Understanding and Implementing Standards and Guidelines for Emergency Management

Several regulations, guidelines, and standards have improved the management of emergencies and disasters in the United States over the last two decades. Such publications have been developed and released by organizations and government agencies such as ASTM International (formerly the American Society for Testing and Materials), the Occupational Safety and Health Administration (OSHA), the Environmental Protection Agency (EPA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Department of Veterans Affairs (VA), and the National Fire Protection Association (NFPA).

The principles within these standards and guidelines regarding

  • mass-casualty incidents,

  • hazardous materials,

  • decontamination, and

  • emergency management program development.

Multiple- and Mass-Casualty Incident Standards

ASTM standard F-1288, Standard Guide for Planning for and Responding to a Multiple Casualty Incident, covers planning, needs assessment, training, interagency coordination, mutual aid, and other important issues as they relate to multiple-casualty incidents. It identifies key terms and activities and explains how the incident management process is organized at the scene (ASTM 1990).

In addition to that standard, George Washington University recently developed a peer-reviewed model for mass-casualty response that integrates the functional requirements of medical, public health, and emergency management agencies in the Medical and Health Incident Management System (MaHIM) (available online at http://www.gwu.edu/~icdrm/). The model was based on the definition of a mass-casualty incident involving 5,000 casualties, 10 percent of which would be considered significant (Barbera and Macintyre 2002). Casualty refers to any human accessing health or medical services, including mental health services and fatality care, as a result of a hazard impact. The MaHIM model clarifies the types of activities that may become necessary at the community-health-system level and how they would be organized in a mass-casualty incident.

It is a useful tool for jurisdictional and regional system development, education, and planning. The Department of Health and Human Services (U.S. DHHS 2002) and the Department of Homeland Security (U.S. DHS 2003) promote this type of management-system framework and are considering applying MaHIM to support current public health and hospital bioterrorism preparedness (CDC 2003). MaHIM is entirely consistent with broader efforts to create a national incident-management system (The White House 2003).

Hazardous-Materials Legislation

A sentinel event occurred in 1985 in Bhopal, India, in which thousands were killed and injured as a result of the release of a toxic gas from a nearby industrial facility. Congress responded to the concerns of such a disaster occurring in the United States by enacting the Superfund Amendments and Reauthorization Act (SARA) of 1986, amending the Comprehensive Environmental Response, Compensation and Liability Act of 1980.


The basic purpose of SARA Title III, also known as the Emergency Planning and Community Right-to-Know Act, was to promote emergency planning to respond to chemical releases and to ensure that information regarding chemicals in the community is available to the public and emergency response agencies. These goals are accomplished by

  • establishing state emergency response commissions and local emergency planning committees (LEPCs) with responsibility to develop emergency plans to be followed in the event of a chemical release and

  • implementing a series of notification and reporting requirements to state and local emergency planning activities with respect to type and quantities of specific chemicals.

Environmental Protection Agency

As part of SARA Title III, the EPA will not enforce HAZWOPER for environmental consequences stemming from necessary and appropriate actions such as decontamination during the phase of an emergency response where an imminent threat to human health and life is present. However, once this phase passes, every attempt should be made to contain the runoff and dispose of it properly (Makris 1999).

Beyond industrial or transportation accidents involving hazardous materials, recent events have directed major emphasis on preparedness for occurrences involving weapons of mass destruction. Because of this threat, hospitals and health departments have become much more involved in communitywide emergency preparedness efforts.

One question that has been hotly debated is how SARA Title III, or more specifically HAZWOPER, applies to healthcare facility preparedness for these types of hazardous materials. OSHAs position until lately had been that if the contaminating substance was unknown, staff performing decontamination at a hospital who were not in the immediate area of the release were required to wear Level B personal protective equipment (PPE), including a mask supplied by an external air source.

Many experts disputed the necessity of this elevated measure of pro tection, contending that Level C PPE using a full face mask with powered or nonpowered canister filtration systems was adequate for hospital decontamination (Macintyre et al. 2000). In September 2002, OSHA took the position that as long as the choice of PPE was based on a risk assessment conducted by the employer, the agency would not require any particular level of PPE and respiratory protection (Fairfax 2002).


Healthcare facilities that do not prepare for the potential arrival of contaminated patients face a dilemma. Refusing to assess and, if necessary, stabilize a contaminated patient is a violation of the Emergency Medical Treatment and Active Labor Act (U.S. GAO 2001). Employees who have not been adequately trained or equipped to deal with the situation can refuse to participate, leaving the facility only one choice: to dial 911 and request support from the local public safety system. These same resources, however, may already be fully involved at the site of the release.

Department of Vetemns Affairs

The VA developed a mass-casualty decontamination program that is based on a site-specific hazards vulnerability and capability analysis of the facility and surrounding community. Permanent or semipermanent showering facilities (in smoking shelters, along an external wall, etc.) are seen as advantageous over temporary tent-type facilities because of the speed of setup and lower expense (VA 2002a). Macintyre et al. (2000) believe that the following aspects are key to an effective decontamination protocol:

  1. Event recognition

  2. Activation

  3. Primary triage

  4. Patient registry

  5. Collection of clothing and personal property

  6. Decontamination

  7. Secondary triage

  8. Treatment and post-incident activities (e.g., media and family relations, medical surveillance, critique, etc.)

Healthcare-facility-decontamination training programs should follow NFPA standard 473, Standard for Competencies for EMS Personnel Responding to Hazardous Materials Incidents (Beatty 2003). NFPA 473 (this standard may be reviewed at http://www.nfpa.org/PDF/473.pdf?STC=nfpa) identifies the levels of competence required of emergency medical services personnel who respond to hazardous-materials incidents (NFPA 2002a). It specifically covers requirements for basic (Level I) and advanced (Level II) life-support personnel in the prehospital setting. This standard also provides information on training, recommended support resources, medical treatment considerations, patient decontamination, and hazardous-materials characteristics and references.

Emergency Management Standards

Joint Commission on Accreditation of Healthcare Organizations

In January 2001, JCAHO updated its emergency preparedness standards (standards EC.1.4, EC.2.4, and EC.2.9.1[1.] found in the Environment of Care, or EC, section), adopting the four phases of comprehensive emergency management: mitigation, preparedness, response, and recovery. Other key additions to the emergency management standards were requirements for a hazards vulnerability analysis (HVA), the requirement that healthcare organizations implement an incident command system (ICS) consistent with that used by their community, and the acceptance of tabletop exercises for one of two required annual drills. Specific requirements for drills include the following:

  • A facility designated as business occupancy must execute one drill annually.

  • Hospitals, long-term-care organizations, ambulatory care facilities, and behavioral health facilities not classified as business occupancy must conduct drills twice a year at least four months, but not more than eight months, apart.

  • Facilities offering emergency services or designated as disaster receiving stations must base one exercise on an external disaster, and it must include volunteer/simulated patients who must be triaged, put on stretchers or in wheelchairs, and transported through the system as if they were actual patients.

  • An organization must participate in a community drill that is relevant to its priority emergencies and that will assess communications, coordination, and the effectiveness of the organization’s and the community’s command structures.

The events of terrorism that took place in the United States in fall 2001 brought several more changes to the overall 2002 standards, including clarification on the process and products of the HVA (in particular, that procedures should be developed for each priority hazard identified), a requirement for cooperative planning with other healthcare facilities in the geographic area, and procedures for emergency credentialing. In 2003, components of the hospital emergency management standards were extended to long-term care, ambulatory care, behavioral health care, and home health care settings (Environment of Care News 2002). For 2004, the EC standards have been renumbered and reformatted but have not undergone any substantive changes in requirements.

National Fire Protection Association

NFPA emergency management Standard 99, entitled “Healthcare Facilities,” contains very similar requirements to JCAHO (NFPA 2002b). One big difference between the standards is the additional material in the annexes of the NFPA standard: explanatory material, references, and additional planning considerations (NFPA 2002a).

NFPA Standard 1600, Emergency Management and Business Continuity Programs, has gained international recognition and consensus among the public and private sectors. This standard articulates the generic elements of these programs and serves as the basis for an emergency management program evaluation and accreditation system by state, local, and tribal governments (NEMA 2001). Thus, NFPA 1600 represents a standard for communitywide emergency management programs (NFPA 2002c).


No emergency preparedness program is complete without a continuous quality improvement (CQI) program. The optimal way to ensure that programs and plans are updated and effective is through the use of a sound CQI program that evaluates the various parts of the emergency management program, identifies deficiencies and issues for action, and develops and tracks solutions for those identified problems. Plans will need to be changed or modified as resources, requirements, threats, and vulnerabilities fluctuate.

CQI programs should include prospective, concurrent, and retrospective review. Prospective review may evaluate resource inventory control and tracking, personnel training, or currency of memoranda of understanding. Concurrent review usually occurs as drills, exercises, or response operations are conducted and evaluated. Retrospective review often involves identifying specific events (such as a motor vehicle accident involving multiple casualties) and performing a retrospective record review to determine areas of difficulty in operations that may translate to further problems in the event of an even larger disaster.

A periodic review of the facility plan is advisable every six months to one year. The plan should also be reviewed after any exercise to accommodate shortfalls or better ways to accomplish certain disaster tasks. However, the best and most critical time to review your facility plan is after a real disaster that tests every part of your plan. A critique of the disaster from impact to recovery should indicate areas of the plan that worked well and areas that did not work as planned.

After objectively reviewing the findings from your disaster critique, the plan is ready for revision, addressing any gaps and shortfalls discovered. Action to be taken should be fully documented, with time frames for completion or implementation. Those you cannot act on at the present time should be noted and carried forward for future action. A substitute or other means of remedying the situation or problem should be found.

After the plan has been revised, approved, and shared with all involved, it must be tested and reviewed once again, implementing suggestions for improvement at each opportunity. A good planning and quality improvement process never ends.

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