Disasters: What Parents can do to Help their Children Cope

By Nicholas Long Ph.D., Department of Pediatrics, University of Arkansas for Medical Sciences

There are several things that parents (and others) can do immediately following a disaster such as the events which unfolded September 11 that can help children cope more effectively. The following “psychological first-aid” recommendations can help prevent long lasting psychological effects.

Your Reaction is Critical. Children will look to their parents and other adults for clues on how they should react. If they see a lot of alarm and fear they will become scared. Parents who act calmly and in a matter-of-fact manner during the time following a disaster send a strong message of security to their children.

Keep a Normal Schedule. Try to keep to normal daily routines and schedules as much as possible. When disasters interrupt children’s routines and schedules they tend to become more anxious.

Talk with Your Children. Encourage your children to talk about the disaster. Let them talk about what they have heard. Correct any inaccuracies they might have (explain that following disasters there are often many minors that turn out not to be true). Encourage them to describe what they are feeling. Talk to your children in a calm tone. Tell your children what you know about the disaster.

Offer Reassurance. Following a disaster the issue of greatest concern to most children is their safety (and the safety of their family). Reassure your children. Stress the reasons why your children should feel safe (for example, they do not live near where the disaster occurred).

Encourage and Anticipate Questions. Your children will likely have many questions that they would like to ask. Encourage them to ask you questions. Try to anticipate their questions so you can think ahead about how you might respond. Common questions include: Why did it happen? Will it happen again? Why would someone do that?

Seeking Professional Assistance.
If your child shows significant or long-lasting problems (for example, anxiety, depression, fears) as a result of the disaster you should contact your child’s health care provider for assistance or referral.

OSHA Enforcing Bloodborne Pathogen Standards
The Occupational Safety and Health Administration (OSHA) began enforcement in July of its revised rules governing bloodborne pathogen safety standards. The revisions add to or modify the standards in place since 1992 and apply to all employers who have employees with reasonably anticipated occupational exposure to blood or other potentially infectious materials. The revisions make four changes to the standards:

• add or modify definitions relating to engineering controls;

• impose new requirements on employers’ exposure control plans;

• require employers to solicit employee input as to the identification, evaluation, and selection of effective engineering and work practice controls; and

• impose certain record keeping requirements on employers.

In general, the revisions require employers such as physicians to account for changes in technology that eliminate or reduce exposure to bloodborne pathogens and document their efforts to consider and implement commercially available safer devices.

Clinics with ten or fewer employees are exempt from OSHA record keeping requirements and from maintaining a Sharps Injury Log, but must still comply with the standards. For more information visit the OSHA web site at www.osha.gov. A summary of the revised regulations along with fre­quently asked questions is available at www.osha-slc.gov/needlesticks.

Arkansas Pharmacy Tech Ratio Increases
The Arkansas State Board of Pharmacy (ASBP) voted in its June 22, 2001 meeting to increase the ratio of pharmacy technicians to pharmacists from the current one-to-one plus one per shift to two-to-one. The staff of the ASBP was directed to expeditiously draft the changes to the rules so as to begin the approval process.

The Arkansas Hospital Association has worked closely with the ASBP and the Arkansas Pharmacists Association to gain support for this change. Unless unexpected delays occur, the revised rules should become effective by late summer 2001.

Arkansas Verbal Order Rule Change
The Arkansas Department of Health’s (ADH) rules and regulations governing hospitals currently require that physicians sign verbal orders within 24 hours. The rule was written to give hospitals regulatory support in getting their physicians to sign orders more expeditiously.

Recently, Joint Commission on Accreditation of Healthcare Organization (JCAHO) surveyors issued a Type I recommendation to an Arkansas hospital, citing that two of about 30 verbal orders examined had not been signed, dated, and timed by the physician within the 24-hour period. 

The surveyors noted that the Arkansas regulation is far more stringent than similar rules found in most states, where 48 to 72 hours for authentication is often allowed. In several states, the regulations are even more lenient, stating that authentication must occur “within a reasonable time.”

When the hospital’s executives talked with physicians, the doctors indicated that days off, call coverage, etc. make it difficult to comply with the 24-hour requirement. Also, sometimes when signing the order, physicians simply fail to record the date or time, omissions which would not have caused a deficiency if the “reasonable time” standard had been in place.

The Arkansas Hospital Association communicated with the ADH about this matter and the issue was placed on the agenda for the July 11 meeting of the ADH’s Education Committee that writes hospital rules and regulations. 

During the meeting, the committee recommended approval for a request by the Arkansas Hospital Association and numerous hospitals throughout the state to change the state’s rule concerning the timeframe for physicians to sign verbal orders. The rule currently requires physicians to sign their verbal orders within 24 hours.

The committee changed that with language which states “orders shall be authenticated in a timely manner as defined by the hospital’s medical staff bylaws, including verbal orders, legible and dated signatures.” Before Governor Huckabee signs it, the new rule must make its way through the Arkansas Administrative Procedures Act process. Barring unforeseen delays, the rule should be effective later this year. Until then, physicians must continue to abide by the current 24-hour time limit.

Arkansas Medicaid Offers Electronic Documents
The Arkansas Medicaid program is offering its health services providers alternative ways that they can keep up-to-date on all program policies. Medicaid providers have the option to receive their provider manuals and official program notices on CD, via the Internet, or by e-mail. 

A survey has been sent to all providers regarding preferences for receiving the information in an electronic format. The new electronic version of the manuals and notices makes it possible to:

• search manuals electronically;

• use a clickable table of contents to quickly find information;

• receive updated manuals each quarter (no lost or misplaced information);

• eliminate storage of large paper manuals; and

• increase access to information.

Arkansas Medicaid Director Ray Hanley is hopeful that providers will choose to replace their hard copy Medicaid documents with the electronic versions. Hanley said that electronic distribution of the material gives the potential for saving several hundred thousands of dollars annually in printing and postage costs ¾ money that would be better spent paying for healthcare services.

The Arkansas Hospital Association encourages each hospital to respond to the survey, which will be included with an upcoming Medicaid Remittance Advice. Download manuals from the Web site, www.medicaid.state.ar.us/ArkansasMedicaid/Manuals/MANLmain.htm.

Governors’ Group Seeks HIPAA Delay
The National Governors’ Association (NGA) is lobbying key members of Congress to extend the deadline for adoption by states and providers of a uniform set of codes that could help to simplify healthcare transactions. 

Pending House and Senate bills (H.R. 1975 and S. 836) propose to extend deadlines for adoption of the uniform codes by two years without affecting privacy provisions required under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

NGA members are concerned about the unintended mandates and consequences of the HIPAA law and feel the current implementation period doesn’t provide adequate time to identify, analyze and address the impact that the HIPAA requirements will have on health systems and other entities. View the NGA’s concerns in a letter posted at www.nga.org.

Begin HIPAA Work NOW!
If you haven’t already begun preparations for implementation of HIPAA rules and regulations, you need to do so NOW.  Attorney Lynda Johnson suggests the following action steps:

• Review existing consent forms and remember that old consents are still good consents
• Evaluate whether joint consents should be used for multiple entities in a system
• Develop new consent form
• Develop authorization form satisfying requirements.  Determine activities for which authorizations will be needed on a recurring basis.
• Forms should request and authorize use and disclosure only to minimum extent necessary
• Authorizations for research will also need to meet requirements for informed consents for clinical studies and be approved by IRBs
• Seek and document appropriate IRB waivers for research purposes
• Update privacy policy, and develop and post notice of privacy policy
• Include opt-in/opt-out right in marketing and fundraising materials
• Seek written agreement for inclusion in facility directories and disclosures to family/friends and clergy
• Document exercise of opt-in/opt-out rights
• Document evidence of authority of personal representatives
• Configure document flow for medical records maintenance
• Develop process for implementing revocation of consents/authorizations and restrictions on use
• Maintain psychotherapy notes separate from other medical records of individual
• Comply with more stringent state law requirements
• Develop educational materials and train staff regarding consent/authorization requirement

HHS Issues HIPAA Guidance on Privacy
The Department of Health and Human Services’ (HHS) first set of guidance materials on the Health Insurance Portability and Accountability Act’s (HIPAA) privacy regulation was issued July 6. Compliance with the regulation is required by April 14, 2003 for most covered entities, including hospitals. 

In a September 7 Arkansas Hospital Association Compliance Forum, Little Rock attorney Lynda Johnson discussed the guidance document. Examples of clarifications made in the guidance include:

• Healthcare providers may exercise professional judgment to determine whether obtaining consent would interfere with the timely delivery of necessary healthcare services.

• Hospitals do not have to build private, soundproof rooms to prevent overheard conversations about patients’ conditions. Rather, the rule requires that hospitals provide reasonable safeguards to protect confidential information, such as using curtains, screens, or similar barriers, which are often already used.

• Friends and relatives are permitted to pick up a patient’s prescription at the pharmacy, as often occurs today.

• Healthcare providers need to obtain consent from a patient for use or disclosure of personal health information only one time.

• A provider that provides a service after obtaining patient consent may bill for the service even if the patient immediately revokes consent after the service is provided.

The guidance indicates that the department plans to issue proposed modifications to correct unintended negative effects of the privacy rule, but didn’t provide a timeline for the modifications. Expected changes include:

• Permitting pharmacists to fill prescriptions phoned in by a patient’s doctor before obtaining the patient’s written consent

• Allowing direct-treatment providers receiving a first-time patient referral to schedule appointments, surgery, or other procedures before obtaining the patient’s signed consent

•   Permitting patient charts to be maintained at bedside, to clarify that X-ray light boards need not be isolated and to clarify that Covered Entities are not required to shred empty prescription vials

• Adding guarantees that covered entities are free to engage in whatever communication is required for quick, effective, high-quality healthcare, including routine oral communication with family members, treatment discussions with staff involved in coordination of patient care, and using patient names to locate them in waiting areas

The HHS said it will publish any future rule changes in the Federal Register and will invite comment from the public. The guidance is available in Microsoft Word format on the Office for Civil Rights’ home page, www.hhs.gov/ocr/hipaa/index.html#InitialGuidance.