by  Ann L. McNary, JD

Ms. McNary is a Senior Risk Manager at PRMS, Inc.

FUNDING: No funding was provided for the preparation of this article.

DISCLOSURES: The author is an employee of PRMS Inc., a risk-management consulting company for health care providers.

This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and on-site risk management audits, and other resources offered to health care providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers might provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other health care professionals so “clinician” is used to indicate all treatment team members.

Innov Clin Neurosci. 2020;17(4–6):53–55

Question:

I’m a psychiatrist getting ready to open my solo practice. I’ve put together my Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance plan, my office policies and procedures, and all of my patient forms. Is there anything else I should think about?

Answer:

Yes! It sounds like you are off to a good start, but another thing you should really consider is an emergency plan for your practice. As I sit here writing this, we are in the midst of the COVID-19 pandemic, which has caused most doctors to significantly alter the way they are practicing right now. Recent years have brought a series of natural disasters all of which have had immeasurable impact on the physicians in the affected areas.

Even if you live in a part of the country where the likelihood of that type of event seems remote, don’t forget about emergencies that could occur just within your own practice. What if something happened to you and you were unable to see patients? It’s often impossible to prevent these events from occurring, but you can take steps to minimize their effect on your practice and protect the safety of those involved.

Getting Started

While it sounds daunting, an emergency plan need not be complex. Your plan might not look anything like that of a colleague. The important thing is that it takes into account the special circumstances and needs of your particular practice.

The first step in creating your plan is to identify potential risks. Think about risks that could occur not only in your actual physical office, but also outside of your office that can still significantly affect your practice. You might have a fire, flood, medical emergency, or violent patient within your office. Emergencies originating outside of your office might include a hurricane, tornado, earthquake, terrorist attack, or pandemic. Once you have your list together, try to rank each according to the likelihood that each could occur. Identifying how and where your office is most vulnerable will determine where to focus your attention so you can concentrate your efforts on the main areas of risk.

Once you have a list together, think about what you might need to alleviate, or at least mitigate, each risk taking into consideration what safety plans might already be in place. Let’s use the example of a fire in your building:

• Does the landlord/building maintenance have an evacuation plan or fire plan?
• If there aren’t building emergency plans, should you discuss this issue with the landlord/building maintenance?
• Who is the emergency contact if anything goes wrong in the building or if a problem is anticipated?
• Are there working smoke detectors?
• Is there a functional sprinkler system?
• Are there fire and other alarms?
• Are fire extinguishers checked regularly?
• Are fire exits and evacuation routes unobstructed?
• Are fire doors unlocked?

There isn’t a need to reinvent the wheel here; take this information and incorporate it into your plan. Locate and make copies of building and site maps with critical utility and emergency routes clearly marked.

• Identify and clearly mark entry-exit points (both on the maps and throughout the building).
• Post maps for quick reference by employees.
• Keep copies of building and site maps with your emergency plan and other important documents and also at an off-site location.
• Consider what other steps might be necessary for your particular office:
• Should you have a designated location for staff to congregate after evacuating the building?
• Should someone make sure fireproof cabinets are closed?
• Are there other requirements for your patient population?  For example, a geriatric psychiatrist might treat a large number of patients with mobility issues.
  

Helpful hint. Every state and most large cities have an emergency management office tasked with providing guidance and information in case of disaster. Most, if not all, of these offices have websites with useful information that will aid in emergency planning. Oftentimes, these offices will have resources that advise you about risks that are unique to your area. The website for the New York City Office of Emergency Management, for example, can tell you whether your office is in a low-lying area at risk from flood damage during a hurricane.

Filling in the Gaps

Once you determine what plans and procedures are already in place at your location, focus on filling in the gaps. You might live in a tornado-prone area but work in a building without a designated storm shelter, and your emergency plan might direct staff and patients to a particular area on the lowest level away from doors and windows. Or you might work in a building that has experienced flooding during severe storms, which means developing a plan and allocating resources to prevent the loss of patient and business records. This might include: having electronic back-up records taken weekly to a secure off-site location, transporting active patient records to a safe location when a severe storm is imminent, and storing inactive patient records with a medical record storage company.

Medical and psychiatric emergencies is another area that will need to be included in your plan. If you are considering using medical supplies/equipment or drugs to respond to an emergency, take into account the following issues:

• Can drugs be properly stored and secured?
• Who will have access? Does the system allow for quick access in an emergency while maintaining security?
• Is there a protocol for checking expiration dates and having an adequate supply available?
• If there is personal protective equipment available in the office (e.g., gloves, masks, resuscitation devices), is it easily accessible? Are the protocols for use defined?
• Do you and/or your staff have the appropriate credentials and training to intervene using drugs or medical devices?

It is recommended that any emergency plan include strategies for managing one of the most likely situations to arise in psychiatric practices: a patient or visitor who is agitated or becomes out of control and might injure himself or others. “Front-line” staff (e.g., receptionists, secretaries, administrative assistants) should be educated and trained to recognize potential emergencies and request help. Visible problem behaviors in a visitor or patient include appearing to be under the influence of alcohol or drugs, pacing and agitation, talking or complaining loudly, using profanity, and making any type of threat to others.

Staff should be trained to take the following immediate steps, such as activating the emergency system to notify other office staff of a problem, staying at least two arms’ lengths away from the agitated person, separating others from the hostile person (if possible), and being prepared to call 911. You might also consider installing a “panic button” system, or other communication system, for staff to notify others if help is needed.

Practice Continuation 

After you have addressed what you can do to manage emergencies within your office, you will want to give some thought to the worst case scenario: your inability to continue to see patients in your office following the emergency. In the event you were not able to see patients in your office for an extended period of time, where would you be? What plans/information would you need to meet their clinical needs? How would you make patients aware of this situation? If you were not in your office, would you able to:

• Access your appointment schedule?
• Access current contact information for patients?
• Leave an outgoing voicemail message to alert patients to the change?
• Access your patients’ records?
• Access necessary equipment (e.g., computer, scanner, fax)?

If the answer to any of these questions is “no,” think about what you might do to compensate for this and incorporate that into your plan.

Plan for the Unthinkable: What if Something Happens to You?

One potential emergency that cannot be overlooked is if something were to happen to you. Prepare a set of instructions for staff, family members, and willing colleagues regarding what should be done in the event of your sudden incapacity. The incapacity can be due to an accident, illness, family emergency, or other type of unanticipated event that takes you away from your practice on short notice. The plan need not be complex, but as with any emergency preparedness plan, it should be documented, readily accessible to those who may need to implement it, and regularly updated.

A list of suggested items to be covered in a contingency plan includes:

• Contact information: your cell phone number, home phone number, email address, and home address.
• Contact information for your spouse, life partner, adult children, or anyone else who would likely know of your whereabouts or sudden health problems.
• A statement that staff is authorized to contact these people in the event of your unexplained absence from the practice.
• Instructions regarding how long staff should wait before implementing the emergency contact plan in the event of any unexplained absence. (One hour is probably the longest period of unexplained absence the plan should allow.)
• Instructions regarding who is authorized to have access to patient records in your absence. These instructions also should specify what information can be released from the records.
• Instructions regarding prescription refills and release of information to third parties.
• Instructions regarding how to deal with patients who become upset, either physically or emotionally, in the event of a crisis.
• Names, addresses, and phone numbers of psychiatrists who have agreed to act as emergency backups. There should be more than one. Staff should be trained on proper referral procedures and proper termination-of-care procedures.
  

Putting it All Together 

Finally, put your plan in writing and share it with your staff:

• Everyone should know the location of the written emergency plan. Copies of emergency and evacuations plans, if any, for your building should be attached.
• Decide on a central telephone number where staff can call to get information if the office is closed or inaccessible due to an emergency.
• Emergency contact numbers should be available near all telephones.
• Have staff review the plan periodically. Hold an in-service training on responding to emergencies at least yearly.
• All staff members should be involved in identifying potential emergencies and updating the plan.

Conclusion

Psychiatrists and other healthcare professionals are often accustomed to planning for and responding to medical emergencies in acute care settings. Once in an office setting, however, many professionals fail to recognize the need for emergency planning. But injuries and damages resulting from disasters in an office setting are often just as devastating as those arising from emergencies in a hospital. Advance planning, staff training, and periodic reviews can ensure an effective response in even the most modest of practice settings and prepare both your staff and patients for the unthinkable, so when an emergency does occur, you can confidently maintain your focus on patient care.

For additional information, visit the following sites:

1. Federal Emergency Management Agency: www.fema.gov
2. FEMA links to your local state Emergency Management Agency: https://www.fema.gov/emergency-management-agencies
3. American Red Cross: www.redcross.org/services/disaster/beprepared/busi_industry.html
4. U.S. Department of Homeland Security: www.ready.gov