergencies that temporarily deny you access to your office, you may need to store some materials off site. While it may be impractical to keep a sizeable collection of the following in one location solely in preparation for a disaster, at least ask yourself how sure you are that you could get each of the following in the event of each type of disaster you are preparing for, and create a cache of all the items that would not otherwise be reliably available. Think about any other special needs your practice may have, too. This list is hardly exhaustive: Moreover, certain types of disaster will require additional off-site resources -- a generator (tested and ready!), a complete back-up set of patient records, etc. Flashlights Charged cellular phone Pulse oximeter Stethoscope Blood pressure cuffs Thermometers Otoscope/opthalmoscope ACLS kit or crash kit Necessary medications (analgesics, antibiotics) Wound care supplies (gauze, gloves, tape, suture supplies IV/phlebotomy supplies Oxygen with needed accessories Insurance forms Lab request forms Copy of phone tree Progress note sheets Medical reference books Patient list Prescription pads Pens and paper

Patients scheduled to be seen later that day were notified by telephone that their visits would have to be rescheduled or moved to the fast-track area of our hospital's emergency department or, later, to an unused inpatient wing of the hospital. Staff members were stationed outside the family practice center to assist any patients who needed help to get to the new location. Family practice residents and core faculty provided care at the off-site location while nursing staff triaged patient concerns. Charting was done on hospital progress notes, and billing information was recorded for processing later.

The program director, office manager and safety and EPA officers set out to identify the exposure and potential for harm. All employees were advised to seek care through the employee health service. More than 20 members of the residency program staff were seen and had chest X-rays and blood tests taken. No health problems were identified.

Seven days after the initial exposure, summary analyses of the fumes and residue were completed. No toxic substances were found. Cleaning of the office suite took place over the next three days, and office operations resumed 12 days after the initial exposure.

Fortunately, no patients or staff were injured, and the episode had no significant legal, medical, financial or operational ramifications. But it did raise our awareness of the need for contingency plans, drills and office training for common emergencies. We revised our fire evacuation plan (of which many staff members were unaware). In addition, we planned fire drills to include patients and began assembling our off-site emergency kit. While we were able to scramble and find an alternate office location, we were fortunate in our proximity to the hospital. To take advantage of less ideal alternatives -- community organizations with adequate physical space such as churches, lodges or convention centers -- would have required advance planning that we hadn't done.

In this era of medical competitiveness, it is important for practices to be flexible and able to respond to the needs of their patients in as wide a variety of situations as possible. The keys to attaining this flexibility are anticipation and planning. Preparing for disasters requires the investment of a small amount of time and money, but if the worst happens, the benefits for you and your patients will be great.

Office fire drill evaluation form Date: _______________ Time: _______________ Execution Time drill started: ________ Time drill completed: ________ Were patients evacuated promptly, safely and without undue panic? Yes No Was the preplanned evacuation route used? Yes No Did staff meet at the designated site outside the office? Yes No Were the safety guidelines met? Yes No Was the evacuation route adequate? Yes No Was the plan effective? Yes No Was the fire department alerted (in fact or in simulation)? Yes No Were the office doors closed? Yes No Were efforts made to contain or extinguish the fire? Yes No Were patient records isolated or protected? Yes No Were "wounded" patients and staff members adequately triaged? Yes No

Dr. Klinzing is program director for Bryn Mawr Family Practice residency program. He serves as system chair of the Department of Family Medicine for Main Line Health Hospitals in Jefferson Health System and director of medical education for the Bryn Mawr Hospital.

Dr. McClure is a second-year resident at the Bryn Mawr Family Practice residency program.

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