Biomedical Engineering Reference
In-Depth Information
items via objective criteria. Performance items
may include use of specific equipment, proce-
dures, emergency plans, communications systems,
or a combination of those. Given the longstanding
JCAHO requirement of at least two exercises per
year, hospitals should house considerable exper-
tise in exercise design, conduct, and evaluation.
In fact, a most significant recurring pitfall in
hospital exercises is a distorted picture. An exer-
cise, like a written plan, may meet JCAHO stan-
dards without conferring significant benefit in
terms of actual preparedness or response capability
on the hospital(s) in question.
The most common types of exercises (tabletop
and functional) do not involve hands-on operations
but rather focus on decision making and plan eval-
uation. Even full-scale exercises, which combine
command-level decision making with hands-on
tasks, are limited in terms of space, personnel, use
of supplies, and the exercise schedule itself. Hospi-
tals must be able to receive and manage actual
patients during exercises, requiring either addi-
tional staffing to allow exercise operations to go on
alongside everyday operations or limiting the scope
and duration of play. Additional staffing for exer-
cises means additional cost and staff scheduling
challenges.
Because of the need for advance scheduling of
personnel and simply having sufficient personnel
on hand, two common exercise deficiencies ensue:
lack of surprise and preferential testing of the
most populated shifts. Lack of surprise may mani-
fest itself in numerous ways, including on-duty
staff having recently reviewed emergency proce-
dures (when they otherwise would not have done
so), necessary equipment and supplies in unusual
states of readiness and/or stocked in unusually high
levels, and specialized equipment set up in advance
of the exercise, even though there would have been
no reason to do so under non-emergency condi-
tions. Examples include ED physicians immedi-
ately diagnosing rare conditions that are part of
the exercise scenario, with equally rarely used
medications being immediately available in the
ED or pharmacy and, in more than one exer-
cise, a large ED having a full decontamination
station set up, with staff wearing full PPE, before
play even began. Any exercise scenario induces a
certain degree of artificiality, but effective exer-
cises are designed so that artificiality does not
interfere with evaluation of identified objectives.
Untoward, artificial, staff preparation for an exer-
cise adds artificiality that directly compromises
effective evaluation. In addition, the overwhelming
lack of exercises on evening and night shifts tests
capabilities only when a hospital is at its highest
staffing levels. This not only deprives some staff of
exercise experience, but also deprives the facility
of evaluating performance during off-shifts.
The combination of insufficient training and
ineffective exercises deprives staff of experience in
improvisation and decision making, thus increasing
the likelihood that a single significant obstacle
(for example, difficulty setting up decontamination
equipment, or even presentation of a contaminated
patient) can derail the exercise or actual response.
1.11 Suggestions
There are multiple potential solutions for the
challenges herein identified. Clearly, fundamental
changes are needed, either in the expectations of
hospitals (unlikely) or the resources made avail-
able to them to further the cause of prepared-
ness (more likely and currently improving). The
following suggestions are based largely on oper-
ational, intrafacility details (“what works”). There
is no question that hospital preparedness must be
part of a regional approach to health systems and
general preparedness across agency, jurisdictional,
and corporate boundaries. Hospitals are part of a
greater whole, but
each
hospital must also have
a degree of self-sufficiency to enable independent
operations should regional assistance be unavail-
able. My suggestions focus on making things
work better in individual hospitals; in so doing
I temporarily de-emphasize larger-scale financial,
political, and legal issues, which I will reexamine
at the end of this article.
1.12 Communications
The first step in designing an internal communi-
cations system that works in emergencies is to
