* Healthcare provider participation in planning for and responding to a significant disaster event is an area of emergency planning that requires more intensive support and will be critical to the successful outcome of such events.
* A systems framework for catastrophic disaster response planning that accommodates the likely shift in standards of care during a catastrophic disaster event is an important construct that details how such planning can proceed.
The buildings begin to sway and church bells start to ring. It is not a Sunday morning. But it will be like no morning the United States has ever experienced. In a matter of seconds, the dormant New Madrid Earthquake Fault line opens under the pressure of a 7.7 magnitude earthquake. In those few moments, tens of thousands of Americans are killed and injured in the collapse of numerous buildings, and the transportation, energy and healthcare infrastructure of two major American cities, Memphis, TN and Little Rock, AR are almost completely destroyed. Nearly 130 hospitals are damaged. Those who have survived the quake are barely functioning and yet teeming with casualties. Medical care is delivered with whatever resources remain available and very difficult triage decisions have to be made. Not all patients can receive the degree of care that might otherwise be expected due to severe resource limitations. Emergency departments, ICUs and operating rooms are completely filled. School auditoriums and tents put up in parking lots are used to manage the overflow of patients. Communications, power supplies and the transportation infrastructure are all severely affected.1
Could such an event occur? As healthcare professionals, would we know how to respond? Would we be able to prioritize the delivery of lifesaving medical care to the thousands or tens of thousands of patients whose lives depended on our making the correct decision? The answers to these and other related questions must be an unequivocal “yes.” The public, including our patients, already assumes that we have thought through such terrible scenarios and have a plan of action ready to be implemented under such circumstances. The truth, however, is that with some exceptions, many of our colleagues do not contemplate such dire circumstances and are not meaningfully engaged in planning for such efforts. Many more colleagues profess a superficial interest in such matters, but ultimately ascribe to the position that they will let “the authorities” figure out what needs to be done. Such an approach will not work. Healthcare organizations, hospitals, public health departments, and emergency medical services agencies can and do prepare for such contingencies, but unless the medical provider community, defined here as those who primarily deliver care in the out-of-hospital setting, in private practices and clinics, are actively engaged in planning to respond to such events, the organized effort needed to respond to such catastrophic situations may be less than optimal.
Surge Capacity and Capability
A catastrophe of great magnitude, whether from natural causes such as an earthquake or pandemic outbreak or as the result of an intentional terrorist attack with an improvised nuclear device, will require a health and medical response that is fundamentally different from any that has ever been implemented in response to a disaster in the United States. Health systems are designed and organized to provide the optimal care to individual patients and to implement a modest surge to provide care to a large number of individuals following a large-scale incident. Surge capacity can be thought of as the ability to deliver medical care above and beyond what the community is capable of providing2–5; however, medical care is not based solely upon the capacity available in the system—hospital beds and the necessary equipment, supplies, and pharmaceuticals that necessarily accompany those beds.6 It also is highly dependent upon the capability to deliver such care—the specialized knowledge and training of providers, such as pediatricians and surgeons, who may be required to respond.7 Five consequential disaster events of the last decade—the terrorist attacks of September 11, 2001, anthrax bioterrorism in 2001, the devastation wrought by Hurricanes Katrina and Rita in 2005, the H1N1 influenza pandemic of 2009, and the EF-5 tornado in Joplin, Missouri, in 2011—never fully stressed our medical and public health capabilities beyond their breaking points. Although these events resulted in significant surges in demand for patient care and, in the case of the hurricane and tornado natural disasters, the loss of fully functioning healthcare facilities, these were relatively short-lived events. Communities in geographic proximity to the hurricane-ravaged Gulf Coast states and Joplin were able to mount a rapid and sustained response effort to manage casualties from these devastating natural disasters and to help reestablish medical care to the affected communities. What each of these events did highlight was the long-term effect that loss of healthcare infrastructure could have on the communities that they serve. Without question, there were significant alterations in care delivery systems and exposure of issues related to patient access to care, especially in already-fragile sectors such as the access to mental health services. Adjustments to the existing healthcare system were made based upon the available resources, with the goal being the resumption of ongoing care in the communities that were affected. These events demonstrated just how close our healthcare delivery system is to collapsing under the strain of an overwhelming demand for patient care services, with limited surge capacity and capability, and no clear playbook detailing how a more complex, organized response may unfold. If the devastation had been more widespread and pervasive than was ultimately the case in these disaster events, then what would the delivery of medical services have looked like?
Hospitals, in particular, have been planning for disaster response for a number of years, with increasing focus on developing surge capacity and capability and ensuring that mission-critical functions are preserved in the disaster setting. In the emergency management world, these efforts are described as business continuity planning and continuity of operations planning.8,9 Hurricane Katrina taught us the important lesson that planning for such events must occur with an emphasis on systems failure. The ad hoc response to the untenable situation at the Memorial Medical Center in New Orleans after the breach of the levees in September 2005, resulting in legal proceedings leveled against the doctors and nurses responsible for delivering care in that facility, demonstrates why such planning is of the utmost importance.10 Moreover, the out-of-court settlement by the healthcare organization responsible for that same healthcare facility demonstrates that hospitals and, by extension, healthcare providers, can and will be held liable for an absence of cogent planning.11
Importance of Preparedness
During a catastrophic event, hospitals will be required to manage the most critically ill or injured victims of disaster. Elective procedures will be deferred to a later date and the hospital will be required to surge its ability to care for many patients. These efforts cannot simply be “turned on.” They require consideration and planning: Where will such care be delivered? What resources will be used and how will they be prioritized? Who will care for these patients? In the worst-case scenario, hospitals must be able to care for patients for whom there are limited resources. Mechanical ventilators, intravenous pumps, medications, and staffing all may be in short supply. The hospital must prioritize patients who have a chance of survival, based on the best-available evidence at the time. The focus on outcomes will necessarily shift to trying to do the best for the largest number of patients.12–14
Preparations in the past few years for a pandemic influenza response have highlighted the importance of focusing on expanding surge capacity response from the traditional healthcare setting into the community, creating what in essence amounts to an alternate care system. This includes developing plans for delivering care in alternate care facilities15–17; developing more robust home healthcare options; ensuring availability of traditional, private-practice, ambulatory-based care; and exploring the use of “flat space” areas in the management of patients in the traditional hospital setting.2,18,19 The intent of creating this stratified model of healthcare delivery during emergency events is to preserve the hospital setting for patients who are most in need of hospital-level care. Stratification implies the matching of a patient’s healthcare needs with a level of care that is capable of meeting that need. This is more likely to be affected in a slow-onset sustained event, such as a pandemic, rather than a sudden, no-notice event, in which the time required to establish this stratified system presents obvious difficulties. Current planning efforts under development for response to an improvised nuclear detonation, the ultimate no-notice event, are working with the concepts of developing an alternate care system; therefore, the notion deserves serious exploration in all settings.20
To effect such plans, staffing must be procured and guaranteed. It is not enough to assume that disaster volunteers or federal disaster workers will arrive en masse to provide the necessary manpower. Healthcare workers in the affected disaster areas must be expected to provide the bulk of the healthcare manpower pool. They will need to know where their services are in greatest need: Will it be at the hospital, at an alternate care center, manning their private-practice, office-based care setting? The greater the extent to which such a stratified system can be planned for before the onset of an event, the more likely such efforts will be successful. Who will make the decisions? Who will decide where patients receive care? If such a range of services is indeed in place in the community, the effect on the supply side of the healthcare delivery equation will be significant. If, however, private practices close, health clinics are shuttered, and hospitals are the only means for delivering care, this limitation of clinical care options would have a significant impact on the access to care for victims of disaster.
Crisis Standards of Care: Providing a Framework for Catastrophic Response
Healthcare practitioner concern for legal protections remains an important aspect of planning for disaster response. The need to better understand the issues of liability risks and the importance of contemplating the effect of how medical care delivery will likely change under disaster response conditions led the US Department of Health and Human Services to engage the National Academy of Sciences’ Institute of Medicine (IOM) in exploring the issues related to establishing standards of care for use in disaster situations. The IOM issued two reports21,22 that contemplated these difficult issues. With the shift from the “probable” to the “practical” that accompanied the emergence of H1N1 pandemic influenza in spring 2009, additional focus was placed on guidance to establish standards of care in catastrophic disaster situations. The IOM issued a letter report that laid the foundation for the implementation of “crisis standards of care” and elucidated a surge response framework that better delineates the level and type of medical care that may be delivered along a spectrum of surge response ranging from conventional care to contingency and crisis care.23 Crisis standards of care are defined as the recognition that “a substantial change in health care operations and the level of care that can be delivered in a public health emergency will be justified by specific circumstances.” During disasters, medical care must promote the use of limited resources to benefit the population as a whole. It highlights the importance of basing the delivery of such care on a transparent ethical footing that would allocate services to save the greatest number of lives possible.
One of the key points made in the second IOM report and hence its title, A Systems Framework for Catastrophic Disaster Response, is that the response to catastrophic disaster requires the complete and comprehensive participation of all of the elements that comprise the emergency response system. It is not simply the hospitals that will bear the burden of response but also can we expect that the public safety agencies, including the emergency medical services authorities, will manage the response? A catastrophic disaster by its nature, scope, and breadth requires a comprehensive response. In the IOM report, recognition of the role of the provider community, the doctors and nurses who contribute to the delivery of the nearly 90% of healthcare services that occur in the out-of-hospital setting, was highlighted by recognizing that this workforce constitutes the first step in the creation of such a comprehensive framework (Fig.). Provider engagement, community engagement (working with the community to explore community values related to the allocation of scarce resources), development of clinical indicators and triggers that demarcate the shift from resource shortages to the need to triage remaining resources, and development of specific clinical pathways to managing the surge in demand for health and medical services are critically important processes that require concerted efforts in ongoing disaster planning.
Fig. A systems appro...Image Tools
Importance of Provider Engagement
Ultimately, the ability to render care to the tens of thousands of patients who may be affected in a scenario such as that introduced at the beginning of this article is contingent upon the ability of the provider community to step into action. It is important to note that the topic of provider engagement extends far beyond the conventional consideration of healthcare providers responding as disaster volunteers. An event of the magnitude described previously would essentially thrust all providers in a given community or larger geographic area into the role of first responder and first receiver; volunteers, if they were able to support the affected area, may arrive later in the response, if at all. The ability to coordinate local doctors, nurses, and allied health professionals in responding to local disaster is, therefore, critically important, but has it been planned for?
A number of studies in the past decade have examined the need for training and education of the healthcare workforce in disaster preparedness and response efforts.24–28 Several national efforts to develop competencies in disaster preparedness and response within the healthcare workforce are under way29–31 and a number of ways by which private practitioners can get more involved in disaster planning and response have been developed (Table). A number of curricula also have been developed and are being offered, including those coordinated by the American Medical Association, the Society for Critical Care Medicine, and the American College of Surgeons; however, it is generally recognized by the field that such efforts continue to lag behind the imperative to involve more providers in disaster planning and response. Moreover, there is a need to educate the healthcare workforce about the difficulties and challenges related to the ethical decision making that inevitably accompany a disaster of such magnitude.32–35 Despite efforts focused on improved disaster planning and participation of the health and medical community, including presidential directives and federal grant guidance capability alignments that promote such efforts, the results are inconsistent and, in many areas, lacking. Programming disaster education in the curricula of medical schools and residency programs may be the most productive way to ensure that physicians are taught the basics of disaster planning and response.
Table Disaster respo...Image Tools
Addressing Liability Concerns May Enhance Participation in Planning
The disaster that resulted from Hurricane Katrina demonstrated how healthcare providers may be second guessed for decisions made during a disaster, despite their best intentions. The IOM reports do not advocate for blanket legal liability protections, nor do they suggest that negligent care should be condoned during a disaster. The reports clearly articulate that the rule of law must be respected and that patients must have rights to protect themselves in times of disaster. Certain liability protections may be necessary, however, to provide healthcare practitioners with the leeway to make difficult decisions under catastrophic conditions, including having to withdraw life-sustaining services from patients when such care is deemed futile and the same resources may be better applied to other patients who have a better chance of survival. The reports suggest that healthcare providers examine such protections within their own practice environments and, where they are lacking, initiate the necessary steps to attempt to rectify such oversights.
An example of the outcome of such a collaborative discussion is drawn from the experiences of the health and medical community working with the state legislature in the Commonwealth of Virginia. The Virginia Hospital & Healthcare Association’s Hospital Emergency Management Committee, formed in the aftermath of the 2001 terrorist attacks, represents the formal coordination of healthcare disaster planning in the state and proposed that this issue be considered by the 2008 general assembly. The language the legislature adopted and passed into law explicitly states, “In the absence of gross negligence or willful misconduct, healthcare providers who responds to a disaster are immune from civil liability… . If the emergency and subsequent conditions caused a lack of resources, attributable to the disaster, rendering the health care provider unable to provide the same level or manner of care that would have been required in the absence of the emergency.”36 The status of liability protections offered by states in disaster situations should be examined and steps should be taken to ensure that healthcare providers receive the same sort of protections that other first responders (emergency medical services, police, fire) already have taken when working under disaster conditions.
Healthcare providers face many challenges when responding to catastrophic disaster events, including the extraordinary and unprecedented issues related to the need to allocate scarce resources among the many patients who seek care. As noted previously, this may include the reallocation of certain lifesaving resources from patients who are no longer benefiting from their use. For example, mechanical ventilators used as part of the support for patients who are septic, hypotensive, and refractory to the resuscitative efforts initiated may be better used to support the immediate surgical and postsurgical interventions required to manage an isolated traumatic brain injury, a category of patients who are more likely to survive. In addition, issues are bound to arise regarding scope of practice and usual practice standards, including workplace conditions and workplace safety concerns. With a shortage in staffing, how will nurse-to-patient ratios be adjusted? Will paramedics be allowed to perform more invasive procedures if working in the hospital? Can pharmacists make independent decisions regarding the administration of certain medications? These sorts of issues ultimately lead to concerns regarding professional liability, both on the part of those healthcare workers thrust into the position of having to provide such services and those whose responsibility it is to oversee such actions. Balancing the professional demands of those who take the Hippocratic oath to “do no harm” yet want to provide the best possible care for their patients is difficult. The need to consider the personal risks involved in the care of others, particularly under catastrophic conditions, is a dynamic tension that must be accounted for and planned for.
Given the fact that the vast majority of healthcare dollars are spent managing patients in the outpatient setting, the inclusion of community-based healthcare providers into community-wide disaster planning efforts is of the utmost importance. The notion of provider engagement, in which private-practice healthcare practitioners are actively drawn into planning for community-wide disaster response, is of critical importance to the success and sustainability of such community efforts. Participation comes with a number of burdens, the least of which are the time, effort, and expense of becoming prepared to respond to disaster events. More troubling may be the problematic transition that healthcare providers must undertake in shifting the focus of medical care outcomes from those of individual patients to those that benefit the population as a whole. It is difficult to make decisions that may mean life or death for patients with whom healthcare providers have an established relationship and yet whose individual outcomes must now necessarily be put behind the decisions made for the benefit of the community as a whole. Ultimately, then, healthcare providers must serve as the “medical conscience” of the community, helping to guide the development of public perceptions and values related to the delivery of health care in a resource-poor catastrophic disaster environment.
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