The National Fire Protection Association is an old and venerated partner with deep roots in the protection of members and society at large on the issue of Fire Protection. Over time, however, the NFPA began offering guidance on Healthcare Facility Emergency Preparedness and Procedures, and has included fine-tuning recommendations in their touted updated NFPA 99 Guidelines. Unfortunately, like many other Congressional, non-federal and federal oversight entities; American Institute of Architects (AIA), Joint Commission (JC), Department of Health and Human Services (DHHS-ASPR-CMS), Department of Homeland Security (DHS), American Hospital Association (AHA), Department of Energy (DOE), Nuclear Regulatory Commission (NRC), American National Standards Institute (ANSI) and Office of the President, ponder over when to move essential life and limb saving actions from “Should to Shallâ€.

The Secretary of Health and Human Services Sibelius’s Speech today focused on an “Evidenced-Based†theme for the solutions to the nation’s challenges in providing healthcare to future populations. The same should be the basis on which the healthcare industry approaches the safety and security of the country’s locus of care.

Any reasonable mind would accept the fact that over the last decade All-Hazards threats have placed the trusting public at great risk. A number of the nation’s economic sectors have been resistant to becoming a full partner in the country’s strategy for Homeland Security preparedness. The Public Health and Healthcare sector is and has been characterized as the “weakest link in the Homeland Security chainâ€.  The NFPA has been slow to provide timely guidance to the healthcare industry to meet the increasingly hostile environment posed by known natural and man-made threats. One could understand that the NFPA 99 standards on Health Care Facilities (2002) did not reflected the 9/11 terrorist’s attacks. Or the 2006 reflect the lessons learned from Hurricane Katrina tragedy.  It is mind-numbing to think that 7+ years after Katrina to use Hurricane Sandy as a catalyst to change “Should to Shall†and envision doing that in three years.

The same can be said about AIA Guidelines for the Design and Construction of Health Care Facilities (2002-2006-2010).

Despite a plethora of 9/11 Commission Recommendations, Homeland Security Presidential Directives and Presidential Executive Orders (both political parties) the Public Health and Healthcare Sector remains ill prepared to meet their expected roles and responsibilities for known all-hazards.

Concerns over The “objectivity†of guidance by those organizations and other entities which provide standards and codes were expressed well before 9/11 and Katrina. The Presidential Advisory Commission on Consumer Protection noted:

While Fire Protection is one of many important disciplines required to make a healthcare facility safe for All Hazards, the NFPA does a disservice to the public users of the healthcare industry by taking at face value the opinions of self-serving “expertsâ€, making uncritical statements about the great job done during Sandy, how far we have come since Katrina, and the stellar job being done to improve readiness. There is ample evidence that this may be misguided and that by perpetuating the myths, large healthcare organizations and oversight entities are putting lives at risk through “sins of omission†and/or “sins of commissionâ€. From where I sit, sins of omission are often the most harmful to the public good, and require the least courage.

For this discussion, we will reference two articles published in the Jan/Feb 2013 NFPA Journal. For our organization, which dedicated to informing the public and helping healthcare facilities prevent loss of life, it is truly disheartening to see an organization with a proven track record in their domain, trade on their reputation in Fire Safety in the adjacent discipline of All Hazards Readiness and re-enforce the known gaps in Readiness the vested interests. For example, this article extolls the virtue of the New York City Teams in evacuating the estimated 6,000 patients during the storm due to flooding and loss of electricity in hospitals. We take exception to several statements made in the article, including:

Assertion: “According to the Greater New York Hospital Association, which helped coordinate the evacuations, about 6,000 people were evacuated from various health care facilities in New York City — nursing homes and adult day facilities among them — including five city hospitals.   “The fact that not one patient died or was seriously injured as a result is a testament to the incredible work done by teams of dedicated people who communicate regularly throughout the year on how to prepare for a host of potential emergency situations,†says Susan C. Waltman, the association’s executive vice president and general counsel. “Communication, cooperation, and collaboration are critical elements to the success of any emergency preparedness plan.â€

Reality: We do not know whether people died as a result of evacuations during Superstorm Sandy because there is no appropriate mechanism to count them as deaths directly related to the storm. As of mid-January many nursing home patients were still on re-location cots rather than in their rooms. There is also no real way of knowing about the outcomes of the 6,000 evacuees and whether the chaotic evacuation contributed to poor outcomes or even death.

 Assertion: “Since evacuation is considered a worst-case scenario in health care settings, Superstorm Sandy has initiated discussions on shortfalls in emergency planning procedures at these facilities, similar to what occurred after Hurricane Katrina ravaged New Orleans and the Gulf Coast in 2005.â€

Reality: Evacuation is a worst-case scenario and becomes even more so DURING the storm and in the flooded environment, in the decade prior to Katrina Nursing Homes were regularly evacuated for hurricanes as the safest MO for patients. As hospital and facilities ownership has become more concentrated, more decisions are being made by remote location rather than on the ground – whether more of a decision made by “risk managers†than healthcare administrators is another question to be discussed in a later post, but the critical decision to Protect in Place (PiP) or Evacuate is the most important decision that can be made and in cases like Sandy and Katrina, the EXACT same mistakes were made:

1) Watch the storm come over the course of several days and let politicians and commercial interests decide to avoid evacuation,

2) Scramble when the surge knocks out generators and rely on National Guard soldiers to help evacuate the frailest patients during chaotic conditions, causing a traumatic experience for the patients.

3) The article asserts that there is no written guidance on how to decide whether to Evacuate or Protect in Place. This is a total misunderstanding of the available Guidance for making the most critical decision for healthcare authorities to make. We covered this in an article for the Journal of Healthcare Protection Management several years ago. A PDF copy of which is here. We also see many other discrepancies in the Katrina sidebar of the article in terms of procedure and available guidance, and even the mission of developing and implementing an Emergency Management Plan. For example, the statement that patients will be more comfortable if services are available is a no-brainer and is the key reason for having a plan in the first place. The fact that the article fails to inform that 334 of the 971 bodies recovered after Katrina were found in hospitals and nursing home facilities. We think it is fair to say that 334 would probably not have perished if a proper, large-scale evacuation was implemented according the PAM excise findings just a year earlier, which happened to be a clone of what was to be Katrina.

4) You cannot have it both ways: Manhattan was evacuated to Hurricane Irene, citing evacuation as the proper action after health authorities weighed the risks; why they neglected to do this for Sandy, which was known to be approaching rapidly with forecasts of a truly epic storm, is unknown. Many questioned whether it was politically or economically motivated, willing to risk the lives of the frailest patients – the youngest and oldest or sickest. Our article prior to Sandy’s NY landfall, we asked the question: Would New England be as Tolerant as New Orleans?

From the same article:

“Assisted by hospital staff and emergency responders gripping flashlights, Chu descended 13 flights of stairs by foot as hospital personnel evacuated her newborn son. She noticed other new mothers and seriously ill patients — some attached to IVs and other medical equipment — being transported on plastic “med sleds,†used for emergency rescues, or in the arms of rescuers. “Everyone was pretty calm,†Chu told the Associated Press. “I would call it organized chaos.â€

“Rescuers traversed the darkened stairwells as many as 15 times to evacuate the hospital’s 325 patients, including babies from the neonatal intensive care unit who were attached to battery-powered respirators. The patients were then transported to 14 facilities in the Greater New York area. (Langone supplied these figures, but declined an interview with NFPA Journal for this story.)â€Â Doesn’t sound too much like a safe environment.

The fact that the generators could be knocked out by flooding in the first place is a testament that people do not learn from history – they moved the generators out of the basement and left the fuel pumps below the flood plain. The NFPA Journal in a separate article discussing the lives lost at St. John’s Hospital in Joplin made the following “lessons learned†pronouncements:

• “Lesson Learned: Install Redundant Sources of Primary Powerâ€

• “Lesson Learned: Harden and Protect Backup Power Sourcesâ€

• “Lesson Learned: Install Backup Power for the Backup Powerâ€

Despite being published right next to the Sandy article, there is no mention of these lessons learned in Joplin as they might apply to Sandy. The article fails to inform that the Long Term Care facilities were not part of the Local, State, County and Area Emergency Management Plan, despite self-reporting that told a different story. Seven years after Katrina, no professional industry watcher should need to be reminded that emergency power and backup should be above the flood plain; it is safety 101.

Another cause for concern as they step out of their depth of expertise is quick membership in the Mutual Admiration Society of those who perpetuate the Healthcare Readiness myths;

Assertion: “For instance, the 2012 edition of NFPA 99, Health Care Facilities, has reinforced provisions that help identify hazard vulnerabilities and organize an emergency operations plan. The Joint Commission, which certifies and accredits more than 19,000 health care organizations in the U.S., has also bolstered similar provisions mirroring elements of NFPA 99. Long-term care facilities have developed more stringent mutual aid plans that include mandatory, emergency evacuation exercises.â€

Reality: TJC does accredit 19,000 hospitals and all of the hospitals in New Orleans where the aforementioned patients died during Katrina were accredited by CMS contractors, as were all of the evacuated Sandy hospitals. Recent DHHS-IG Reports (OIG OEI-06-06-00020) and OEI-06-09-00270) found that over 90% of the Healthcare Facilities self-reported being prepared for having an Emergency Operations Plan (EOP) for All Hazards Events. A more revealing statistic, however, is that among 26 facilities that were audited on-site for their EOPs, 0% had followed the suggested guideline checklist to complete the EOP. Without sounding too jaded, my instinct tells me that the 0% number is probably closer to reality for the general population. Also, for those who are not following the discussion on a regular basis, “reinforced provisions†and  “initiated discussions†can be translated from Newspeak into adding recommendations with a “should†rather than “shall†in front of them. Not mandatory for certification yet, another nod to apparent financial interests over the safety that is stated as the primary mission. We have seen what happens when the guidance is considered too onerous by the facilities who should be implementing it. The industry push-back that left TJC impotent after trying to strengthen requirements in 2007 is the best undeniable example of industry interests versus safety and security of patients. This is also cited in the article as evidence of progress when in fact it tells a different story.

As background, TJC is a virtual monopoly that theoretically controls the flow of Federal funds to healthcare institutions, including Medicare, using accreditation and deeming status. While it has been instrumental in helping achieve better CLINICAL safety in healthcare, it has been lockstep with industry on slowing the adoption of All Hazards Preparedness due to push back from it largest members; in fact it has given up its’ responsibility to the trusting public and morphed from industry watchdog to big money lapdog – which is an egregious failure to the most vulnerable among us – Hospital and Nursing Home inpatients. More so because its’ history as a Congressionally-supported monopoly has left very little room and miles of red tape for any would-be competitors or innovators. To our knowledge, only a handful of hospitals have been denied deemed status and actually lost access to Federal dollars for non-compliance, which is the only stick really carry.

Why do we think the same may be true for NFPA? It is a question of the same behavior and claims; in the section of the article called “Setting the Standardâ€, the following claims are made:

Assertion: “Following Hurricane Katrina, the NFPA 99 committee made a point to extensively update the code’s provisions on emergency management. Dedicating Chapter 12 to this subject, the 2012 edition of NFPA 99 includes a section on developing a hazard vulnerability analysis (HVA), which identifies threats — natural, man-made  or technological — to a facility and the impacts on patients and staff. The code also includes a list of mitigation strategies to eliminate the identified hazards.â€

Reality: There is no lack of advice and guidance on how to prepare an HVA and EOP, an Internet search will get you what you need from FEMA, DHHS, DHS and State Agencies. The point is that until it is required rather than suggested it will never be a priority. Required with Accountability – both are sorely lacking in today’s environment.

Conclusion: The article also speaks of “hundred year†storms – and it seems like we have had several within the last decade, making timing of the essence. If NFPA really wants to make a difference they could change a few of the “should†recommendations to “shall†recommendations within the NFPA 99 and follow through by withholding certification for those who don’t comply, otherwise they should stick to indoor sprinklers and wildfires and fight their political battles there.

Post Script: Despite this type of critical editorial content, we rarely, if ever, get feedback that our position may be misguided. We welcome and invite an ongoing discussion of other points of view on these and other exceptions that may be taken by any interested parties.