DISASTER PLANNING

Detailed preparation helps maintain patient services and aids recovery

In 2005, the Ophthalmology Department at Hanusch Hospital, Vienna, Austria, received a disturbing call from the neurology service. They had admitted a patient they strongly suspected had prion disease. Six weeks earlier this patient had uncomplicated cataract surgery at the hospital, raising the possibility that subsequently treated patients had been exposed.

'My predecessor immediately closed the operating theatres,' says Oliver Findl MD, Hanusch's current ophthalmology chair. Seven days later the patient died. Pathology confirmed spongiforme encephalopathy and immunohistochemical evidence of prion proteins.

While the risk of transmitting CJD via contaminated instruments was probably extremely low – in fact, no cases for cataract surgery have ever been reported – it could not be ruled out entirely. So, 153 patients treated after the infected patients were informed of their potential exposure in the presence of a psychologist, according to a published account in Spektrum der Augenheilkunde (2006) 20/4: 191-195.

The hospital staff also could not be sure which operating rooms or instruments may have been contaminated directly or indirectly, nor could they be sure that their regular sterilisation routines eradicated the prion. So out of an abundance of caution, all operating rooms were decontaminated, and all instruments destroyed. During the seven working days this took, 111 admissions for surgery were cancelled and delayed.

While this precise incident was not anticipated, Hanusch's crisis staff was prepared. They immediately researched the disease and mobilised resources to contain it and inform the public. Nonetheless, the cost of this incident was estimated to have been e360,000.

To reduce both the human and financial impact of future contamination events, including less lethal but more common threats such as toxic anterior segment syndrome, Hanusch implemented several new processes, Dr Findl says. These include a bar-code tracking system for surgical instruments and phaco cassettes, which allows the hospital to track which devices were used with which patients, and which were processed together. This helps both narrow the universe of potentially contaminated devices, and identify potentially exposed patients. Pre-sterilisation cleaning processes have also been revised to reduce risks, and disposable instruments are used where possible. Incoming patients also are screened for risks, such as any invasive neuro procedures such as spinal taps, neurosurgery or dura transplants, though the efficacy of this precaution is undetermined, Dr Findl adds.

With the science and regulation of hygiene ever advancing, keeping up takes effort and expertise. While large institutions like Hanusch generally have sufficient in-house resources, including dedicated infection control and risk management staff, to manage this kind of disaster, private clinics and small units may not, Dr Findl notes. These practices may be best served by outsourcing instrument sterilisation, and hiring consultants to ensure ongoing compliance, he suggests. The cost of such prevention may be high – but the human and financial cost of even one avoidable outbreak could easily be much higher.

Threat assessment An infection outbreak is just one of a nearly infinite range of disasters that can strike a practice. These include relatively common accidental events such as fires and power loss due to winter storms, all the way up to hurricanes, floods and the combined earthquake-tsunami-nuclear meltdown now under way north of Tokyo. And then there are man-made threats, such as bomb threats, robberies and terrorist attacks. Any one of them could temporarily compromise your ability to deliver patient care, or even shut down your practice permanently, says Owen Dahl, Houston, US, author of The Medical Practice Disaster Planning Workbook (Greenbranch Publishing, 2000-2009).

Mr Dahl recommends assessing your specific physical and medical risks, and preparing a plan to address them. The overall goals are to survive the event, maintain services if possible, and re-establish your business. Among the universal precautions he advises:

• Protect medical records – Access to records can allow you to practice even if your physical location is completely destroyed. This is easy for practices with electronic records. Install fire-and-water-resistant drives on-site, back up off-site, or even use a remote-hosted record system. Paper records are tougher. On-site record rooms should be behind firewalls and resistant to floods. Off-site copies should be kept in facilities with similar protections.
• Maintain patient communications – Major disasters, such as earthquakes, hurricanes, floods, often disrupt both landline and mobile phones. HAM or citizen band radios and satellite phones can reestablish immediate communication. Forwarding practice communications to an answering service or information recording can help, as can updating a practice Website. Broadcast TV and radio may also be important communication tools.
• Prepare employees – All practice staff should know who to contact and what to do in an emergency. Phone trees may come in handy.
• Coordinate with local hospitals and emergency agencies – Hospitals, fire departments, police and regional and national medical and emergency response agencies typically have detailed plans. Coordinate your plans with theirs.
• Pack an emergency kit – It should include clinical items you may need in an emergency as well as documents – such as your medical licence or other credentials – that you may need to work even in an emergency situation. You may also want to take important financial information, chequebooks, contracts or other business-related papers that will help you restore your practice after a disaster.
• Get proper insurance – This is especially important for private practices. Make sure your equipment and premises are covered sufficiently to replace them if needed. Loss-of-income insurance may also be worth looking at if it can be had. Also be sure to document your practice equipment with photographs, purchase receipts and other documents that may be needed to file a claim.
• 'It's not just the headline event you should worry about. It's much more likely to be a fire or flood or accident,' Mr Dahl says. But if you're prepared, it won't be the end of the world.