NOVEMBER / DECEMBER 2005

FORUM

Hospital disaster management: Preparing for the unexpected

The tsunami that struck southern Asia last December killed over 225,000 people, radically changing the world’s perception of destruction. While the scope of this disaster may have brought the issue of disaster planning front and center, in fact the tsunami was part of a disturbing trend. According to the International Federation of Red Cross/Red Crescent (IFRC) World Disasters Report, from 1994 to 1998 reported natural and technological disasters averaged 428 per year. From 1999 to 2003 the rate rose alarmingly to an average of 707 disasters per year, and the death toll for 2003 of 77,000 dead was triple that of 2002.

The range of potential disasters for which a hospital must be prepared to respond goes beyond those caused by natural events. The IFRC report shows that transportation accidents, defined as a single incident in which 10 or more were killed or 100 were injured, rose 75 percent during the second half of the decade. The threat of terrorism is a growing concern for global and local health authorities, as is the specter of rapidly spread infectious disease. In 2003, Severe Acute Respiratory Syndrome (SARS) made its way from Hong Kong to Toronto in a matter of hours. Today hospitals are watching and waiting for a similar threat to emerge—with much greater potential—if avian flu explodes into a pandemic.

Hospital personnel evacuate a patient via the escalator.

The reach and devastation of recent large-scale emergencies has underscored the need for health care organizations to enhance their capacity to effectively respond to such situations. Hospitals have a two-pronged mission in the event of a disaster: provide patient care and protect their own staff and facilities. The potential consequences of not being prepared or providing an inadequate disaster are obvious: loss of life and tremendous financial costs due to physical destruction. Yet a hospital’s reputation and competitive position may suffer if there is even a perceived failure on their part.

What distinguishes disasters from the routine emergencies hospitals manage is that they often bring unexpected circumstances that require clinicians and staff to respond to situations they have not faced before. Disasters overwhelm the existing coping mechanism of the system, thereby creating enormous stresses on the organization, potentially causing some or all operational and functional elements to function below regular levels or fail altogether. This HMI World Forum explores the challenges of enhancing disaster and emergency preparedness, and presents some internationally recognized approaches to developing, implementing, and assessing disaster management planning for hospitals.

Arnold Howitt: Key for hospitals is to “think creatively about responses.”

Preparedness challenges
At a time of rising costs in health care and a global quest for cost-saving strategies, programs and infrastructure designed to prepare for something that most hope will never happen may be a tough sell. Some may simply think it’s a waste of time and already stretched resources.

Arnold Howitt, PhD, executive director of the Taubman Center for State and Local Government at Harvard’s Kennedy School of Government, and faculty co-chair of an executive training program on crisis management, is co-author and co-editor of Countering Terrorism: Dimensions of Preparedness. He points out that hospitals often view themselves as individual entities, unconnected to the other facets of the public health system. Howitt emphasizes how important it is for hospitals, practitioners, and planners to think beyond the boundaries of health care. “During a catastrophe, a hospital may become critically dependent on conventional agencies such as fire, police, and emergency medicals services, but it may also require the services of public works entities, utility companies, or others—unconventional agencies and partnerships that they may not have considered,” said Howitt.

Howitt says one serious resource challenge hospitals must overcome is the lack of treatment beds to handle large numbers of patients in a disaster. “We know that most hospitals [in the U.S.] have a very thin surge capacity due to efforts to squeeze the excess from health care,” says Howitt. “We need to think creatively about responses and how to manage emergencies. We need to identify unconventional methods, such as sites for care facilities even if they don’t meet standards.”

Stephanie Rosborough, during a relief effort in Uganda: Being too focused on one kind of threat can be “too narrow an approach.”

Stephanie Rosborough, MD is an emergency physician and senior international emergency medicine fellow at Brigham and Women’s Hospital in Boston. At the time of this writing, she was in Pakistan as part of a response effort in the aftermath of a recent earthquake. Under the auspices of the International Rescue Committee (IRC), Rosborough’s team is working with Pakistani authorities to conduct assessments and provide desperately needed aid. She says that too many hospitals fall into one of three categories of preparedness: “The first type are those that recognize the need but haven’t done anything about it. The second includes those that have a plan, but it’s a paper one that sits on a shelf and no one knows about it. The third type has a plan and train the staff but may only do it once every few years.”

The false sense of security that results from “paper plan syndrome”—the belief that an organization is prepared simply because there is a written document—is another danger for hospital emergency planners, as Cristine McCombs can attest. The Commonwealth of Massachusetts recently reassessed its emergency plans in the wake of this year’s hurricane season. McCombs, director of the Massachusetts Emergency Management Agency, which helps coordinate disaster responses for the state, said, “I always say to the team here that plans are living documents. They are not meant to be created and put on the shelf. ”

Preparedness is an investment

Robert Freitas: “The unfortunate reality is that it only takes one large disaster to wipe out all the hard work and reputation of a health care facility.”

Although at an early stage of development in many parts of the world, hospital standards and accreditation can offer useful guidance for putting the elements of emergency management in place. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Joint Commission International (JCI)—the U.S.-based domestic and international accreditors of hospitals, respectively—have defined standards for emergency management and preparedness.

Joint Commission Resources (the education and publication arm of JCAHO) points out in its health care emergency planning manual that in some industries, such as manufacturing and financial services, companies leverage disaster planning and preparedness for marketing purposes. These industries are assuring their various stakeholder groups from a business continuity perspective. For a hospital, that term fits, but the stakes can be very different.

Robert Freitas, MHA, of the Division of International Disaster and Emergency Medicine of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, highlights the common dangers disasters pose to hospitals. “The unfortunate reality is that it only takes one large disaster to wipe out all the hard work and reputation of a health care facility,” he said, adding that “the situation in New Orleans and the destruction there [due to the recent hurricanes and subsequent flooding] will most likely result in the permanent closure of two or three hospitals in the area. If you think about how it will impact health care in an area already underserved, it is easy to see how this is a serious health care problem.”

We know that the physical facilities of a health care organization, as well as the infrastructure and equipment, are very expensive. Freitas makes the point that disaster preparedness and management should be a regular component of a hospital’s budget—to protect these costly investments. “Many health care organizations budget large sums of money annually for facility insurance based on the need to ensure that the hospital can get up and running again following a disaster. An investment in planning is just as important, as insurance will not cover the potential loss of reputation, the impact on the health of a community or region, and the loss of economic well-being if a hospital is out of commission, even for a short time,” he said.

Flooding in Mumbai knocked out power for days, but hospitals with backup systems stayed operational.

Being prepared by being proactive
Disasters are categorized in different ways, often according to their causes. One approach is to organize them as natural, intentional (also man-made), and unintentional. Response to any and all of these is a function of disaster or emergency management, and is divided into phases: mitigation, preparedness, response, and recovery. An effective hospital emergency management plan must address each of these areas.

Mitigation is aimed at reducing a hospital’s vulnerability to disasters. This includes the quality of the physical structure, the presence of fire suppression and life-saving equipment and infrastructure, and redundant systems for electricity, heating and cooling, ventilation, and medical gases. While domestic standards vary widely, many require a thorough facility assessment supplemented by a remedial action plan which is to be tested regularly. The responsibility for facility review generally resides with a director of facilities or chief environmental engineer who then reports to hospital administration accordingly.

Experts emphasize the planning process for several reasons. First, faced with innumerable potential crises, trying to plan for every contingency is unrealistic; therefore a hospital must assess and prioritize. The most efficient way to decide which disasters to plan for is to conduct a formal Hazards Vulnerability Analysis. Using probability, risk, and preparedness with respect to the kinds of disasters liable to strike the organization as the benchmarks, planners can make an educated guess about which disasters are most likely to happen, identify the potential effects on the facility and patients, and determine which pose the greater risk.

Rosborough points out that being too focused on one potential threat can also be a problem for planners. “In Nepal I worked with a hospital in the Katmandu area that had no emergency medicine specialty. With concern over the civil conflict happening at the time and the potential for large numbers of wounded, the physicians wanted to be trained to respond to mass casualties. But the point was made that they are located within an earthquake zone that also made them vulnerable, so preparing solely for victims from armed conflict was too narrow an approach,” she said.

Second, planners must take a cautious approach when building the necessary assumptions into their plan. A classic example of a problematic assumption is that communications systems, such as regular telephone or cellular systems, will be operational. Yet time after time these systems fail when a crisis hits, leaving hospitals, first responders, and agencies struggling to coordinate an effective response. Another common assumption is that the emergency power produced by generators will automatically be operational when regular power fails. Many of these generators, however, are located in the basement of the hospital, where they are vulnerable to flooding. These and other assumptions must be challenged and evaluated carefully.

Third, the assessment process facilitates the development, updating, and improvement of a hospital’s written plan. One of the plan’s purposes is to answer the many questions that potential threats pose. How will special patient populations such as surgical, critical care, or trauma patients be evacuated? What will be the roles of finance, administration, and public relations? Does the hospital have a crisis communications plan? Who releases what kind of information to the press and the public, and when? In this way the plan communicates the roles and responsibilities of the staff and the individual units and departments throughout the organization.

A hospital damaged during a hurricane

To be the most effective, a written plan should be considered a work-in-progress requiring ongoing review and revision. In the plan and in practice, a command structure is an operational necessity. Many health care organizations use the Hospital Emergency Incident Command System (HEICS). This type of formalized approach to the management of disasters enables everyone in the organization to understand their role in the event of a disaster and the roles of others. HEICS stresses functions, not personalities or rank in the organization, and allows for a more flexible approach to emergency management that holds people accountable for their actions.

Fourth, training and drilling provide opportunities for staff to practice and become familiar with disaster plans. Such exercises can also be tailored to test specific skills of the staff, hospital-specific capabilities, or community-wide responses. One study found that staff members demonstrate the highest level of understanding of a hospital’s emergency management plan one month after training occurs.

JCAHO and JCI both require that hospitals develop a written plan that is coordinated with the community, and conduct drills with staff and other agencies using that plan. Both require hospitals to conduct exercises at least twice a year, one of which must be community-wide, with the aim to assess coordination, communications, and the effectiveness of command structures.

Drills are a big component of hospital preparedness, but real-life experience helps too. Philip Anderson, MD, of the Division of International Disaster and Emergency Medicine of Harvard Medical Faculty Physicians at Beth Israel Deaconess Medical Center, says, “If the system has experienced actual events that exercised broad areas of the hospital disaster management plan, these may provide an institutional experience equal to or more valuable than a staged drill. On the other hand, if there is a significant workforce turnover, the organization acquires new facilities or equipment that impact preparedness or response capabilities, or new hazards are identified, then there may be value in holding additional exercises.”

Conducted regularly, disaster exercises also enable an organization to assess its own vulnerabilities with respect to its response capabilities and make improvements. Anderson adds, “Drills provide the critical opportunity to build familiarity and relationships between staff, responders, and other agencies that can prove invaluable during an actual event.”

The learning curve
There is a wide body of literature that challenges misconceptions about planning and disasters, provides data, and illustrates the often terrible consequences. A recent literature review conducted by the Agency for Healthcare Research and Quality (AHRQ) found that most lessons learned related to one or more of the following categories: incident command system, communications (both internal and external), clinical care (triage, patient care, patient flow, and patient tracking), security, materials and resources, and decontamination. As part of the wealth of information available, experts regularly point to the all important lessons learned, drawn from the experience of other health care organizations.

The fear, expressed by Rosborough, Freitas, Anderson, and Howitt, is that these lessons go unheeded and are not being used as forces for change. But if the recent large-scale emergencies highlight anything, it is that disasters happen and they can happen anywhere. It is critical to expect the unexpected and adopt a proactive approach to preparedness in order to prevent failures and ensure that these costly lessons are not learned the hard way.

Copyright 2006 Harvard Medical International