Staff at Beth Israel Deaconess Medical Center in Boston had only 10 minutes from the time they learned bombs had exploded at the Boston Marathon to when victims began flooding the hospital. The medical center received 24 patients from the marathon that morning—10 of whom had life-threatening injuries.
Hospital staff immediately sprang into action. The event was similar to scenarios they had practiced during emergency preparedness drills, said Julius Yang, MD, PhD, a Beth Israel hospitalist.
“We know in this type of event, the primary need is not internists, but trauma care and surgeons,” said Dr. Yang, who worked during the bombing aftermath. As hospitalists, “our role, which we have practiced, is to work with ED staff to decompress the emergency department of non-casualty medical patients. Our teams helped pull those patients up very quickly to inpatient beds.”
But the massive ordeal also posed several unforeseen challenges for the hospital, such as when the entire city was placed on lockdown later that week.
“Ambulances were allowed to come in, but we had to figure out how to get key personnel in to make sure we had the staff to take care of patients,” Dr. Yang said. “Thankfully, with the timing of things, the lockdown was released in time for us to replenish our staff.”
Beth Israel was well situated and trained to handle the bombing aftermath, but the outcome could have been worse had the incident occurred elsewhere, said Dan Hanfling, MD, special advisor of emergency preparedness and response at Inova Health System in Falls Church, Va., and vice chair of the Institute of Medicine's (IOM) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations.
The response could have been “very different if you were running that marathon in a rural community where the health care resources are much more [constrained],” he said.
Unanticipated disasters such as the marathon bombings and the September 2013 Navy Yard shooting in Washington, D.C., pose questions about how hospitals can best prepare for such emergencies. Although health systems have made great strides in disaster preparedness over the last decade, there are still improvements to be made, Dr. Hanfling said.
A new toolkit
The need for a more comprehensive approach to disaster planning led to an IOM report, “Crisis Standards of Care: A Toolkit for Indicators and Triggers,” which was released last July and details how doctors and medical staff can more clearly identify and address looming crises. The report is the third in a series intended to improve delivery of health care services during large-scale disasters and public health emergencies.
The IOM report outlines how hospitalists and other clinicians can pinpoint indicators and triggers that aid decision making about care in disasters. For example, an indicator could be ED wait time. If wait time exceeds a certain number of hours, that would be the trigger for response tactics such as increased staffing to be initiated.
Advance planning by health care teams is vital to successfully employing emergency management strategies, according to the IOM report. The paper includes a toolkit to facilitate discussions about indicators and triggers within and across health care organizations.
The voices of hospitalists should be included in disaster planning discussions, said Dr. Hanfling, a co-editor of the IOM report. If physicians are unsure of their role, they should ask questions and seek out preparedness leaders for clarification, he said.
The hospitalist's role
Hospitalists' duties depend greatly on the type of disaster, said Kristi L. Koenig, MD, director of the Center for Disaster Medical Sciences and professor of emergency medicine at the University of California, Irvine School of Medicine.
During a major trauma incident, hospitalists might be most useful in addressing surge capacity. In the event of a pandemic, hospitalists might need to manage scarce resources such as ventilators.
The time and scale of the disaster impact the degree to which hospitalists must act, Dr. Koenig added. “Disasters know no boundaries and no time zones,” she said. “You need to know what to do whether it's 3 in the afternoon or 3 in the morning. If [the disaster happens] during off hours, you may be the senior person who needs to manage it until someone else gets there.”
Colorado hospitalist Jason Persoff, MD, knows firsthand how disasters can force doctors to work outside their usual capacity. The physician is a storm chaser and was in Joplin, Mo., when a tornado demolished the town in 2011.
Dr. Persoff and a fellow doctor volunteered at the lone remaining hospital, Freeman Hospital West, as injured patients from St. John's Regional Medical Center were evacuated to there.
“I'd never once considered the possibility that [hospitalists] may have a role in a trauma disaster,” said Dr. Persoff, a nocturnist at the University of Colorado Hospital in Aurora.
Dr. Persoff shifted from providing trauma care to evaluating patients and working to reestablish treatment such as oxygen and chest tubes. The challenge was determining appropriate care without medical records or histories available.
Heavy on Dr. Persoff's mind during the ordeal was the need to develop his own personal family emergency plan. “I saw providers struggling with not being able to get a hold of their families and not knowing if they had been killed or their house had been wiped out,” he said. “That was tough to watch.”
Creating a family emergency plan is crucial for hospitalists and other health professionals for personal and professional reasons, agreed Dr. Koenig. “It's difficult for physicians to come to work unless they know their families are safe,” she said.
Crises in rural settings
Geographic location and medical center size significantly impact the way in which emergency responses must be planned and conducted.
Smaller, rural medical centers tend to have fewer resources than larger hospital systems, Dr. Hanfling said. For this reason, they are likely to activate their emergency preparedness plans at earlier thresholds.
“A small critical-access hospital that has 25 beds is going to quickly transition to a crisis response if there are 50 or more patients seeking care at the same time, whereas in a big trauma center, 50 patients would be a challenge but wouldn't necessarily push it toward crisis,” he said.
Hospital professionals should modify their crisis indicators and triggers to fit their size, resources and surroundings, he said.
In addition, rural hospitals should consider and discuss what supplies and specialists they are lacking and how they would access these resources in the event of an emergency, said Dr. Koenig. Telemedicine is one option, she added. For example, during a large-scale burn incident, telemedicine would enable rural physicians to electronically consult with burn specialists about which patients to send to burn hospitals.
Because physicians in rural settings regularly work with fewer resources, they are often proficient at doing the most with the least means, said Steven N. Matles, environmental health and safety officer at the University of Nevada School of Medicine in Las Vegas and vice president of AMMI Inc., a health care emergency management consulting company.
“In most cases, you frequently have a number of ancillaries who are multi-skilled anyway, which is a good thing” during a disaster, he said.
Instituting command systems
Developing a strong incident command structure is another component of effective disaster response at hospitals, preparedness experts say.
More than 90% of U.S. hospitals use some form of Hospital Incident Command System (HICS), said Mr. Matles.
HICS was created in the 1980s as a way for hospitals to prepare for and react to various types of disasters. The system establishes a clear chain of command and allows for the integration of various agencies and community departments. Such systems can be customized to fit large and small health care facilities and every community, said Mr. Matles, who helped draft an updated version of HICS due out in early 2014.
Hospitalists are vital in developing a strong HICS at their hospital, particularly when it comes to patient evacuations and relocation plans, Mr. Matles said. Hospitalists have an acute awareness of a hospital's patient population, which can help HICS administrations understand the type of equipment and care that might be necessary during a large-scale move.
“It's going to take a hospitalist's eyes to see that,” Mr. Matles said. “They've got knowledge about what your typical patient population is going to look like and what is needed to support that population.”
Regular drills are critical to a hospital being ready for large-scale emergencies, experts said.
The Joint Commission requires accredited hospitals to conduct several disasters drills annually, said Daniel Castillo, MD, Joint Commission medical director in the Division of Healthcare Quality Evaluation. The Joint Commission evaluates how well the drills are performed and whether hospitals develop actionable plans to improve shortcomings. The purpose of the drills is to make sure the organization, hospital staff and the community are prepared for all types of hazards, and that everyone is actively and effectively communicating and working together, Dr. Castillo said.
“We can at times become a little complacent, even with our drills,” Dr. Castillo said. “The important thing is to become more proactive. If you haven't put a lot of time and effort into a drill and something happens, you're not going to be able to deal with that disaster as well.”
Taking part in drills not only prepares hospitalists, but helps them get to know hospital leadership and emergency management, Dr. Yang said. He encourages hospitalists to seek out disaster training available through HICS and the Federal Emergency Management Agency (FEMA).
Perhaps most important, hospitalists should never underestimate the crucial function they play in disasters and the value they provide, Dr. Yang said.
“Not just that we know clinically how to take care of patients, but that we actually become experts in how the hospital works as a system. If any piece gets cut out of that, we are the clinicians [who] understand how to repair how the system works,” Dr. Yang said. “It's a great opportunity to capitalize on that and to provide value during a trying time.”