In the last century, there has been a significant reduction in the proportion of deaths caused by communicable disease due to the advent of effective medications and vaccinations.(1) Despite these advances, contagious diseases still require recognition and preparation to minimize human, economic and societal hardship and cost.
The U.S. Centers for Disease Control and Prevention has classified communicable diseases as category A, B or C. Category A diseases have a high potential for adverse public health impact and large-scale dissemination and are thus the highest priority agents.(2) These currently include anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fevers like Lassa fever, yellow fever, Marburg disease, and Ebola virus disease (EVD).
Unlike conventional disasters, infectious diseases can affect large groups of individuals over prolonged periods in multiple regions. This places significant stress on a larger range of healthcare resources. For example, the September 11, 2001, attacks had minimal impact on hospitals in the affected areas. Of 6,000 patients treated by 91 local hospitals, only 500 were admitted.(3) Compare this to the pandemic flu (H1N1), which caused over 12,000 deaths, almost 275,000 hospitalizations and 60 million infections between April 2009 and April 2010 in the United States alone.(4)
There is not only a human cost but also an emotional and financial impact related to the outbreak of any highly contagious disease. In 2003, severe acute respiratory syndrome (SARS) was recognized. It spread to over 12 countries,(5,6) with more than 750 deaths and 8,000 people infected. It was estimated by Bloomberg News that SARS cost the global economy more than $40 billion, due in large part to public panic.(7) At the time of this writing, the economic effect of Ebola virus disease (EVD) is estimated to be in the hundreds of billions of dollars in West Africa and has even been cited as contributing to recent volatility in the U.S. stock markets.(8)
Public health measures to control and contain infectious outbreaks are crucial and critical. Adequate preparedness at each level of the healthcare system can lead to seamless, high quality patient care, limit inadvertent contagion of healthcare workers and patients, and mitigate public anxiety.
Disaster medicine can be defined as the coordinated medical response to unexpected disruption of the system of healthcare delivery.(9) The goal during a disaster is to mitigate death, disease and further injury. This is done through preplanning, education and training that includes drills. As of January 1, 2014, it is a Joint Commission requirement for critical access hospitals to have an emergency manager(10) for disaster management. Good resources for disaster medicine education include the Society of Critical Care Medicine’s Fundamental Disaster Management course.
Disaster Management - Preparation Stage
In concert with mitigation strategies, preparation is the most important stage of the disaster cycle. It involves multiple steps, such as identifying the incident command leadership for the intensive care unit (ICU). The leadership should perform a hazard vulnerability analysis, preferably organized with the hospital’s emergency manager, develop an emergency management plan and regularly conduct realistic drills to develop operational insight into how a surge of sick people might strain the resources of the ICU.(9) The ICU leadership team should identify the institution’s greatest disaster risks, preparedness gaps and vulnerabilities. This also is a Joint Commission requirement for hospitals, and these plans must be discussed with senior hospital leaders who oversee strategic planning and budgeting.(10) The concept of surge capacity building is critical for the successful rollout of a plan. An effective tool is the so-called staff, stuff, space, and structure paradigm.(11)
Critical Care Staffing
This may involve cross-credentialing, accelerated or expedited credentialing (as Louisiana did for physicians and nurses during Hurricane Katrina), and canceling vacations and recalling staff.
Critical Care Stuff
This entails having access to emergency medical supplies through vendors or regional or national stockpiles.(12,13)
Critical Care Space
Inova Health System in Virginia responded to the September 11, 2001, terrorist attacks by making 343 additional beds available within three hours, and the District of Columbia made available 200 beds from their existing 2,904 staffed beds.(14) One option is canceling elective procedures to free up beds for surge capacity building. In the case of infectious disease outbreaks, environmental engineering experts can redesign heating, ventilating and air conditioning systems to provide negative-pressure environments.
Critical Care Structure
The United States Air Force has maintained critical care aeromedical transport teams, each consisting of an intensivist, a critical care nurse and a respiratory therapist who can use portable ultrasound equipment, mechanical ventilators and point-of-care testing to provide care for up to three patients.(11,15) A team structure like this can be adapted by using critical care nurses who are cross-credentialed in dialysis and have ventilator experience. Such medical personnel could play a triple role when demands exceed resources.
Disaster Management - Response Stage
The disaster management plan should contain a predetermined threshold or trigger for activating the plan. Components of the plan should have backups if the primary plan fails. Having a trained project manager on the team helps. Most accreditation organizations, including The Joint Commission, require emergency management programs, emergency operations plans and standardized incident response systems. Adapting and using the California Hospital Incident Command System is a way to meet this requirement.(16) It is cost-effective to adopt or adapt a proven model rather than develop a new one. Some experts suggest nontraditional ways to exercise the command system through staff picnics, health awareness days or inclement weather days.
Multipronged communications -- both within an organization and externally with emergency services, such as police departments, fire departments and emergency medical services -- using both traditional and nontraditional modes should be trialed and tested.(17) A dedicated and aggressive media outreach approach can be very helpful, as evidenced by Emory University Hospital when care was provided to two EVD victims; the hospital did not see any decrease in the volume of elective or emergency utilization due to the intense media outreach to local and national audiences.(18) Using the buddy system for putting on and taking off personal protective equipment should be a standard.(19-21) A staff support system should be in place to take care of the anticipated emotional and physical toll.(22)
The death of an EVD victim and subsequent infection of two healthcare workers in Dallas suddenly brought a highly contagious disease back to the forefront of public awareness. It suggested a lack of preparedness on the part of most U.S. hospitals to deal with a category A infectious disease.
Lessons can be drawn from the SARS outbreak in Toronto and other recent mass casualty incidents in the last decades.
ICU directors are in the unique position of having some of the most highly trained staff in their hospitals. They should be able to leverage their staffs’ skill sets to develop an effective disaster plan.
The concept of a disease contained only in another part of the world no longer exists due to the rapidity and breadth of modern travel. Diseases in China, Hong Kong, the Arabian Peninsula, or West Africa take less than a day to reach the coasts of the United States, Canada or any country.
The Society’s Fundamental Disaster Management course and other disaster courses offered by professional associations are a vital resource for ICU and hospital leaders looking to facilitate and improve disaster preparedness.
The opinions expressed here are those of the author (Dr. Geiling) and do not represent official views or policies of the Department of Veterans Affairs or the U.S. Government.
The opinions expressed here are those of the author (Dr. Kyereme-Tuah) and do not represent official views or policies of the Geisinger Medical Center or Department of Critical Care Medicine.
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16. Section 1.6.5, Accreditation consistence. Hospital Incident Command System Guidebook. Available at: http://www.emsa.ca.gov/media/default/HICS/HICS_Guidebook_2014_10.pdf
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18. Ribner B. Ebola: lessons learned. From: IDWEEK 2014. Available at: http://www.idweek.org/ebola_idweek_2014/#1
19. Canadian Critical Care Society, Canadian Association of Emergency Physicians, and Association of Medical Microbiology and Infectious Disease Canada. Ebola clinical care guidelines: a guide for clinicians in Canada. Interim report, August 29, 2014. Available at: http://www.ammi.ca/media/69846/Ebola%20Clinical%20Care%20Guidelines%202%20Sep%202014.pdf
20. Appendix 3: Personal protective equipment for routine patient care. In: Geiling J, Burns SM, eds. Fundamental Disaster Management. 3rd ed. Mount Prospect, IL: Society of Critical Care Medicine; 2009.
21. Appendix 4: Enhanced airborne precautions for procedures with high risk of aerosolization. In: Geiling J, Burns SM, eds. Fundamental Disaster Management. 3rd ed. Mount Prospect, IL: Society of Critical Care Medicine; 2009.
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