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Hospital Safety Center April 2010


April 1, 2010

Options for corpse storage during emergency response

Disasters point to ham radio benefits, too

The January earthquake in Haiti ravaged a city and left hundreds of thousands dead and injured, quickly overwhelming healthcare services. 

A few weeks later, a power plant explosion rocked Middletown, CT, putting the local hospital into emergency response mode. (For more details on these incidents, see the box on p. 2.)

Although unrelated, these two disasters nonetheless provide a strong case for planning ahead about how to handle actual or potential mass fatalities.

Joint Commission emergency management standard EM.02.02.11, element of performance (EP) 7, requires hospitals to plan for managing mortuary services during a disaster, particularly should an incident escalate within the community. 

Although the United States may never see a death toll approaching that from Haiti’s earthquake, even several hundred deaths in a community would overrun most morgues.

Some hospitals have storage shelf areas that can be cleared and temporarily used to hold bodies. Other sites anticipate using outdoor staging areas; if that approach is used, isolate the area from onlookers to maintain the privacy of the victims. (See a sample fatality management standard operating procedure on p. 4.)

Following the Connecticut power plant explosion, Middlesex Hospital, a 275-bed community facility in Middletown, was quickly put on alert about a potential mass casualty event, says Jim Hite, the facility’s emergency planner and director of safety and security.

Hite also had concerns about cadavers from this incident. Although a field morgue was set up at the power plant, he knew the hospital might be asked to store corpses. The facility’s morgue capacity is 10 bodies, but the building has a utility hookup that allows refrigerated trucks to connect to hospital systems at the loading dock. 

Had it been needed, the hospital could have had a refrigerated trailer at the hospital within a couple of hours to handle an overflow of deceased victims, Hite says. The hospital also had 100 body bags ready, which were available as part of the facility’s H1N1 flu preparation.

As it turned out, there were five deaths in the explosion, so morgue services weren’t taxed.

Local facilities might share cold storage

Beyond refrigeration trucks, there are several other good choices for temporarily storing mass fatalities. 

Beverage and beer distributors, cold storage warehouses, refrigerated rail cars, and mortuary emergency cooling systems (also called MERC units) are all worth investigating in your community, says John B. Linstrom, MIFireE, CHS-III, executive director at The Linco Group, LLC, an emergency management consulting firm in Apple Valley, CA.

One option to avoid is the local ice rink. “The surface is slippery for workers, [and] there is no optimized method to store the deceased without freezing them to the surface or stacking the dead on pallets,” Linstrom says, adding that the stigma of corpse storage may also cause families and others to avoid the rink in the future.

Other lessons from earthquake and explosion

Hospital safety and emergency management committees should also review the following response aspects from the Haiti and Connecticut disasters:

• Choose incident commanders wisely. During off-shifts and weekends, the nursing supervisor on duty at Middlesex Hospital is the designated incident commander. That approach was important because the plant explosion occurred on Sunday morning during Super Bowl weekend, when many top administrators weren’t at the hospital.

While the facility’s e-mail and phone alert system reached out to off-duty managers and staff, the nursing supervisor huddled with other nurses, security officers, and hospitalists to plot out immediate actions in response to the explosion, Hite says. For example:

- Hospitalists began determining which patients could be rapidly discharged in order to free up beds

- OR staff began preparing the post-anesthesia care unit to open up beds

- Security officers were posted at every hospital entrance in anticipation that concerned visitors and reporters would congregate at the facility seeking information about victims

• Consult with ham radio operators. It’s been proven time and again that communication systems will go down in any emergency, but Haiti’s circumstances have strictly reinforced that notion, as there were likely areas of the country with zero modern communication devices operating following the earthquake.

Amateur ham radio is a good resource to look into because it has the ability to overcome other communication outages.

“A cellphone cannot talk to a cellphone without running through a cell tower,” which can be compromised during a communications failure, says Allen Pitts, media and PR manager at the American Radio Relay League, a national association for amateur radio.

However, ham radio operators are far less reliant on intervening equipment. “Give a ham his radio, a battery, and a piece of wire and [he] will be able to communicate,” Pitts says.

A hospital that includes volunteer ham operators as part of an auxiliary team allows the facility to have a backup means of communication to the outside world, he says. Further, ham operators are often involved with other emergency groups, such as the American Red Cross, which may give your hospital a lifeline during a community catastrophe.

If you’re unfamiliar with ham operators in your area, go to www.arrl.org/sections for help tracking them down.

• Look into field triage to alleviate ED stress. In the immediate hours after the power plant explosion, Middlesex Hospital treated 12 victims from the scene. The call was eventually made to shut down the emergency operations center at the hospital because it appeared the response was over.

However, the facility then received word that 20–30 more victims were being held at a state hospital in Middletown near the power plant. 

Rather than again ramp up the emergency operations center, Middlesex Hospital instead sent an ED physician, a nurse, and a security escort to the state hospital. The clinicians performed field triage of the victims there, and 12 of them came by van to Middlesex Hospital and registered for treatment in the waiting room, Hite says. This approach also kept ambulances free for more urgent calls and took the surge off Middlesex’s ED, he adds. 

Other hospitals may want to work this type of approach into their emergency planning, and perhaps even recovery, stages.

• Consider geographic information systems (GIS). We first wrote about GIS in the January Briefings on Hospital Safety. In terms of a large-scale disaster like Haiti, GIS can map supply stockpiles and related travel routes, which will help multiple organizations better manage supply chains, says Ric Skinner, GISP, owner of Stoneybrook Group, LLC, a health geographics consulting firm in Sturbridge, MA. Following a disaster, there may be accelerated shortages of critical supplies and an inability to quickly restock them, Skinner says.

• Determine your family center plans. Middlesex Hospital opened its family center in the aftermath of the explosion for relatives and friends of victims. The center is staffed with crisis counselors and clergy, and cafeteria workers supply sandwiches and coffee, Hite says.

In fact, part of the cafeteria transforms into the family center through the use of retractable walls.

Snapshot of disasters in Haiti and Connecticut

  • Haiti, January 12: A large earthquake heavily damaged Port-Au-Prince and collapsed many buildings, including at least one hospital. International emergency aid arrived quickly, but supply bottlenecks at a harbor and the disaster’s widespread nature left many in need of desperate help. Triage efforts in the street and in tents were common sights on newscasts as clinicians, many of them volunteers, treated thousands of victims.
  • Middletown, CT, February 7: An explosion—believed to have been caused by some sort of natural gas leak or purge—occurred at the Kleen Energy Plant, which was under construction at the time and not operating, according to Middletown officials. Contractors were conducting various tests at the site when the blast happened. Five people died and about two dozen were injured.


Preview of the Hospital Safety Center Symposium

EC scoring may herald survey compliance pitfalls

Although it may not rank high on your chore list, take close reads of the scoring behind the EC standards, because they give you compliance hints.

A significant amount of the EC elements of performance (EP) are designated with a C score, meaning surveyors only have to find two instances of noncompliance to issue a requirement for improvement (RFI), said Steven MacArthur, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. He spoke during a February HCPro audio conference titled “Physical Environment Compliance 2010: Analyzing The Joint Commission’s Latest Interpretations and Survey Hotspots.”

For example, EC.02.03.05, EP 15, requires hospitals to inspect portable fire extinguishers monthly. If a surveyor finds two extinguishers without proper documentation for the monthly checks, a citation could follow.

Direct impact for some fire safety rules

Although the effects of direct impact EPs aren’t a terrible strain on safety programs, that ranking points to hot spots in the EC standards, said MacArthur, who will also be a featured presenter at the 4th Annual Hospital Safety Center Symposium, which takes place May 6–7 in Las Vegas (go to www.hospitalsafetycenter.com for more details). He’ll discuss the ties between the EC standards and infection control strategies at the symposium.

To quickly review, direct impact requirements—noted by a triangle icon surrounding the number 3 in the standards—are likely to create immediate risks to patient safety. The risks stem from a lack of processes to offset the threats. Under this level, hospitals must submit evidence of standards compliance for cited EPs within 45 days of a survey’s completion to The Joint Commission.

Under EC.02.03.05, there are three direct impact requirements:

  • EP 4, which requires testing visual and audible fire alarm components every 12 months. Hospitals trip up on this provision when they can’t show that all of the individual devices have been tested, MacArthur said. (See “Survey monitor” on p. 8 for more about how this concern came up during a Joint Commission visit.) Often, the problem lies with an over-reliance on outside vendors who perform this testing but don’t provide proper documentation.
  • EP 11, which mandates testing fire pumps under flow every 12 months. This EP was made a direct impact requirement for this year, likely based on the amount of problems with fire pump testing noted in the field.
  • EP 19, which requires testing smoke detection shutdown of HVAC equipment. When testing smoke detection devices on air handlers, verify that the intake and exhaust sides of the units close properly.

Generator testing also brings concerns

Emergency generator requirements under EC.02.05.07 also have implications from direct impact requirements.

“There are a lot of direct impact RFIs lurking in the weeds here,” MacArthur said.

EP 6 requires testing automatic transfer switches 12 times per year, at intervals of at least 20 days apart but no more than 40 days apart. Similar to fire alarm components noted earlier, a common problem with automatic transfer switches is a lack of records showing that each switch underwent testing, MacArthur said.

Also, don’t forget to institute interim measures under EP 9 if a required emergency power system test fails. Follow up on any testing failures immediately and get temporary safeguards in place as needed, MacArthur said.

“Your vendor documentation is of all importance,” he added. Ask vendors for written summaries of any emergency power testing problems they discover.


The benefits of customizing your HICS position chart

Rewording job titles and responsibilities helps tailor incident command

Many of you have turned to the Hospital Incident Command System (HICS) for organizational support during emergency exercises and actual disasters. 

HICS is an incident management system that allows hospitals to distinguish specific job responsibilities during a disaster using a position chart and accompanying job action sheets. 

However, some emergency managers find that the standard HICS chart includes too many positions or uses job titles that don’t coincide with their facility. Forward-thinking hospitals like Cookeville (TN) Regional Medical Center have conquered this problem by making their own adjustments. 

In 2008, Cookeville Regional emergency management employees whittled down the original 78-position HICS organizational chart to cater to the specific needs of their facility, says Mike Hellman, safety coordinator at the facility. 

“One of the reasons we got this ball rolling was because we were doing a regional tabletop drill during the time of the avian flu, and we started an incident command center and started using all the forms and trying to assign all these positions,” Hellman says. “And we were more worried about the positions and what each position’s responsibilities were, rather than the actual drill we were responding to.” 

Combining positions proves useful

A big part of downsizing the HICS chart was figuring out which positions could be eliminated or combined, based on personnel responsibilities at Cookeville Regional. 

That responsibility fell to Paula Jackson, RN, MBA, the permanent ED director, with input from others in the ED, such as Mary Stoltz, RN, BSN, currently the acting ED director. 

“I talked to her about it while it was going on, and it was obviously apparent that there weren’t enough people to assign to all [the positions], so we tried to figure out which positions we could live without or combine together into one or two or three positions,” Stoltz says. “We changed it three different times before we settled on this [version].” 

For example, the original HICS document called for one person in charge of mechanical, one person for electrical, and another for heating and cooling. 

However, there is just one person at Cookeville Regional responsible for facilities management, so all three positions weren’t needed under the hospital’s HICS approach, Hellman says. 

In another instance, the original HICS chart separated transportation and traffic control, but Cookeville Regional put those responsibilities under one person. 

Building HICS to fit your facility

The hospital also left enough HICS language in the job action sheets to maintain the original skeleton of the HICS system, which is familiar to most emergency preparedness personnel. 

Emergency planners have categorized the job action sheets and explained the responsibilities of the positions addressed, Stoltz says. “So if a stranger walks in here and is familiar with HICS but not with me, they should be able to read their job action sheet and take care of things,” she adds. 

HICS revisions pass Joint Commission muster

Further, you don’t need to fear any regulatory repercussions from The Joint Commission by amending HICS. 

Emergency management standard EM.01.01.01, element of performance 7, requires that the hospital use an incident command system that will integrate with the community’s command structure.

The Joint Commission doesn’t assign a specific type of incident command approach, so HICS is one option that is acceptable under EM.01.01.01.

Hellman says Cookeville Regional was surveyed in 2008, after it had utilized its new HICS chart during a tornado that brought in patients from surrounding counties. Surveyors were satisfied that the hospital had properly demonstrated compliance with emergency management standards.

For facilities that are attempting to reevaluate their HICS chart, Hellman suggests looking at specific positions and processes within the hospital and seeing whether they need to be better reflected under HICS.

Don’t be afraid to rename or combine HICS positions so that they make more sense within your organization. 

“We know what we call certain things,” Hellman says. The revised HICS chart “just feels more customized to our facility, and people are comfortable using it that way.”

Shadowing NIMS requirements

HICS aligns to an extent with the federal National Incident Management System (NIMS). Hospitals need to address 17 elements to comply with NIMS, which ties in with some emergency management funds from the government.

HICS assists hospitals in meeting most of these 17 elements, but HICS isn’t totally compliant with all NIMS activities for hospitals.

Editor’s note: To read full details and materials for HICS, go to www.emsa.ca.gov/hics.


Survey monitor

Past tabletop efforts rewarded during emergency session

Bucking what anecdotally appears to be a trend, Skaggs Regional Medical Center (SRMC) in Branson, MO, actually conducted a tabletop exercise for surveyors during the hospital’s Joint Commission visit.

Many facilities Briefings on Hospital Safety has talked to in the past year have noted there were no tabletop drills requested during the emergency management session. SRMC was prepared for its tabletop, however, because it frequently uses such methods to educate emergency management committee members about disaster response.

“I have done tabletops with [our employees] several times a year,” says Lou Smith, RN, CHSP, CPHRM, safety and risk manager at SRMC. Smith is in charge of emergency planning.

She’ll bring committee members, hospital directors, and managers into a conference room with little cards in front of each person—for example, one card will ask someone to assume responsibility for logistics, and another will be to take the role of incident commander. From there, Smith explains the scenario, the expected amount of victims, and resulting problems in the community.

“I [also] put surprises … in there,” she says. For example, in a scenario, “I cut off the phones. How are you going to talk now?”

That type of training paid off when surveyors conducted their own tabletop during the July 2009 visit (the hospital’s official reaccreditation was posted in October). 

During the session, Smith kept quiet and let the emergency management team do the talking. Surveyors often look at committee member participation, rather than the lead emergency management planner taking the lead, as a way to test how many people are familiar with the emergency operations plan.

The surveyor’s scenario for the tabletop was a tornado that hit the hospital. That setup was no problem for SRMC, given that staff had previously drilled on that scenario. Tornadoes and ice storms top the hospital’s identified risks from its hazard vulnerability analysis, which is required under EM.01.01.01, element of performance 2.

Smith makes sure that disaster readiness figures into mundane events, too. She recalls activating the emergency operations center when a water main broke outside the hospital.

“That gives people a familiarity of doing it so they get into that mode,” she says.

City has millions of visitors

Branson has more than 50 live performance theaters, bringing tourists from around the country and bolstering the summer population of the city up to 2 or 3 million (the city has about 7,000 actual residents).

SRMC is licensed for 175 beds, but the average daily census is 76 beds, Smith says. Annual ER visits total about 36,000.

“That’s a big ER for a facility of this size,” she says. “So we have to be ready to take care of an emergency should it happen.”

Community cooperation is key in such cases, and Smith’s experience at the hospital helps in this regard. She’s been employed at the facility for 35 years and was formerly the ER director for two decades, so she is able to tap into years’ worth of contacts with fire officials, police, utility providers, ambulance companies, and officials at the nearby College of the Ozarks.

Documenting individual device tests

The EC review was generally painless, Smith says. However, one slipup—which didn’t end up as a citation but could have under EC.02.03.05 (inspection and testing of fire protection equipment)—involved the documentation of various life safety device tests. The hospital presented surveyors with a sheet that stated that the facility’s fire safety systems and features had all been checked.

“They did not like that,” Smith said. “They wanted documentation that each individual device was tested and was good.”

This is an important point that many safety and facility managers misunderstand. The idea reflects a common saying among Joint Commission officials: “If it’s not documented, it didn’t happen.”

Fortunately, SRMC was able to produce the records of the individual tests, which staved off any findings. 

Surveyors like evacuation preparation

Surveyors were impressed with SRMC’s staff training for Med Sleds®, which are portable rescue sleds that allow clinicians to quickly evacuate patients out of units and down stairs by dragging them along the ground.

SRMC has instructed 105 people on Med Sled evacuation techniques by using three-person training teams, in which each participant takes turns manning the head and rear of the sled and acting as a mock patient strapped to the device. The teams practice negotiating stairwells with the sleds, Smith says.

About 10% of the hospital’s 1,049 employees are now familiar with Med Sled use, and each of the facility’s eight units has a regular-size and bariatric sled available.

ER employees wondered why they had to train on the sled use given that they are on the ground floor, but Smith’s reasoning is that those workers may be called to the upper levels to assist in evacuations during a fire or other emergency.

One survey readiness tactic that Smith employs on environmental rounds is to ask nurses to find the location of the nearest portable fire extinguisher.

“I give them a minute to find it and I time them,” she says. “And they’re hustling if they can’t find it.”

If a minute expires and a nurse has been unable to point out the extinguisher’s location, Smith shows him or her, and then requests that the nurse tell everyone else on the unit about the extinguisher’s location, too. That way, many staff members can benefit from the education.

Seek out fans of emergency training to help you

Lou Smith, RN, CHSP, CPHRM, likes emergency management.

“I’m passionate about it, and I engage people who feel that passion and get them excited about it,” says Smith, safe


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