Disaster Planning & Emergency Preparedness Guidelines
THE RENAL NETWORK, INC.
Approved - June 1996
DISASTER PLANNING & EMERGENCY PREPAREDNESS
Standards for emergency preparedness have long been a part of the federal regulations governing ESRD facilities, and are included in the guidelines used by state survey agencies to certify and monitor dialysis units. In recent years there have been major natural disasters throughout the country which have incapacitated dialysis facilities and dislocated patients. In 1989, hurricanes in Florida created a medical emergency for dialysis patients in the Clearwater area. At least four dialysis facilities were inoperable or inaccessible during the Midwest floods of 1993. Earthquakes and mudslides in California have reinforced the importance of assuring that dialysis facilities and ESRD patients are adequately prepared for emergencies.
This outline is intended as a guide and resource to help individual dialysis facilities develop their own emergency preparedness plans. The Renal Network would like to thank the Mid-Atlantic Renal Coalition (Network 5), the ESRD Network of Florida (Network 7), the ESRD Network of Texas (Network 14), and the TransPacific Renal Network (Network 17) for sharing their disaster preparedness guidelines .
The following guidelines are quoted directly from Subpart U Regulations - Conditions for Coverage of Suppliers of ESRD Services (42 CHF Chapter IV) and the Interpretive Guidelines which are used by state survey agencies in their certification activities.
These guidelines should be considered minimum standards; they leave much to the discretion of the individual facility in terms of the types of emergencies covered. Federal guidelines emphasize that policies must be written, that drills be conducted, and that staff and patients be trained in emergency procedures.
FEDERAL REGULATIONS: Section 405.2140 (d) Standard: Emergency Preparedness
Written policies and procedures specifically define the handling of emergencies which may threaten the health and safety of patients. Such emergencies would exist during a fire or natural disaster or during functional failures in equipment. Specific emergency preparedness procedures exist for different kinds of emergencies. These are reviewed and tested at least annually and revised as necessary by, or under the direction of, the chief executive officer. All personnel are knowledgeable and trained in their respective roles in emergency situations.
- There is an established written plan for dealing with fire and other emergencies which, when necessary, is developed in cooperation with fire and other expert personnel.
- All personnel are trained, as part of their employment orientation, in all aspects of preparedness for any emergency or disaster. The emergency preparedness plan provides for orientation and regular training and periodic drills for all personnel in all procedures so that each person promptly and correctly carries out a specified role in case of an emergency.
- There is available at all times on the premises a fully equipped emergency tray, including emergency drugs, medical supplies, and equipment, and staff are trained in its use.
- The staff is familiar with the use of all dialysis equipment and procedures to handle medical emergencies.
- Patients are trained to handle medical and nonmedical emergencies. Patients must be fully informed regarding what to do, where to go, and whom to contact if a medical or nonmedical emergency occurs.
Standard (d), Emergency Preparedness: Ascertain whether there are set procedures for emergencies (fire, natural disaster, and medical) whether everyone knows his role in such emergencies and whether there is an emergency tray with drugs kept current. Patients who are undergoing dialysis must be made aware of procedures for disconnecting themselves from the dialysis equipment in case of fire and other natural disaster.
A complete drill is essential, since frequent practice is the only way to assure automatic response when an emergency does arise. There may be a need for frequent rehearsal scheduled at the end of a dialysis session, and to demonstrate with one patient all of the techniques required for fast, safe, and efficient completion of the process. It is important for the self-dialysis patient to be familiar with the facility's emergency procedures since he may be expected to take necessary steps to protect himself.
The Life Safety Code does not have a specific requirement for outpatient clinics or dialysis activities. Consequently, because of the nature of these patients being artificially restrained by means of the dialysis mechanism, certain institutional requirements for drills are pertinent. Fire exit drills in hospitals shall include the transmission of a fire alarm signal and simulation of emergency fire conditions except that the movement of infirm or bedridden patients to safe areas or to the exterior of the building is not required. Drills shall be conducted quarterly on each shift to familiarize hospital personnel (nurses, interns, maintenance engineers, and administrative staff) with signals and emergency action required under varied conditions. The purpose of a fire drill is to test the efficiency, knowledge, and response of institutional personnel. Its purpose is not to disturb or excite patients.
Note that the drill is intended primarily for the benefit of personnel, to rehearse the procedures and details worked out in the facility's plans to handle the emergency or disaster. While the regulatory requirement is that the procedures for different types of emergencies be tested at least annually, training of staff and patients in the agreed-upon procedures to include practice and timed rehearsals of specific procedures should of course supplement a full-stage drill.
THE NEED FOR A PLAN
There are many reasons why a facility should have an emergency operations plan. The prime reason should be the protection of both the patients and employees of the facility. Other major reasons for planning and preparation are:
A plan which is widely disseminated and understood by patients and staff reduces reaction times, improves coordination, and minimizes confusion. Experience has proven that the emergency planning objectives of saving lives and protecting property are achieved through coordinated emergency response operations.
A plan provides the facility with a tool to establish formal coordination with other entities that A facility may need to assist both your patients and facility in time of crisis.
A plan well disseminated and practiced provides a valuable training tool for educating and preparing facility staff and patients for emergencies.
A plan provides a framework for responding in any emergency situation whether anticipated or not.
DEVELOPING A PLAN
Successful emergency and disaster planning is the process of dealing with whole sequences of undesirable events. An emergency plan that clearly defines and describes policies, procedures, responsibilities, tasks, and operational actions as they pertain to each response function before, during, and after any emergency situation is invaluable. To ensure adequate planning for all applicable hazards, the content of the plan must be responsive to the result of the facility's specific vulnerability analysis (see page 6).
No single list of planning considerations can be prescribed generically for all of the dialysis facilities within Networks 9 and 10. The primary concern is that all important activities be properly covered in the plan.
The following are internal and/or natural disasters which may disrupt operations in dialysis facilities. With a few exceptions, these emergencies could occur in any facility in the Network area and should at least be considered in emergency planning. It is the responsibility of the individual unit to assess the likelihood of a particular natural disaster occurring in the area and establish priorities for in-depth emergency planning.
Internal Emergencies: Fire, explosions, equipment failure, power failure, gas leaks, formaldehyde or other chemical spills, after shut off or contamination, violent acts/bomb threats.
Natural Disasters: Tornado, earthquake, storms (electrical, snow, ice), floods, forest fires or other external fires.
When designing the disaster preparedness plan, it is essential that the plan address each check list in four basic areas: Direction & Control, Communication, Alerts & Warnings, and Evacuation & Closure.
- DIRECTION & CONTROL: Does the plan have provisions for:
- Who is responsible for the development of the facility's emergency management plan.
- Who is responsible for routinely reviewing the emergency preparedness plan for appropriateness and adequacy.
- Who is in charge for each type of emergency situation.
- Who determines the need to evacuate the facility.
- Delineation of leadership authority and responsibility of each of the facility's key positions during emergencies.
- Coordination with the Local Emergency Management office.
- Assuring the continuing emergency preparedness education of both staff and patients.
- Adequate and appropriate back-up treatments and services.
- Emergency phone numbers, contacts for supplies, and equipment.
- Listing key telephone numbers.
- Describing the methods of communication between: Leadership & facility, staff and facility, and patients and facility.
- Back-up communications sources such as cellular phones.
- Producing and updating exit route diagrams from facility.
- Emergency communication with local Emergency Management office.
- Requesting emergency services and supplies.
- Communicating patient emergency information on emergency phone numbers, evacuation procedures, self-termination from treatment, emergency renal diet, and emergency supplies for the home.
- Civil defense communication sources.
- Alternate transportation sources.
- Receiving weather reports from the weather service.
- Notifying patients and staff of imminent facility operation changes during treatment.
- Preparing the facility for potential or imminent disaster.
- Describing warning systems used to alert patients/staff at their homes of treatment scheduling changes.
- Defining the responsibilities of personnel and describing activation procedures.
- Alerting other dialysis facilities that back-up services may be needed.
- Requesting emergency assistance from government agencies.
- Routine checks that warning system is functional.
- Staff and patient procedures for emergency termination of dialysis.
- Indicating under what conditions facility evacuation must occur or be considered.
- Who will make the decision to close the facility.
- Diagrams to show where and or how to shut of utilities and machines.
- Diagrams to show how to start and use facility back-up water treatment systems or connect back-up power source.
- Who is assigned to the role of utility and machine shut-off.
- Moving equipment and supplies to safe secure area.
- Protecting computerized hard copy medical records along with procedure manuals and other vital records.
- Indicating how medical records will be provided to back-up facility.
- Assisting patients attain transportation to back-up facility.
All dialysis facilities are vulnerable to any number of natural or manmade hazards. An analysis of the facility's vulnerability to particular hazards can provide the basis for developing a practical, workable emergency operations plan and appropriate standard operating procedures.
In analyzing and assessing the vulnerability of the dialysis activity, the following must be considered which are unique to the dialysis facility: environmental, indigenous, and economic factors. These are the basis for:
Estimating the likelihood of damage, either by direct effects or by indirect effects resulting from a facility(s) damaged elsewhere.
Making plans for protective measures within individual facilities to minimize the impact on dialysis operations and structural damage.
Based on its unique location and operation, each facility must recognize its vulnerability to particular hazards. Facilities which are located newer industrial plans may be vulnerable to the effects of explosions or chemical leaks. Facilities located near water are at risk from flooding. All facilities are possible targets of sabotage or bomb threats. It is also important to remember that just because a facility is not considered at risk during a disaster or emergency, that facility's proximity to facility that is affected could effect the operations if the impaired facility's need to transfer patients.
It is essential that all staff thoroughly understand their respective roles and responsibilities if disaster threatens. Emergency telephone numbers should be accessible and all employees should know where emergency supplies are located. The following items should be included in new employee orientation and reviewed with all staff on a regular basis.
- Staff responsibilities for emergency planning
- Plan for staff orientation and training
- Staff duties if a disaster threatens: Patient and staff contact, securing facility; patient scheduling/triage.
- Plan for fire/disaster drills
- Plan for protection of patient records
- Plan for back-up facility
- Emergency supply/evacuation box
- List of emergency phone numbers, contacts and supplies
- Power failure procedure (with and without emergency generator)
- It is important that the plan includes the duties and responsibilities of all staff members if a disaster necessitates the evacuation of patients. The following procedures should be a part of initial orientation and reviewed periodically with all staff.
- Duties and responsibilities of all staff
- Removal from machine: Blood return procedure; clamp-disconnect procedure
- Instructions for securing building
DISASTER INFORMATION FOR THE PATIENT
All patients admitted to a facility should be provided basic emergency information which addresses at least the topics listed below.
- Emergency numbers/civil defense stations
- Evacuation procedures
- Self removal/clamp procedures for appropriate patients
- Emergency renal diet
- Emergency supplies
- Patients should also be reminded of the importance of having emergency supplies on hand when inclement weather threatens.
RECORD KEEPING & QUALITY IMPROVEMENT
Since federal and state regulations require staff training and emergency drills, these activities should be well documented. Staff training and emergency drills should continuously be assessed and improved.
- Documentation of training
- Assessment of training and recommendations for improvement
- Documentation of drills
- Assessment of drills and recommendations for improvement
COORDINATION WITHIN THE COMMUNITY
The need for a well developed and practiced disaster plan can not be over emphasized. One critical provision often overlooked by facilities is the incorporation of the community's disaster plan with theirs. In the aftermath of Hurricanes Andrew and Hugo, it was reported that one of the hindrances of getting assistance to damaged dialysis facilities was a basic lack of knowledge. In some cases local Emergency Management Coordinators and Health Officers were not aware of the existence of the dialysis facilities or their emergency needs.
The facility disaster plan should be coordinated with the local community. In most cases, the disasters that impact the average dialysis facility will not generate a need or request for assistance from the community's emergency management operations. In those cases where widespread destruction from disasters like floors or tornadoes occur, however, the need for help will be highly probable.
Ideally, facilities should include in their plan a procedure for notifying their local community's Emergency Management Office of the following specific information:
- Key personnel
- Hours of Operation
- Number of Patients
- Resources facility requires to perform dialysis services
- Resources patients require to travel to or from the facility
- Overview of medical services provided
EMERGENCY RESPONSE ORGANIZATIONS
The following is a list of emergency management organizations and a brief description of services they provide. The state emergency organizations and the Federal Emergency Management Agency can provide the facility with planning assistance and literature. As noted, communication with the local emergency management office is strongly recommended to coordinate disaster planning. The local disaster coordinator can provide consultation and advice specific to individual facility and community disaster plans.
Local Emergency Management Agencies: The specific local emergency management office/coordinator can be found in the Government Pages of the local phone book, or by contacting the state disaster planning agency listed below. The local emergency management agency prepares and maintains a current local or inter-jurisdictional emergency plan which provides for hazard mitigation, emergency preparedness, and response and recovery.
State Disaster & Emergency Management Agencies: The state agency prepares and maintains a comprehensive state emergency management plan and takes an integral part in the development and revision of local and inter-jurisdictional emergency management plans. Emergency management plan consultation services are available.
ILLINOIS EMERGENCY MANAGEMENT AGENCY
110 E. Adams St.
Springfield, IL 62701-9963
INDIANA STATE EMERGENCY MANAGEMENT AGENCY
302 W. Washington St., Room E208
Indianapolis, IN 46226
KENTUCKY DISASTER & EMERGENCY SERVICES
100 Minuteman Pkwy.
Frankfort, KY 40601
OHIO EMERGENCY MANAGEMENT AGENCY
2855 W. Dublin Granville Rd.
Columbus, OH 43235-2206
FEDERAL EMERGENCY MANAGEMENT AGENCY (FEMA): This agency provides the single point of contact within the federal government for emergency management activities. It provides multiple services ranging from disaster preparedness, disaster recovery, to financial assistance programs. Excellent source for publications.
P.O. Box 70274
Washington, D.C. 20024
PUBLIC HEALTH SERVICE
Division of Emergency Readiness & Operations
5600 Fishers Lane, Room 4-81
Rockville, MD 20857
FEMA KENTUCKY-REGION 4
1371 Peachtree St., N.E.
Atlanta, GA 30309
FEMA ILLINOIS, INDIANA & OHIO-REGION 5
175 W. Jackson St., Fourth Floor
Chicago, IL 60604
RECOMMENDED EMERGENCY TELEPHONE CONTACT LIST
The following is a list of emergency numbers which each dialysis unit should include in its emergency plan. Ready access to alternative suppliers and providers of services could be a decisive factor in an emergency situation. It is important to update the list frequently.
EMERGENCY SERVICES: State Department of Emergency Services
- Regional Department of Emergency Services (DES)/Office of Emergency Management (OEM)
- Local/County DES or OEM
- Public Broadcasting System
ROUTINE EMERGENCY NUMBERS
- Power Company
- Local Water Company
- Local Gas Company
- Local Telephone Company
- Local Emergency Management Office
- Water Treatment Supply Vendor
- Dialysis Machine Supply Vendors
- Medical Supplies
- Emergency Transportation
- Generator Source
- Security Guards
- Waste Disposal
- Emergency Backup Facilities
SUGGESTED LIST OF FACILITY EMERGENCY SUPPLIES
- Emergency Generators or Electrical transfer switch and connect terminal for a portable generator
- Copies of the Emergency Renal Diet Plan
- Portable Radio
- Appropriate Amount of Emergency medical supplies
- Access to cellular communication
- Sources for obtaining Kayexalate supply
- Offsite emergency contact lists
EMERGENCY PLANNING RESOURCES
Listed with each agency are disaster preparedness resources and planning guides, with prices, available directly from that agency. More information can be obtained by contacting the listed organization directly.
FEDERAL EMERGENCY MANAGEMENT AGENCY (FEMA)
P.O. Box 70274
Washington, D.C. 20024
- FEMA Publications Catalog (FEMA-20). Free. Compendium of all available FEMA publications.
- Emergency Management Guide for Business and Industry (FEMA-141). Free. Reviews the need and importance of emergency preparedness. Reviews how business can plan for and evaluate vulnerability. Reviews major planning considerations and how to write an emergency plan.
- Are You Ready? (H-34). Free. Teaches basic steps to take in case of natural disasters.
- The CEO's Disaster Survival Kit (FA-81). Free. Reviews for the CeO or administrator ways to minimize risk, politically, legally, financially, and personally if disaster were to strike their facility. Helps identify how to react appropriately after a disaster occurs.
- Tornado safety Tips (L-148). Free.
- Emergency Broadcast System (L-93A). Free.
- Safety Tips for Hurricanes (L-106). Free.
- Hurricanes-Floods-Safety Tips for Coastal Flooding (L-111). Free.
JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS (JCAHO)
P.O. Box 75751
Chicago, IL 60675-5751
- Disaster Preparedness: Facing the Real Crises. $40 plus $3.95 shipping and handling. General preparedness for healthcare facilities.
MID-ATLANTIC RENAL COALITION (ESRD NETWORK 5)
1527 Huguenot Rd.
Midlothian, VA 23113
- Emergency Preparedness Guidelines and Resources. $5.00. Outline of what is needed in an emergency preparedness plan and available resources for help.
SOUTHEASTERN KIDNEY COUNCIL, INC.
(ESRD NETWORK 6)
7200 Stonehenge Dr., Suite 300
Raleigh, NC 27613
- Disaster Preparedness for Dialysis/Transplant Patients. Free. Outline of what is needed in an emergency preparedness plan and available resources for help.
ESRD NETWORK OF FLORIDA (ESRD NETWORK 7)
One David Blvd., Suite 304
Tampa, FL 33606
- Policies and Procedures for Disaster Preparedness. $20.00. All inclusive resource that provides insight on the development of emergency plans along with a comprehensive list of disaster preparedness policies and procedures for facility adaptation. Also includes sample patient emergency diet plans, and patient emergency supply list.
END-STAGE RENAL DISEASE NETWORK OF TEXAS, IND. (ESRD NETWORK 14)
1755 N. Collins, Suite 21
Richardson, TX 75080
- Disaster Planning. $10.00. A resource manual for developing a comprehensive dialysis facility disaster preparedness plan.
THE TRANSPACIFIC RENAL NETWORK
(ESRD NETWORK 17)
25 Mitchell Building, Suite 7
San Raphael, CA 94903
- Disaster Preparedness for Dialysis Facilities. $125.00. Guide that provides information on the subjects of disaster preparation and mitigation, facility and medical management, organization, and operations. Sample ready-to-use emergency procedures are included.
- Disaster Preparedness for Dialysis Patients. $5.00. Patient education booklet. Provides information on emergency meals, supply lists along with other records and information the patient would need in time of a disaster.
THE NATIONAL KIDNEY FOUNDATION
30 East 33rd St.
New York, NY 10016
- Planning for Natural Disasters (Pub. 08-08 CM). $2.00. A guide for renal facilities, complete with sample checklists and forms.
- Planning for Natural Disasters: A Guide for Kidney Patients (Pub. 0807 CM). Free. A guide for patients which include sample meal plans, lists of emergency supplies, and forms.
- "Coping With Calamity: How Well Does Health Care Disaster Planning Work?" JAMA, December 21, 1994, Vol. 272, No. 23.
- "Disaster Preparedness: Is Your Unit Really Ready?" Caroline S. Counts and Barbara F. Prowant, ANNA Journal, June 1994.
- "Earthquake! How One Dialysis Center Coped as a 6.8 Trembler Rocks L.A." Contemporary Dialysis & Nephrology, April 1994, Vol 15., No. 4.
- "Dialysis Units in the Midwest Scramble for Clean Water After Massive Flooding," Cynthia Knapp Lefton, Nephrology News & Issues, September 1993.
- "Hurricane Andrew: How Dialysis Patients -- And the Professionals Who Care for Them -- Survived," Robin Allen, Contemporary Dialysis & Nephrology, February 1993.
- "Stormy Weather," Marie Nordberg, Dialysis and Transplantation, January 1993.