Reader Question: Emergency credentialing helps disaster response
But don’t go overboard, expert advises
Question: Like many hospitals, we’re trying to improve our emergency response plan in light of last year’s terrorist attacks. We’ve heard suggestions that we should have an "emergency credentialing plan" for physicians who are not affiliated with our hospital but show up in an emergency and want to help. Is this necessary or beneficial? How would we set up something like that?
Answer: An emergency credentialing system can be a good addition to your emergency response plan, but don’t go overboard with it, says Fay Rozovsky, JD, MPH, DFASHRM, a risk management and quality consultant. She is senior vice president of the March HealthCare Group in Richmond, VA.
The Sept. 11 attacks prompted many hospital leaders to question their preparations for a large-scale disaster, and emergency credentialing is an issue that falls squarely in the laps of quality and peer review professionals. In the New York attack, hospitals accepted help from hundreds of physicians who volunteered their services for expected victims. Many of those physicians went home without ever touching a patient because the flood of victims never materialized.
Nevertheless, the situation has led many to wonder whether the medical staff office should have a policy for credentialing physicians who are not members of the hospital’s medical staff or privileged at the facility.
It is a good idea to have a simple system in place, Rozovsky says, but she cautions Hospital Peer Review readers against the notion that they could do true credentialing in the midst of a disaster. For practical reasons, it wouldn’t work. "If we were ever in a situation like New York, with phones jammed and phone lines reserved for emergency use like ordering blood, how in the devil does one do emergency credentialing?" she asks. "You won’t be able to call Albany. Relying on a book published months ago doesn’t guarantee anything. When we’re talking about a true catastrophe of such magnitude that it’s overwhelming and lives are in the balance, you have to look at the emergency exceptions to every rule that requires credentialing."
The law and most federal regulations allow for good Samaritans and emergency conditions, Rozovsky says. Even those that don’t explicitly state an emergency exception can safely be interpreted to allow one under true disaster conditions in which a hospital needs every available physician. "That’s what a disaster is all about," she says. "The normal rules don’t apply because they just can’t apply."
That does not mean, however, that you should just open the front door and let in anyone who claims to be a physician. How much credentialing you can do depends on how much time and manpower you have to spare. For a routine sort of mass-casualty incident, such as a bus accident, you should try to stick with your credentialing program and verify any physician’s qualifications before allowing him or her to treat a patient. But on the other end of the spectrum, with a catastrophe, you may have to be satisfied with much less.
At a minimum, ask for identification from anyone volunteering his or her services as a physician. A good addition to a disaster plan, Rozovsky suggests, would be a system in which volunteer physicians are directed to a medical staff office where they can show identification and some type of physician verification. If more information is available, such as a certificate of malpractice insurance, record that information also. The medical staff office could photocopy their identification cards and provide a badge designating that they have checked in with the hospital. "Asking to see their identification and state licensure card is not really credentialing. It’s more like granting temporary privileges," Rozovsky says. "But that may be the most you can do if there are lots of hurt people outside waiting for help."
At a minimum, gathering the physicians’ identification allows for follow-up after the event. She also suggests that a hospital’s disaster plan should include training staff on how to work with volunteer physicians. If possible, it is best to pair the volunteer physician with a physician or nurse from your own facility, she says. That way, the in-house staff member can help the volunteer with unfamiliar surroundings and procedures. Pairing a volunteer with a staff member also allows the volunteer physician to be watched. "The volunteer physician should be limited in the scope of care he provides. If he says he’s a neurosurgeon, don’t let him go in the operating room and start working on someone’s brain," she says. "If a staff member sees the volunteer doing anything unusual or going beyond that basic care level, a stop sign should go up. You should encourage staff to speak up if they’re not comfortable with what they see."
Liability is not a big concern in such a situation, Rozovsky explains, because you can show that you were acting in good faith and the situation was extraordinary. Nevertheless, she advises contacting your risk manager and possibly your insurer for their input on any emergency credentialing policy. "We’re not talking about getting lax just because your emergency room is busy one night," she says. "But I have to believe that the people who survived those towers coming down in New York, as badly injured and burned as they were, just wanted a doctor. They didn’t want someone keeping the doctors outside because they couldn’t check their credentials. Sometimes, we just have to be practical."
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