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The Big One


 

In March 2005 the Agency for Healthcare Research and Quality and the HHS Office of Public Health Emergency Preparedness published a report of guidelines for officials on how to plan for delivering health and medical care in a mass casualty event.1

After federal, state, and local authorities’ failure to supply desperately needed assistance following Hurricane Katrina, that report of recommendations from a 39-member panel of experts in bioethics, emergency medicine, emergency management, health administration, health law, and policy is more crucial than ever. This report offers a framework for providing optimal medical care during a potential bioterrorist attack or other public health emergency.

How well do you know your institutions’ plans and protocols for these types of events? How personally prepared are you and your families? Overall, what should your highest concerns be in order to prepare yourself now and in the future?

Definitions

The term disaster is defined many ways, but typically all definitions involve some sort of impact on the community and interruption of services from business as usual beyond the point where outside assistance is needed. Defining what is meant by a mass casualty incident (MCI), on the other hand, is more relative to the location in which it is being declared.

“Typically a mass casualty event is thought of as one in which the number of patients exceeds the amount of resources that are routinely available,” says Andrew Garrett, MD, FAAP, the director of disaster response and pediatric preparedness programs at the National Center for Disaster Preparedness at Columbia University’s Joseph L. Mailman School of Public Health, New York. “But that is a dynamic definition because in Chicago a bus accident with 15 patients might not be a mass casualty incident, but in rural Cody, Wyoming, a car accident with four people might be. It’s where you exceed the resources that are available locally that is important.”

The difference between an emergency, a disaster, or an MCI revolves more around semantics, the environment in which you will work, and the short-term goals of patient care. “We’re not asking people to reinvent the way in which they practice medicine,” says Dr. Garrett “but a disaster or MCI changes the paradigm in which they do it—to do the most good for the most people.”

Gurneys, patients, and staff members fill the hallway in the Red Zone trauma center at the Grady Hospital’s ED in downtown Atlanta. At this city's main trauma hospital, multi-hour lines of waiting patients clog the hallways—even on slow days. Doctors at Grady say they probably couldn't handle an MCI or incident with more than 20 or 30 severe injuries.

Who’s in Charge?

The Hospital Emergency Incident Command System (HEICS) was adapted from a plan to coordinate and improve the safety of the wildland firefighting system in California. It was transitioned to serve as a model in hospitals to meet the same goals of staff accountability and safety during a disaster response. HEICS places one “incident commander” at the top of the pyramid in charge of all the separate areas of responsibility, such as logistics, finance, operations, medical care, safety, and so on.

“The way the system works,” says Dr. Garrett, “is that everyone working in a hospital response is supervised by only one person who answers to the command staff. The goal is that there’s one incident commander who knows everything that’s going on at the incident to avoid the trap of multiple people making command decisions at the same time.”

Redundant command structure is a common problem in a large-scale response to disaster. That was certainly the case in Hurricane Katrina, he says, where multiple agencies—federal, state, and local—did not follow this model of disaster response.

“It’s a simple concept,” says Dr. Garrett, “but unless responders practice it, it is difficult to utilize in a real emergency.”

Every hospital should have a HEICS or similar structure set up and the key emergency response roles pre-identified by job title, he says. And while knowledge of weapons of mass destruction (WMD) and incident command is improving, says Stephen V. Cantrill, MD, FACEP, associate director, Department of Emergency Medicine at Denver Health Medical Center, “Some hospitals have taken it seriously; others wish the whole thing would go away.”

More than likely, in the event of a disaster, the HEICS organizational tree is outlined all the way to the top commander in your hospital’s plan. Your role, in general, may have already been determined in this plan, but the conventional wisdom in your hospital (as in most) may be: You’ll learn your roles and responsibilities when the time comes. In fact, depending on your setting, the hospitalist may hold the most senior position in-house overnight or on the weekend—especially if there is not an emergency department at the hospital.

“The thing is, at first people are going to look to the most senior clinician to be in charge during a crisis,” says Dr. Garrett. Perhaps the smaller the hospital, the more you need to know what to do and what is expected of you to fit into the larger picture in the community. “And even if it is a smaller hospital the system and the needs are the same.”

Hospitalists are invaluable resources in an institution and [in disaster events] they will be pressed into service because of their location. Especially in the private sector when it hits the fan, the hospitalist is going to be one of the first people to be called.—Stephen Cantrill, MD, FACEP

What Types of Care?

Although many types of events can be handled the same way, some involve additional concerns. “With WMD or a contagious disease outbreak, there is the added issue of ‘What’s the risk to me as a provider in the hospital?’” says Dr. Garrett. “And if it’s a community or statewide or national event, ‘What’s the risk to my family?’ Then you’re dealing with issues that aren’t business as usual.”

The hospitalist and the administration will then have to think about other complex issues such as how many people are not going to come to work. Added to that, with a smaller staff, you may need to ask, “What will the scope of my practice be if I’m called to the front of the hospital to help do triage? Roles and responsibilities can change very quickly,” he says.

“Hospitalists are invaluable resources in an institution and in fact [in disaster events] they will be pressed into service because of their location,” says Dr. Cantrill, who with colleagues has trained 15,000 healthcare providers throughout Colorado as one of 17 centers to receive a three-year grant from the Health Resources Services Administration (HRSA) to conduct WMD training. “Especially in the private sector when it hits the fan, the hospitalist is going to be one of the first people to be called.”

What to Ask Yourself, Your Staff, and Your Institution

Administration, Incident Command, Plans, and Instructions

  1. Who handles the plan in your institution? Who will be incident commander? At any hospital these key figures will usually include at least the chief operating officer, vice president of medical affairs, and an institutional facilities manager.
  2. Hospitals run the gamut on the range of their preparedness for disasters. Where is my hospital located on such a continuum?
  3. What do they expect of my hospital? What are the nursing expectations? What is our surge capacity for beds?
  4. What supports will my institution make available for populations with special needs such as the disabled and non-English speakers?
  5. What is the plan to help or provide for all kinds of visitors who are in the facility when an event occurs? This may include everything from people visiting patients to corporate administrators, drug representatives, suppliers, surgeons, or primary-care physicians on rounds, or volunteers.
  6. How involved will I be in larger outer levels of the facility’s plans (such as medical triage) or the more finite levels (such as moving patients when electricity goes out and use of elevators may be impeded)?
  7. What training has my institution done?
    1. How do we run mock disasters here?
    2. What kinds of mocks are we running?
    3. What kinds of mocks should we be running?

Staffing

  1. How prepared are we to go to flex staffing and scheduling to meet surge capacity?
  2. What will be the allowances for staff to leave because of their own family emergencies?
  3. Who will run equipment such as ventilators if electricity goes out (e.g., hand bagging by individual nurses or respiratory therapists)?

Personal and Family Disaster Plans

  1. What is my own personal plan for my family?
    1. Children’s schools?
    2. Spouse’s workplace?
    3. Parents or other older relatives if they are in long-term care or are incapacitated in some way?
  2. What do I need ready to meet my personal 72-hour capacity?

Communications

  1. What are the communication system plans for the external to internal, within internal, and then internal back out to external again—to providers, families, or my own staff’s sick patients?
  2. What data are being relied upon, and where does my accountability lie in terms of documentation we must supply?
  3. Am I going to be expected to do something in addition to the normal documentation I must complete in order to feed state or national data collection and analysis systems?
  4. Is there a way our IT people could create an alert for us with the top priorities in the event of disaster? (An example is an in-your-face pop-up dialogue box that flashes onto every computer in the hospital.)
  5. If we do not have a large-scale disaster plan, can we begin to step up our template for smaller internal disasters such as a fire or a water pipe breakage?
  6. Counties tend to be the sites that coordinate and direct the complete response.
    1. Is my institution’s facilities manager sitting at the table during countywide meetings, or is he/she electronically connected to know what county plans are?
    2. What does my county do? Do we know what our county emergency systems can offer?
    3. Who is responsible in my county for activating a disaster response?
    4. How do they connect to my institution?
    5. With whom do they connect at my institution?
    6. What is my hospital’s system of being notified and notifying me?

Expectations, Roles, and Responsibilities

  1. What responsibilities outside of patient care may I be called upon to take on?
  2. What will or might be expected of me?
    1. Where does my institution’s algorithm end? At the emergency department, or are hospitalists specifically mentioned?
    2. Where does the hospital see me fitting? If that is unknown, have I told my hospital what my own skill set is and what I can offer?
    3. What kind of specialty care do I offer that they think that I can then gear up for?

Resources: Supplies, Equipment, and Support

  1. What is our hospital’s 72-hour capacity? What do I/we need and how do I get it to exist for 72 hours? Some questions may include:
    1. What does the hospital have in storage?
    2. Who are my delivery people?
    3. How often does the hospital obtain delivery?
    4. If I’m at home, could emergency personnel or others get to me? What’s an alternate route?
  2. How many patients can the hospital support with ventilators?

Risks and Protection

  1. What are our largest areas of vulnerability?
  2. What are my local public health resources? What are my best local Web links that will tell me what I need to do for my work and for my family?
  3. What are the personal legal ramifications of acting outside my scope of practice?
  4. What is my institution’s policy and plan for administering antiviral or antibiotic prophylaxis to providers? To their families?
  5. What special risks does my hospital or geography face? What is makes my facility potentially at risk for having a disaster?
    1. Is this a border town?
    2. Do we have earthquakes? Tornadoes, hurricanes, floods?
    3. Do I have a changing transportation structure because freeways are now being closed down?
  6. Overall, what assumptions am I making?

In most disasters, the hospitalist’s medical practice will be a departure from the details of daily practice. “Because the majority of hospitalists have internal medicine as their background … they tend to be very detail oriented, which is really their strength,” says Dr. Cantrill. “But in a case like this, they may not have that luxury.”

Another major consideration and “probably the stickiest one,” is altering your standards of care in terms of providing efficiency care or austere care as opposed to what you normally consider appropriate medical care.

What hospitalists will do in any disaster depends on the event—natural, biological, chemical, or use of weaponry—and how your metropolitan or rural area is set up. If it is a biological or bioterrorist event, the pathogen involved may make a difference. Although anthrax is not contagious, for instance, in the event of a large-scale airborne anthrax attack, the need for ventilators will quickly overwhelm resources.2 “That’s one of our largest areas of vulnerability,” says Dr. Cantrill, “whether we’re talking influenza or pneumonic plague, it still is an important factor: How many people can I support?”

The issue of limited ventilators may not be completely soluble, he explains. In ordinary circumstances hospitals can get, say, ventilators from a strategic national stockpile from which equipment can be flown out within 12 hours. Yet if an influenza pandemic breaks out, then the entire country may be involved, rendering that plan inoperable. And even if you have extra ventilators, do you have extra respiratory techs to administer them?

Dr. Cantrill’s institution, with a grant received from HRSA, offers a two-hour course to train people with some medical knowledge to be respiratory assistants who can manage ventilated patients in an emergency.

Injuries may increase exponentially in the case of a disaster. Other needs include vaccinations, treatment for dehydration, serious heat- and cold-related illness, or threats from floodwater (i.e., water laced with toxic chemicals, human waste, fire ants, rats, and snakes).3

Kate Rathbun, MD, MPH, family physician in Baton Rouge, La., is certified in disaster management and knows well the problems that can arise in providing medical care in such an event.4 When Hurricane Katrina hit in 2005, everyone in range of the winds, rain, and destruction, “hunkered down to weather the storm.” The day after the storm, Dr. Rathbun joined other providers and administrators, opened their clinic, and readied themselves to treat trauma and lacerations. It soon became obvious that their biggest health issue was the inability of the displaced to manage their chronic diseases. (Baton Rouge’s normal population of 600,000 exceeded a million within days.)

In cases of diabetes, cardiac disease, HIV infection, or tuberculosis, for example, being without medications might mean lethal disease exacerbations.3 In many cases, patients have no prior history documentation on presentation, and with computers often shut down the provider is faced with prescribing for or actually putting a stock of medications into patients’ hands.

Additional concerns pertain to those who cannot receive hemodialysis or seizure prophylaxis; or disrupted care for those with special needs such as hospice patients, the mentally and physically disabled, the elderly, and individuals in detox programs.

When Dr. Rathbun and her coworkers put a couple of nurses on the phones to handle incoming requests for drugs, she gave them some standards: If it’s for chronic disease medications, prescribe a 30-day supply and three refills (to ensure that 30 days later they would not once again be inundated with calls). When patients requested narcotics or scheduled drugs, they were told they would have to be seen by a provider.

Branching Points and Skill Sets

What will your community expect your institution to respond to and provide in the event of disaster? Here is where hospitalists can delineate what they can do when the time comes, says Erin Stucky, MD, a pediatric hospitalist at Children’s Hospital, San Diego.

“Most disaster preparedness algorithms have roles based on ‘hospital-based providers,’” she says, “but when it comes down to medical administration, many of them stop at the emergency department.”

From that point on they are likely to say “I don’t know”—that is, the rest of that decision tree is left in the hands of whoever is in the lead positions of physician, administrator, and nurse.

“That’s where the hospitalist can say, ‘Let me tell you my skill set,’” says Dr. Stucky, such as “I can triage patients; I can help to coordinate and disseminate information or help to outside providers who are calling; I can help to coordinate provider groups to go to different areas within our hospital to coordinate staffing … because I know operating rooms or I know this subset of patient types.”

At some institutions where hospitalists have been around for a longer time the disaster plan’s algorithm has branching points that don’t end in the emergency department. “Each [branch] has separate blocks that are horizontally equivalent,” says Dr. Stucky, “and the bleed-down [recognizes] the hospitalist as the major ward medical officer responsible for ensuring that floor 6, that’s neuro, and floor 5, hem-onc, and so on, have the correct staffing and are responsible for people reporting to them as well as dividing them as a labor pool into who’s available to go where.”

In general, however, regardless of setting, she says, a “hospitalist knows intimately the structure of the hospital, the flow between units, and can help other patients to get to different parts of the institution where care is still safe, such as observation areas.”

Communications: Up and Down, Out and In

Part of the global-facility thought process must include what communications will be for everything from the county medical system and EMS response to, within an institution, the communication between floors and between people on horizontal lines of authority. In addition, information in and out of the hospital from workers to their families is crucial so that workers can concentrate on the tasks at hand.

Questions must be considered ahead of time: How do I communicate to those people outside whom I need to have come in? How do I get response to the appropriate people who are calling in to find out how many patients we’re caring for? There may be other calls from someone who says, for example, that the ventilator has stopped working for her elderly mother.

And hospitalists must also be ready to support the urgent care or primary care satellite clinics and communicate what’s going on at the hospital, says Dr. Rathbun, “so that someone like me, who is a primary care practitioner in the community, can know that if I call this number or this person, I’m going to be able to say, ‘I’m down here at the [clinic] and here’s what I’ve got,’ or “I know things are terrible, but I have a diabetic you had in the hospital three weeks ago who’s crashed again, and you’ve got to find him a bed.’”

Communication plans might include the provision of satellite phones or two-way radios, says Dr. Stucky, and this will affect concrete issues, such as staffing and allowances for who can come and leave.

“In our institution we make this [communication] a unit-specific responsibility of the nurse team leader,” she says. “The nurses each have a phone and those nurse phones are freed up for any person available on that unit to be used to communicate with the outside world.”

Personal Disaster Plans

“I think another vitally important—and I mean vital importance in the same manner as vital signs—is for each hospitalist to have a personal disaster plan for their family/personal life,” says Mitchell Wilson, MD, medical director, FirstHealth of the Carolinas Hospitalist Services and section chief of Hospital Medicine in the Department of Medicine at the University of North Carolina at Chapel Hill. “As the front line ‘foot soldier,’ the potential to harm our families during a pandemic is enormous.”

Dr. Garrett agrees. “One of the things that we’re not so good at in this country is coming up with emergency plans for our own family—even those of us who are in the medical business and take care of others,” he says. “Taking this step just makes good sense—and serves to be able to maximize your own availability and also be confident that you have the ways and means to know that your family is safe and secure and given the best opportunity to survive in a disaster.”

According to Dr. Wilson, families with vulnerable members, such as the young, elderly, and infirm, must have a plan in place to minimize the risk to them. “The hospitalist who comes home sick [or] infected is a danger to the very safe place [to] which [hospitalists and their families] seek refuge,” he says.

Preparedness includes delineating in your family what your points of contact will be. “Part of the stress that’s involved in being a physician and being expected to report to work [may involve] worrying where your family is or whether they have a safe meeting place; who’s picking up the children from school; does the school for my children have a plan, etc.,” says Dr. Garrett.

If you know that your children’s school has an emergency plan, your spouse’s workplace has a plan, and any relative in a long-term care facility has a plan, you’ll be much more likely to stay on the job and care for patients.

“And if my child is on a school bus that needs to be evacuated somewhere out of town,” he says, “I want to know there’s a phone number that my whole family knows to reconnect somehow.”

Disease Surveillance

Disease surveillance is of huge importance to detect and monitor biological terrorist and natural threats. The North Carolina Disease Event Tracking and Epidemiological Collection Tool (NC DETECT), a reporting and surveillance system, was awarded the 2005 Nicholas E. Davies Award of Excellence in the Public Health category by the Healthcare Information and Management Systems Society. The Davies Award program honors Nicholas Davies, MD, an Atlanta-based practice physician and former chairperson-elect of the American College of Physicians, who was committed to improving patient care through better health information management. Dr. Davies was killed in a plane crash with Senator John G. Tower (R-TX) in April 1991.

“One of the things that we’ve done in North Carolina that contributed to our receiving the award was the fact that we really did build this from the bottom up,” says NC DETECT’s Waller. There was guidance from the top down, she explains, but efforts began on a basis whereby hospitals came on board voluntarily and agreed to provide the information they had electronically. In turn, the epidemiology team agreed to give information back to them. “It was very much a joint effort working with the local hospitals and the state-level public health people and bringing them together and designing a system that would meet everyone’s needs with the least impact on the workload for the local hospital.”

Waller says the program was designed to alleviate emergency department clinicians from having to do anything extra in addition to their normal methods of documentation. “We were just going to pull out the electronic information they were collecting and then standardize it centrally, utilize it, and provide a report back to them,” she explains.

Although this system is clearly driven to supply needed information to the state, “we recognize that individual clinicians, administrators, and people at the hospital level also need to know what’s going on in their emergency department,” says Waller. “And it gives them a window into the sort of information that they might not have ever had before.”—AS

No Assumptions

Losing utility power is always a concern in emergencies and disasters. “After 9/11 in New York City, lots of people flooded into emergency departments,” says Ann Waller, ScD, an associate professor in the Department of Emergency Medicine at the University of North Carolina at Chapel Hill and the UNC director for NC DETECT. (See “Disease Surveillance,” p. 20.)

“The emergency departments abandoned their electronic systems and went back to paper and pencil because it was faster to just do the bare minimum … and get them into each team than to enter all the information required,” she explains. “That was a real eye-opener for those of us who rely on electronic data.”

Preparing for crisis involves imagining the inaccessibility of all electronic communications and records, including data collection and surveillance, pharmacy, e-mail, and historical documentation and other medical records.

The general rule in disaster preparedness is to plan for 72-hour capacity: How and what do I need to exist for 72 hours? “And the standard is that you should try to do that for your average daily census plus 100 patients,” says Dr. Stucky.

Scheduling and staffing is another issue. “Be prepared to provide flex staffing and scheduling to provide surge capacity,” says Dr. Wilson.

Think on Your Feet: Training

If they are so inclined, hospitalists can become involved in disaster response, through disaster medical assistance teams, community emergency response teams, or through the Red Cross—to name a few. And there are plenty of ways to take advantage of free training, some of which provide CME.

Another important question to ask of your institution, says Dr. Stucky (who co-presented on the topic of disaster preparedness at this year’s SHM Annual Meeting) is whether they have run any mock disasters.

“You have to do that,” she says. “Half of disaster response is preparedness, but the other half is thinking on your feet. And there’s no way to do that without mocking a drill.”

While there can be value in computer-run mock-ups, “there’s nothing like doing it,” she says. “We learn at least 25 things every time we do it.” And though one drill does not a totally prepared institution make, “it does mean at least you have the right people in those strategic positions [and they] are people who can think on their feet.”

A valuable training resource from AHRQ is listed in the resources at the end of this article.5

Be Prepared

With the vast amount of information on disaster preparedness available, one clear goal is to narrow it to avoid feeling overwhelmed.

“I think that is a real challenge,” says Dr. Cantrill, “but the first step is the motivation to at least look.”

Take for example the motivation of a flu pandemic. “It’s going to happen sooner or later, one of these days, but we know it this time,” says Waller. “We have the ability to be more prepared. … This is a huge opportunity to see it coming and to do as much as we can [correctly]. Which is not to say we can avoid everything, but at least we can be as prepared as we’ve ever been able to be.”

Conclusion

For hospitalists, there are several key techniques for individuals to be able to increase their readiness for disaster in the workplace. The first is to avoid relying initially or entirely on external help to supply a response, says Dr. Garrett: “You are the medical response, and there may be a delay until outside assistance is available.”

A second key is to visualize—as well as possible—any circumstances you might face personally and professionally and to formulate questions, seek answers, and talk to colleagues and supervisors about what your role will be. A third factor is to participate in training in the form of drills and tabletop exercises for your hospital. An unpracticed disaster plan may be more dangerous than no plan at all. TH

Andrea Sattinger also writes the “Alliances” department in this issue.

References

  1. AHRQ. Altered Standards of Care in Mass Casualty Events. Rockville, MD: Agency for Healthcare Research and Quality; April 2005:Health Systems Research Inc. under Contract No. 290-04-0010.
  2. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004 Sep;44(3):253-261.
  3. Greenough PG, Kirsch TD. Hurricane Katrina. Public health response—assessing needs. N Engl J Med. 2005 Oct 13;353(15):1544-1546.
  4. Rathbun KC, Cranmer H. Hurricane Katrina and disaster medical care. N Engl J Med. 2006 Feb 16;354:772-773.
  5. Hsu EB, Jenckes MW, Catlett CL, et al. Training of hospital staff to respond to a mass casualty incident. Evidence Report/Technology Assessment No. 95. Rockville, MD: Agency for Healthcare Research and Quality. Prepared by the Johns Hopkins University Evidence-based Practice Center under Contract No. 290-02-0018; June 2004: AHRQ Publication No. 04-E015-2. Accessible at: www.ahrq.gov/downloads/pub/evidence/pdf/hospmci/hospmci.pdf. Last accessed June 1, 2006.

Resources

National Links

  • Centers for Disease Control, Emergency Preparedness and Response: www.bt.cdc.gov/
  • The Hospital Emergency Incident Command System (HEICS) is an emergency management system that employs a logical management structure, defined responsibilities, clear reporting channels, and a common nomenclature to help unify hospitals with other emergency responders: www.emsa.cahwnet.gov/dms2/heics3.htm
  • State, local, and tribal public health departments have their own public health preparedness and response plans.
  • The National Center for Environmental Health (NCEH): www.cdc.gov/nceh/emergency.htm.
  • Two other CDC resources contain materials to address public health preparedness needs: the Division of Emergency and Environmental Health Services (EEHS) and the Environmental Public Health Readiness Branch (EPHRB). See all-hazards public health emergency response guide): www.cdc.gov/nceh/eehs/
  • U.S. Department of Homeland Security, for family preparedness: www.ready.gov/
  • AHRQ bioterrorism link: www.ahrq.gov/news/pubcat/c_biot.htm#biot002
  • George Washington University Institute for Crisis, Disaster, and Risk Management offers programs, including training, in the area of crisis, emergency and risk management: www.gwu.edu/~icdrm/
  • North Carolina Links—North Carolina Office of Public Health Preparedness and Response (NC PHPR): www.epi.state.nc.us/epi/phpr/provides information and resources regarding the threat of bioterrorism and other emerging infectious diseases within the state and around the nation.
  • The Health Alert Network (HAN) system is designed to immediately alert key health officials and care providers in North Carolina to acts of bioterrorism as well as other types of emerging disease threats: www.nchan.org/
  • DPH Immunization branch: www.immunizenc.com/
  • State Web sites, such as San Diego Country Office of Emergency Systems: www.co.sandiego.ca.us/oes/ or the County of San Diego Health and Human Services Terrorism Preparedness: www.co.san-diego.ca.us/terrorism/links.html

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