BSM Blog

Are You Ready for an Emergency?

Case Study

Mr. Johnson dropped off his wife at the surgery center for her procedure before going to the bank to withdraw some money. At the bank, little did he know, two men were watching him from their sedan in the parking lot. Mr. Johnson withdrew his cash, returned to his car, and drove back to the surgery center, with the two men following him. He parked in front of the surgery center lobby and before he could get out of his car, a man from the sedan approached Mr. Johnson at his driver side window, putting a gun to his head and demanding Mr. Johnson give him the money. The lobby was full of patients and family members witnessing the entire incident. A post-anesthesia care unit (PACU) nurse happened to walk into the lobby as this was unfolding; she quickly yelled to the receptionist to call 911, locked the front door, and escorted everyone in the lobby to a more secure location in the facility.

Preparedness is Key

What would you do in that scenario? Are you ready for that situation or another kind of emergency? There are numerous types of internal and external emergencies that pose a threat to ambulatory surgery centers (ASCs) and medical offices. Whether it’s an active shooter, a fire, a power outage, a hurricane, or another event, you must be prepared for what might come your way and be able to safely manage your staff and patients.

Emergencies to Prepare For

To properly prepare for an emergency, it is essential to know your environment. Your environment includes what is happening inside your office or ASC, as well as what could potentially become an emergency outside its walls.

ASCs are required to complete a Hazard Vulnerability Analysis (HVA), an assessment to identify the most common internal and external emergency threats in their environment. The HVA tool is numeric-based, with high-risk emergency types garnering a higher score than lower-risk emergencies. This rating includes the probability of an event occurring, the risk the event poses to life and safety, the degree of disruption to services, and the facility’s level of preparedness.  

Conducting your office or ASC HVA will help you understand your risks. Depending on where your facility is located, you may be at risk for an external emergency like a wildfire but never for a hurricane. However, all facilities are at risk for internal emergencies like an active shooter, power outage, cyberattack, or the spread of an infectious disease such as COVID-19. Knowing your risks is essential to planning efforts.  

Preparing for Identified Emergency Risks

Based on the emergencies your facility is at risk for, you can start to create an emergency preparedness plan that is tailored to your specific needs.

According to the Centers for Medicare and Medicaid Services (CMS), “the emergency preparedness program must describe a facility's comprehensive approach to meeting the health, safety, and security needs of [its] staff and patient population during an emergency or disaster situation. The program must also address how the facility would coordinate with other healthcare facilities, as well as the whole community during an emergency or disaster (natural, man-made, facility).”

More specifically, your emergency preparedness plan should include:

• A safe evacuation plan for all patients, staff, and visitors, including route, method, and alternate facility and location.

• A shelter in place plan if evacuation is not an option.

• A comprehensive communication plan that addresses communicating within the facility and with outside agencies offering emergency services, if needed. (The ability to communicate with the families of patients and staff should also be considered.)

• A secure medical documentation system that preserves and protects vital records and IT data.
• A staff assignment plan that outlines the roles, responsibilities, and essential functions of staff members during and immediately after an emergency.
• A drill policy that includes conducting regular drills with staff for fire, internal medical emergencies, and your most likely external emergency or disaster threat.
• A staff education and training policy that helps ensure staff can competently carry out the emergency preparedness plan.  

Team Preparedness

Your emergency preparedness plan is only as good as your team’s performance when an emergency arises. Therefore, your goal is to prepare your team, and this can be achieved through education and training.

New staff must receive initial training upon hire. Afterward, ASC staff must complete emergency preparedness education and training every two years. It’s a good idea for medical office personnel to follow a similar training cadence.

Education starts by providing your staff with a list of their roles, responsibilities, and other vital knowledge for an emergency. Some examples include but are not limited to:

• Evacuation routes.
• The designated location where patients, visitors, and staff will meet during an evacuation.
• The location of adequate provisions (food, water, medical supplies, communication devices, etc.) if shelter-in-place is warranted.
• Communication means and methods within the center or office, as well as with emergency response agencies, critical resource agencies (e.g., water, gas, electric companies), and family and loved ones.
• A regular account of all patients, staff, and vendors in the building.
• A means for securing Patient Health Information (PHI).

In addition to the items listed above, staff roles and responsibilities within an ASC include but are not limited to the following:

• Arranging the transfer of patients who have not fully recovered or need a higher level of care.
• Contacting family members regarding the status of patients and transfer location.
• Maintaining the proper function of emergency and life safety equipment.
• Notifying patients of cancelled surgeries and when rescheduling may occur.

Staff who know what to do during an emergency can help reduce confusion and ensure that immediate, life-saving actions can be taken.   

Practice Makes Perfect

Your staff can only perform their roles and responsibilities in an emergency with proper and adequate practice. Conducting drills is the best way to achieve this goal. Providing scenario-based drills will help your staff engage in the emergency drill and encourage them to think of how they will maintain the safety and well-being of their patients and coworkers. Their participation is vital to the success of any emergency drill and in the event of a real-life incident.

CMS requires ASCs to conduct one disaster drill a year. Accrediting organizations such as the Accreditation Association for Ambulatory Health Care (AAAHC) require fire drills to be conducted four times a year. In addition, ASCs must prepare for emergencies by conducting a mock Code Blue (cardiac/respiratory arrest) drill, a Malignant Hyperthermia drill (if applicable), and a high-risk disaster (e.g., an active shooter) drill. Also, in response to the COVID-19 pandemic, recent regulation changes include “emerging infectious diseases” emergency preparedness.

It is crucial that all drills are evaluated. Identifying what worked and didn’t and discussing concerns and remedial actions with the team is key. Based on that assessment, revise the plan appropriately and implement it during your next drill. The goal is to continue to refine and practice your plan to get better each time.

Emergency Preparedness is Essential

No one knows when an emergency or disaster will occur, so being prepared for one in advance is essential. Key elements of your emergency preparedness plan include regular drills, staff education and training, and a comprehensive communication plan. Being prepared will increase the likelihood of a successful response in your ASC or medical office when an emergency arises, thereby protecting the safety and well-being of everyone involved.

ADDITIONAL RESOURCES: Emergency preparedness resources are available on BSM Connection and Progressive Surgical Solutions eSupport. Additionally, BSM is hosting a situational awareness webinar on Aug. 18, and registration is open to Connection and non-Connection members. 

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