By Stacey Kusterbeck
Unexpected ED closures can happen for many reasons. Departments may go on diversion because of physical infrastructure issues (e.g., tornadoes, earthquake damage, pipes bursting), because of safety issues (e.g., an active shooter, fire, or electrical problems), or a cyberattack.
Regardless of the reason, “our immediate focus is always on continuity of emergency patient care. Patient safety takes first priority,” says David K. Tan, MD, EMT-T, FAAEM, FAEMS, chief of the EMS division at the Washington University School of Medicine in St. Louis.
In the event of a diversion caused by a cyberattack, says Tan, EDs would need to mitigate any adverse effects on patient care. “It may not be entirely possible to insulate patients,” Tan admits. “But having paper order forms and manual backup plans for otherwise computer-dependent operations would be essential.”
Emergency medicine leaders must immediately notify surrounding hospitals and ambulance agencies of the situation, along with the expected resolution time. State laws vary as to exactly what is required. “In Missouri, we must simply have a diversion plan, and make a good faith effort to make necessary notifications,” Tan reports.
EDs do this through a web-based application, social media outlets, and the Hospital Emergency Administrative Radio (HEAR) system to divert ambulances to open hospitals. “The greatest barrier to effective preparation is having a false sense of security that ‘It won’t happen to us,’” Tan argues. An ED should start with a simple conversation. Representatives from each hospital service line and EMS leadership should be involved.
“Hospitals do this differently, but our particular institution works closely with emergency preparedness personnel,” Tan shares.
The group should formulate an approach to mitigate the effects of diversion, including from a cyberattack that results in loss of computer connectivity and phones. “The problem with many organizations, however, is that is where they often stop,” Tan laments.
A tabletop exercise or discussion is just a starting point; the next step should be conducting a real-time drill. “Be it preparation for an earthquake, tornado, or cyberattack, a real-time drill — with all the stakeholders, including the ED — is necessary to truly begin exposing opportunities for improvement after a preparatory tabletop exercise,” Tan says. Some problems and learning points can be discovered only during a drill. “It is important for hospitals to take the time to plan such an exercise,” Tan stresses.
Barnes-Jewish Hospital in St. Louis recently conducted a tabletop planning exercise for a tornado. The evacuation plan stated the hospital would move patients to other area facilities by requesting ambulances from the local fire department and mutual aid private services. The hospital later conducted an actual drill — and it became apparent that no such ambulances would be available. All the ambulances already would be pulled off to dozens of other citizen calls for help. “This gave us a great opportunity to educate stakeholders on the importance of involving EMS earlier, in the preplanning process,” Tan reports.
In the event of a diversion caused by a cyberattack, EDs need to mitigate any adverse effects on patient care. Maintaining paper order forms and manual backup plans for otherwise computer-dependent operations is essential. Leaders must immediately notify surrounding hospitals and ambulance agencies of the situation, along with the expected resolution time.
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