Briefings on Hospital Safety, April 2017
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March 30, 2017
Fake doc roams Boston hospital
Incident at hospital where surgeon was killed renews security debate
When a man upset over the death of his mother walked into a Boston hospital in January 2015 and killed the doctor who had treated her, it sent shockwaves through the healthcare safety community as an important lesson was learned about how susceptible hospitals are to security breaches.
Or so we thought, until a woman was discovered in September 2015 wandering through a Boston hospital posing as a doctor.
In the earlier particular case, Stephen Pasceri, 55, of Millbury, Massachusetts, walked into the Carl J. and Ruth Shapiro Cardiovascular Center at Brigham and Women’s Hospital on January 20, 2015, and specifically asked for the doctor, Michael J. Davidson. When the two stepped into an exam room to speak, colleagues reported hearing loud voices and then two shots fired as Pasceri shot and killed Davidson and them himself.
The shooting spurred Brigham and Women’s Hospital, as well as other Boston hospitals, to conduct their own security assessments and increase drills, and it inspired others across the U.S. to consider increasing security measures such as visitor pat-downs, security patrols, and metal detectors.
It’s one thing to be able to detect and stop an intruder before they walk into the doors of a hospital and cause trouble, but what happens when the intruder not only gains access, but blends in and spends some time there—potentially even treating patients?
That scary scenario is exactly what happened to Brigham and Women’s nine months later, when it was discovered in September 2015 that a “fake doc” had for several days roamed the halls of the hospital unchallenged, dressed in scrubs, asking questions at a lecture, attending patient rounds, and observing operation—even helping transport a patient to the recovery unit, according to a February report in the Boston Globe.
So what happened? According to the Globe, Cheryl Wang, 42, and a former surgical resident who had been dismissed from a program in Mount Sinai St. Luke’s Hospital in New York City, and had been reported to New York’s state disciplinary board, somehow blended in with the circulating mass of medical personnel, slipping into restricted areas and suggesting she had connections to an attending doctor.
At some point, physicians caught on and she was escorted off the property. Meanwhile, hospital officials posted her photograph near operating rooms and alerted other hospitals in Boston. The next day, she showed up for rounds in a conference room at Massachusetts General Hospital and was told to leave. Astonishingly, when she left, she was followed by Brigham officials to Children’s Hospital Boston, where she tried to do the same thing—she was intercepted and turned away, the Globe reported.
“Ms. Wang was an observer. She did not touch, treat, or provide care to a single patient,’’ Brigham and Women’s spokesman Erin McDonough told the Globe, though security video reportedly shows that Wang gained access to five operating rooms over two days.
The fact that Wang was able to not only gain access to the hospital, but do it several times without anyone noticing and become a part of the medical treatment community raises some serious questions about hospital security. At the very least, many hospitals—city hospitals can be busy places where hundreds or thousands of people come and go—control access to patient treatment areas, operating rooms, and other sensitive areas using security features such as electronic ID badges. But these systems are not without their faults—and they are susceptible to human factors.
In this case, Wang took advantage of this busy environment, hedging her bets that she wouldn’t be noticed as an outsider among the many other doctors, nurses, and residents at the hospital every day. It’s called “tailgating,” a problem that security experts have warned against for years. In this practice, hospital staff hold ID badges against the electronic card reader to gain access to surgery suites, and then groups of people hold the door for one another, not questioning that someone dressed in the same medical garb might not belong there.
According to the Globe article, Wang regularly was seen following fellow employees during shift changes, and was able to sneak into sensitive areas.
“This individual looked and acted like she belonged in our institution. She was wearing our scrubs, knew her way around, understood the hospital culture and terminology, and was familiar with people’s names,’’ McDonough told the Globe in a written statement. “Because of this, we let our guard down. We know that in addition to best practice security measures, the safety and security of our hospital requires the vigilance of everyone who works here. All involved are fully committed to providing a secure [operating room] for our patients and staff.”
For its part, Brigham and Women’s Hospital seems intent on not allowing a repeat incident, and officials have reassessed the facility’s security protocols, according to the Globe. The hospital has changed protocols for allowing observers into operating rooms, and physicians sponsoring a visitor are now required to verify with a student’s educational institution that the student “is in good standing,’’ which is apparently something they never did with Wang. In fact, the report said that Wang was able to forge recommendation letters that helped her win permission to shadow a Brigham surgeon for two days in September. She was apparently able to return several months later in scrubs with the hospital’s logo that she reportedly obtained during her September visit.
What are hospitals doing?
Obviously, the problem of intruders (even those that seem to be legally there) getting into hospitals is a perennial problem, and healthcare safety officials are constantly grappling with the debate of just how secure hospitals should be. On the one hand, hospitals are supposed to be healing places where sick and injured people come to get better, so security officials (and administrators) are hesitant to install too many deterrents that will make the facility seem unfriendly.
At the same time, an increasing number of violent incidents and intruders in hospitals have left facilities scratching their heads trying to come up with the perfect mix of security measures that could help keep the same problem from happening as did at Brigham and Women’s.
As an example, let’s look at some of the measures that Parrish Medical Center in Titusville, Florida, took after an armed man entered the hospital on July 17, 2016 and shot and killed patient Cynthia Zingsheim, 92, and healthcare aide Carrie Rouzer, 36, for no apparent reason. The facility now maintains a law enforcement presence and enhanced security at public entrances, restricts public access to the main entrance and emergency department by requesting identification, and conducts random bag checks.
Security officers are now armed with additional protective equipment and gear and are receiving more training. The health system also is considering installing metal detectors and other equipment to identify prohibited items.
In addition, law enforcement officials say the hospital’s active shooter plan, and brave security guards who confronted and held the assailant until police arrived, were two of the major factors that helped keep the incident from escalating to a worse mass shooting.
The ID badge that helped Wang get into Brigham and Women’s has grown from being just a piece of identification, and is increasingly being used as a security tool in hospitals. With encrypted electronic chips, GPS, and proximity sensor technology becoming increasingly reliable and affordable, hospitals are looking for ways to cut down on the number of badges that staff need to carry. An all-in-one solution allows staff members not only to identify themselves, but also to swipe in for their shifts, pay for meals through a debit card system, gain access to restricted areas, and provide security personnel with an electronic “footprint” to track where in the hospital they have been, if needed—a feature that may have been helpful to track Wang in her comings and goings at the hospital.
Preparing for the next pandemic: Key issues facing the next administration
Experts stress importance of community preparedness, funding, and support from the new administration
If history is bound to repeat itself, then the newly elected Trump administration will undoubtedly face a disease outbreak at a level similar to that of its predecessors.
The only two questions that public health officials have are: How bad will it be, and how prepared is the country for the next pandemic?
For Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases—who has advised five different presidents on issues pertaining to infectious disease outbreaks and testified before congressional committees approximately 250 times—the looming threat of a major disease outbreak is almost a certainty.
“History tells us we will definitely get surprised in the next few years,” he said during a keynote address at “Pandemic Preparedness in the Next Administration,” a discussion hosted by the Center for Global Health Science and Security at Georgetown University Medical Center, in partnership with the Harvard Global Health Institute.
In a Health Affairs article published after the conference, Fauci reviewed the outbreaks that occurred under each of the last five presidents, dating back to the beginning of the HIV/AIDS epidemic under President Ronald Reagan to the modern-day concerns tied to Ebola and Zika under President Obama.
“If history has taught us anything, it is that the new administration is likely to experience at least one infectious disease crisis of significance,” he wrote. “We have learned from the past decades that it is important to have strong global surveillance systems; transparency and honest communication with the public; strong public health and healthcare infrastructure, or capacity building efforts where needed; coordinated and collaborative basic and clinical research; and the development of universal platform technologies to enable the rapid development of vaccines, diagnostics, and therapeutics. We also have learned that it is essential to have a stable and pre-established funding mechanism to utilize during public health emergencies similar to a FEMA-like emergency disaster fund.”
Other global health experts echoed his predictions and added their own concerns.
“It’s quite reasonable we’ll see a large-scale pandemic in our lifetime,” said Rebecca Katz, co-director of the Center for Global Health Science and Security at Georgetown University Medical Center, during the event, underscoring the progress made at the local level to strengthen preparedness and integrate data to improve decision-making.
But Ashish Jha, MD, MPH, director of the Harvard Global Health Institute and K.T. Li professor of health policy at the Harvard T.H. Chan School of Public Health, argued that as a country, the U.S. is still largely unprepared for an infectious outbreak, even after recent scares associated with Zika and Ebola.
“I would argue—still today—in many ways we are not ready for the next big pandemic, which is going to come at some point,” Jha said during opening remarks. “So, the question is how do we get ready? How do we help our government play a more efficient role in preparing the American public and the globe in preventing the next big pandemic?”
For many, the answer boils down to the approach initiated by the country’s incoming administration, the funding mechanisms associated with pandemic response and—perhaps more importantly—the efforts initiated at the community level.
The new administration’s perspective
As with any transition between presidential administrations, there are bound to be some policy changes that can trickle down to the public health sector and impact preparedness efforts.
But several former high level public health officials have expressed concern about President Donald Trump’s foreign policy stance, particularly his isolationist rhetoric that they say doesn’t bode well for global health initiatives or pandemic preparedness in general.
During the Ebola outbreak in 2014, Trump roundly criticized the Obama administration on Twitter for allowing infected clinicians that were treating Ebola patients overseas to return to the U.S. for treatment. Trump called President Obama a “psycho” and “incompetent” for not stopping incoming flights from West Africa.
“The U.S. cannot allow EBOLA infected people back. People that go to faraway places to help out are great—but must suffer the consequences!” Trump tweeted.
Experts say this perspective does not align with the response necessary to combat a large-scale pandemic.
“The idea that somehow the United States can cut itself off from the rest of the world; that we can build a wall—physically or metaphorically—high enough to keep out pathogens, to keep out disease, to protect the American people from disease, and that would make the world a safer place, is so badly misguided,” said Ronald Klain, the former Ebola response coordinator for the Obama Administration at the Georgetown conference.
“There is no isolationist policy that will protect us from disease,” he added.
Former CDC director Tom Frieden, MD, has also highlighted the importance of preparing for a disease outbreak, telling the Washington Post that his biggest fear has always been an influenza pandemic. He added that making the necessary investments in global health and pandemic preparedness is a long-held presidential tradition.
“The Bush administration made important investments in public health, global public health, and in influenza preparedness, and in the Obama administration, we have built on those,” he said. “It’s a baton that gets passed. Preparedness is really important.”
Global policies have significant sway when it comes to addressing pandemic preparedness on a broader level. In a recent study published in The BMJ, researchers found a “remarkable consensus” regarding what went wrong during the Ebola response, but very little has been done to close those gaps.
“Ebola, and more recently Zika and Yellow Fever, have demonstrated that we do not yet have a reliable or robust global system for preventing, detecting, and responding to disease outbreaks,” the authors wrote.
Almost unanimously, researchers and public health officials have also called for lawmakers to change the way the government funds pandemic response efforts. The government can pull from an emergency fund when a devastating natural disaster hits, but no such fund exists for a disease outbreak. This issue was brought to public light during the Zika outbreak last summer, when Congress ultimately agreed to release $1.1 billion in funding after a significant delay.
“We all know that’s a terrible way to do business and that does not leave us in a very safe place,” said Amy Pope, the former deputy homeland security advisor and deputy assistant to the president on the National Security Council during a panel discussion.
GAO outlines federal preparedness gaps
Two recent reports released by the Government Accountability Office (GAO) have addressed gaps in federal pandemic preparedness activities.
The first (www.gao.gov/assets/690/681962.pdf), released in January, addressed federal personnel reassignment and called for improved coordination between federal agencies tasked with authorizing that reassignment during emergencies. The Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA), authorizes the Department of Health and Human Services (HHS) to reassign personnel in all states, but officials at HHS were “generally unaware of the reassignment authority.” Officials at the Office of the Assistant Secretary for Preparedness and Response (ASPR) told GAO that they did not conduct targeted outreach to HHS agencies to inform them of the reassignment process or requirements.
The GAO recommended that ASPR conduct outreach to HHS agencies, including expected time frames for approving reassignment requests, and develop a plan to evaluate after-action reports from states.
“Conducting outreach to HHS agencies and offices on ASPR’s reassignment requests, review processes, and time frames would be consistent with federal internal control standards for information and communication, and would improve HHS agencies’ and offices’ awareness of expected roles, thereby preventing potential delays in decision making in the event of a public health emergency,” the GAO wrote.
The second report (www.gao.gov/products/GAO-17-150), published in February, addressed existing coordination mechanisms between the Department of Defense (DOD), HHS, and the Department of Homeland Security (DHS). The GAO determined that HHS and DHS “have plans to guide their response to a pandemic, but their plans do not explain how they would respond in a resource-constrained environment in which capabilities like those provided by DOD are limited.”
The agency noted that each agency has mechanisms in place to respond to a pandemic, but all three could improve coordination efforts with one another when resources are limited, particularly as HHS and DHS are updating existing plans.
Community coalitions are the future
Although hospitals, public health officials, and emergency preparedness experts can draw on lessons learned from previous outbreaks like Ebola, Zika, and H1N1, the fact that no two diseases are alike makes it difficult to plan for the next pandemic. It’s hard to know how to respond when no one knows what the disease will do and how it will travel between populations.
“There’s no playbook that fits the emerging infectious disease outbreak,” Pope said.
She and Jha highlighted the efforts of community coalitions, which have emerged as a critical emergency preparedness approach over the last several years. Those coalitions have made a noticeable impact during disasters such as the Boston Marathon bombing, the train derailment in Philadelphia, and the Orlando nightclub shooting.
“That’s the model for the future,” she said. “Using this vast healthcare system, that is in some cases very well-funded, and figuring out how to tap into those resources so we’re not using one individual local hospital to be our barrier against whatever is coming next in the U.S.”
The ASPR has repeatedly highlighted the benefits of community coalitions when responding to disasters of any kind.
That kind of community planning will be particularly beneficial for hospitals creating pandemic response plans that can adequately handle a potential surge of infected patients, Klain said.
“We don’t need 20 hospitals in Houston to be ready to deal with Ebola or infectious disease, but we do need one,” he said. “Figuring out what that one hospital is, how well it’s prepared, how people are drilling, and how people are funneled throughout the community are important things.”
Which states are the most prepared for a pandemic?
A recent report from Trust for America’s Health (TFAH) found that state preparedness for diseases, disasters, and bioterrorism varies widely across the country. As a whole, however, states are “often caught off guard when a new threat arises,” such as Zika or Ebola.
Twenty-six states and Washington D.C. scored a six or lower on 10 indicators of public health preparedness, according to the report. In a press call announcing the report, Rich Hamburg, interim president and CEO at TFAH, described an inconsistent approach to emergency response in which state governments are forced to quickly respond to an incident, but then just as quickly move on once the event is over.
“We aren’t adequately maintaining a strong and steady defense and the result is we consistently see health emergencies disrupting, derailing and diverting resources from other ongoing priorities and efforts from across government, in addition to leaving Americans at unnecessary risk,” he said.
Hamburg also noted that states have faced heavy funding cuts over the past 15 years, from $940 million in fiscal year (FY) 2002 to $660 million in FY 2016. This, coupled with a lack of biosurveillance and insufficient research and development for new vaccines, has left some states woefully underprepared.
Among the recommendations issued by TFAH was the need for more involvement from federal leadership—including the White House—a more stable source of funding, emphasizing local coalitions and prioritizing vaccination among children and adults.
The most-prepared states:
- North Carolina
- New Jersey
The least prepared states:
Emergency planning: tornadoes and hurricanes
It’s storm season. Now’s the time to get your facility ready to face the power of Mother Nature
Editor’s note: This is the last in a series of stories that will address common planning concerns when it comes to certain types of emergencies that can strike a hospital facility.
It’s spring time in the U.S., and with the return of warmer weather in most places, the mind turns to pleasant sunny days, lighter jackets, and at worst, spring rain showers from a weather perspective.
But from a meteorological standpoint, Mother Nature is just getting ramped up. In the U.S., tornadoes become more frequent in many parts of the Midwest as cold air in the northern half of the country meets warmer, more humid air in the southern half, creating the perfect soup for thunderstorms that can spawn brutally destructive tornadoes.
In parts of the country such as Florida, the Gulf Coast, and the Atlantic seaboard where tornadoes aren’t so prevalent, preparations begin for hurricane season, which begins in June and runs through November.
Both of these types of storms bring with them their own distinct dangers of wind and water, and while one type is usually small, quick, and violent while the other is large, and can span days over one spot, hospitals must be ready to deal with them both and to stay open to help both existing patients and incoming victims.
One would think after many years of having open hospitals in the U.S., that preparation for these storms would be second nature—and a direct strike is something that is almost statistically unfathomable. But one needs only to look at New Orleans in 2005, and Joplin, Missouri in 2011, to know how unprepared hospitals can be.
Hurricane Katrina hit the New Orleans area on August 29, 2005 as a Category 3 storm, which may not have been a big problem for the city’s medical facilities in normal circumstances, but when 53 of the city’s protective system of levees failed, almost 80% of New Orleans was left under water, sending citizens scrambling to the roofs of their houses to escape the ?oodwaters. Several hospitals were left stranded, with no evacuation plans, a lack of doctors (or the inability to get staff to and from work), and failed utilities that ultimately led to many deaths of patients whose life support systems failed. The storm’s aftermath led to many emergency preparation overhauls, and changed the way healthcare organizations plan and drill for disasters.
“Hurricane Katrina was an indescribable event that forced the hospital and the community to deal with issues that were not planned for,” recalls Ken McDowell, CHSP, CHEP, safety officer for Memorial Hospital at Gulfport in Gulfport, Mississippi, an area that was especially hit hard by the hurricane.
Direct hit from a tornado
On the afternoon of May 22, 2011, an EF-5 tornado with winds approaching 300 miles per hour slammed into the city of Joplin, Missouri and roared head on into St. John’s Hospital. In the aftermath of the tornado, 161 people died, including six at the hospital itself. The roof of the building was blown off, leaving those inside exposed to the elements. Cars in the parking lot were thrown into the hospital’s front foyer waiting room, and shards of glass sprayed patients and staff as just about every exterior window shattered. Communication was completely shut down, and an electrical generator and HVAC system on top of the hospital was tossed off and rendered useless.
Four years later, the city opened the brand new $450 million, 900,000 square-foot “tornado-proof” facility designed to withstand another direct hit. Utilities are hidden in a reinforced concrete utility bunker buried underground. Exterior walls are made with reinforced masonry and precast concrete panels designed to bow in and out to withstand pressure changes in a tornado, and the roof is built in layers—a concrete roof covered with a waterproof membrane designed to keep the roof from tearing off and exposing those inside to the elements. Special windows were made to withstand winds up to 250 miles per hour in the hospital’s most critical areas.
Clearly, man is no match for Mother Nature’s fury, but we’ve shown the ability to rebuild and learn some pretty important lessons out of experience. So how can you get ready for this year’s onslaught of wicked weather? The preparations for both types of storms are quite similar.
Our safety experts, along with those who literally weathered the two storms in Joplin and New Orleans helped us come up with some tips and advice to get you started in your preparations.
Assess your vulnerability. It’s been said many times, many ways. The only way you can get a clear picture of the hazards that could potentially strike your hospital (and more importantly, whether or not you’re ready to deal with them) is to do a hazard vulnerability assessment. If you haven’t done one yet, you’re already out of compliance with CMS and The Joint Commission (it’s a requirement). This is the document that measures the disasters that are likely to hit your community. (Is there a freight train line that carries hazardous chemicals that run through town? Is your hospital in the flood zone for a system of levees? Are you located in Tornado Alley?)
From here, you can tailor your response possibilities, and your drills that will help practice those responses. This is important, because it will help you determine where your weaknesses are. Is your facility prone to flooding? This might be good to know if your area is prone to hurricanes, because now is the time to mitigate that problem with a system of dikes, or to stock up on sandbags, or to practice your evacuation procedures. New York City hospitals learned this the hard way when Hurricane Sandy unexpectedly flooded the basements of older buildings, forcing the evacuations of many patients to other facilities.
Protect your utility infrastructure. This is your lifeblood. Without power, lights, heating, and other important utilities, you will literally be in the dark. If there’s one thing that hospitals that have weathered huge storms have learned, it’s that wind and floodwaters will find the weaknesses in your building’s infrastructure and creep into, or blow away, your utilities. After generators and utility connections were blown either out of or off the old Joplin hospital, architects placed all of the hospital’s generators, boilers, chillers, gas, and oxygen in the underground bunker, and twin electrical feeds will ensure a redundancy should one stop working.
“We do not know of another facility that has been built with tornado and wind protection as this new facility,” says John Farnen, executive director for strategic projects for Mercy Health Systems, St. Louis, Missouri, who helped design the new Mercy Joplin Hospital.
In what has been called an example of upside-down construction, many hospitals are being built or retrofitted with the main primary electrical services located in the rooftop and powered by a fuel pump that is secured in a flood-proof vault with a 150,000-gallon tank and reserve fuel stored on-site. Many emergency fuel tanks are stored in hospital basements or bottom floors. During Hurricane Sandy in New York City, many generators were worthless because floodwaters either contaminated emergency fuel stores, or destroyed the tanks. As a result, some hospitals, such as the newly built Spaulding Rehabilitation Hospital in Boston, are being built with ballasted fuel tanks that can float in floodwaters.
“The weather events of the prior decade drove our decisions, and time has proven us correct,” says Spaulding Director of Communications Timothy Sullivan.
Some facilities are being built so that even if the first floor was completely flooded, critical care could still take place as usual in upper floors. At Spaulding, even the hospital’s parking garage is designed 19 feet above current flood levels, and the entranceway is designed with a special uphill “lip” that will cause water to pool, rather than rush down into the underground parking garage.
Foster mutual-aid relationships. Hospitals need to learn to work together to help out in an emergency. Before Hurricane Katrina, hospitals in New Orleans didn’t have “memorandums of understanding” with other hospitals that let other hospitals accept their patients should the need arise. Now, it’s considered best practice in your emergency plans to have deals with other hospital