Each day in communities all over this country, medical providers are asked to step up and provide care to patients under difficult clinical circumstances. The situation may be as mundane as hospital overcrowding or as extraordinary as the now all-too-frequent active shooter scenes. The common thread among these situations is that the needs created by the crisis are greater than the resources available. The World Health Organization defines a disaster as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”(1) We are all familiar with this concept and practice triage -- matching needs to resources -- on a daily basis in both our professional and personal lives. But what happens when the disaster shows up at your hospital door? How will events unfold and how will you, as a critical care provider, be involved?
It is important to point out some of the similarities and differences in disasters. In general, disasters, regardless of the origin (e.g., hurricane, tornado, bomb blast, pandemic influenza), have many things in common. Initiation of the Incident Command System, coordination across jurisdictional lines, organization of response and relief efforts, and activation of institution-specific disaster plans should be included in an all-hazards approach to disaster management. For example, how first responder services are activated, whether communication systems are interoperable and the use of mutual-aid agreements between jurisdictions should be addressed in advance and should not depend on the type of disaster. However, expectations regarding the types of injuries and illnesses expected and the timing of patient presentation will differ depending on the inciting event. A mass casualty incident (MCI), for which the major triage systems (e.g., Simple Triage and Rapid Treatment [START] and Sort, Assess, Lifesaving Interventions, Treatment/Transport [SALT]) were created, assumes an incident is in one geographic location at one distinct time. The Boston Marathon bombing in 2013 is an example of an MCI. This differs from a larger-scale event such as a hurricane or a pandemic in which people will present to the healthcare system at many locations over a longer period. Take, for instance, the severe acute respiratory syndrome outbreak in 2002-2003 and the ongoing Ebola epidemic. Population-based triage methods are required in such instances. In addition, an MCI and a larger-scale event may occur simultaneously, such as a building collapse during a wide-spread earthquake.
The hospital is but one piece in a much larger puzzle of disaster management. The Joint Commission requires hospitals to have a disaster plan and to exercise this plan annually, as well as to determine how any one hospital will fit into the disaster management paradigm at the community level. In addition, federal funding for health system and public health preparedness calls for the development of a healthcare coalition within communities. These regional coalitions consist of hospitals and other healthcare service providers, as well as their public and private sector partners, coming together to provide a coordinated response to a disaster.
The emergency department (ED) is the typical hospital entry point for most patients in a disaster; thus, it makes sense for many of the initial critical decisions in disaster management to be made here. The call to hospital administration alerting them to an event, activating hospital disaster plans and opening emergency operations centers, mobilizing extra hospital resources (providers, operating rooms, blood bank services), and coordinating efforts with other local hospitals will all be done in close conjunction with ED staff. Activities such as decontamination and patient triage will happen at the ED level, before a patient enters the hospital. The scale of a disaster and the local resources available will ultimately determine the scope of each hospital’s response.
Resource utilization is the single most challenging aspect of disaster management at the provider level. We have all spent years dedicated to taking care of the one patient in front of us. However, a disaster requires us to look at each patient in the greater context of all patients who may need the limited resources available. This theoretical shift toward utilitarianism, the belief in doing the most good for the most number of people, can be challenging during a crisis. In 2009, the Institute of Medicine began the task of defining “crisis standards of care” in order to create a consistent framework for institutions and providers to work within; the results were published in Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response in 2012
.(2) Among the recommendations were alterations to admission requirements to intensive care units (ICUs) and floor beds, changes to staffing ratios and shift lengths, conversion of available spaces into patient care areas, shifting to nurses some care that would normally be handled by doctors, and establishment of a clinical care committee to interface with the Incident Command System and assist providers with difficult triage decisions.
A disaster will place high demands on critical care providers. Limited ICU capacity, equipment availability, staffing requirements, and an overwhelming need for services will place you in a unique position to be an integral part of disaster management. As the standards of care change, it is likely that very sick patients will need to be managed in a non-ICU setting. You will be asked to assist in patient triage decisions to determine appropriate levels of care and to determine which patients will benefit the most from scarce critical care resources. You will need an idea of the scope and scale of a disaster to make these decisions. Working closely with the ED and hospital command staff will give you access to this information and keep the lines of communication open.
1. World Health Organization. Definitions: emergencies. Available at: http://www.who.int/hac/about/definitions/en/
. Accessed October 1, 2014.
2. Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: The National Academies Press, 2012.