The Evolution of Emergency and Disaster Preparedness Efforts in Health Care

Disaster preparedness has evolved dramatically over the past two decades. Before 2001, disaster preparedness in many hospitals was often little more than the development of a single all-or-nothing mass casualty plan. Collaboration, coordination, or joint planning seldom took place among hospitals, or among hospitals and other health care entities such as public health, extended care facilities, clinics, or other entities.¹ Fortunately, disaster planning in U.S. health care has changed; unfortunately, the major drivers for change were actual disasters. After the attack on the World Trade Center on September 11, 2001, then-President George Bush signed Presidential Directive 5, which directed the development of the National Response Framework and the National Incident Management System, both of which were efforts to standardize our response to large-scale threats. During any large-scale disaster, all agencies and efforts are now coordinated through the use of the Incident Command System (ICS), which is used by all governmental agencies and reflected at federal, state, and municipal levels. In addition, the Hospital Preparedness Program (HPP) was initiated; this program has used grant funding to encourage preparedness efforts in specific categories such as communications, decontamination, evacuation planning, and training, and requires a participating hospital to use a standardized incident command system to respond to emergencies. After Hurricane Katrina, the Joint Commission (TJC) revised and augmented its emergency management guidelines, offering significantly more detail and placing greater emphasis on the emergency management section. Accreditation requirements for preparedness for the Centers for Medicare and Medicaid Services (CMS) have recently been revised also and now more closely resemble those of TJC and other Homeland Security and HPP guidance—the goal being to move standards for all individual facilities toward uniformity regardless of accreditation agency. Preparedness and standardization efforts are also encouraged and guided by state and regional entities such as departments of health and state hospital associations. Hospitals are pulled toward preparedness by the desire to be prepared for emergencies and by HPP grant funding, and they are pushed toward preparedness by requirements outlined in accreditation standards (noting that reimbursement for care delivered is contingent on accreditation).

Disaster Preparedness in the Primary Care Setting

Unlike hospitals, primary care practice settings are not generally moved toward disaster preparedness. Practices that are connected to hospitals may fall under hospital requirements and hence have specific guidelines, and some primary care practices are reviewed and guided by TJC’s Standards for Ambulatory Care, but stand-alone office practices and health centers often have little requirement or financial incentive to undertake formal preparedness efforts. Although a survey of primary care physicians has indicated that they are willing to serve during a disaster,² it is not clear how they can best serve, and most feel that they are too busy to train or to participate in planning or other preparations.³ Is it reasonable to ask all health care entities, to include primary care, to prepare for disasters? In short, yes. It is virtually certain that our nation will encounter major catastrophic events in the future, whether from terrorism, from natural events such as Hurricane Katrina, or from a variety of other man-made or natural causes. In other words, it is highly probable that every health care practitioner, regardless of work setting, will ultimately be affected by a disaster of some sort. In addition, as probable as a major large-scale event might be, we are also nearly certain to experience one of the less dramatic events that happen every day somewhere, including information systems (computer) outages, severe weather, extended power outages, loss of water supply or septic system, flooding, or fire. Several of these might necessitate building evacuation or the salvaging of patient records, medical equipment, computers, and other office equipment. Consider the financial impact of a few days or weeks of business loss, or the practical challenge of losing all patient records! Less dramatic than a full-scale disaster, these are events that we also need to prepare for because they are far more likely to happen and because we may not receive much support during the response and recovery phases. These threats also provide practice in planning and preparing for a larger disaster. Although plans do not have to be elegant, the planning process itself makes us better prepared for any event than we were. Dwight David Eisenhower, a general in the U.S. Army before his presidency, is credited with saying that “Plans are nothing; planning is everything.”

Preparing the Primary Care Office for Small-Scale Emergencies and Disasters

In the esoteric realm of emergency management, the cycle of emergency management is broken down into four phases: mitigation, preparedness, response, and recovery.

In the mitigation phase, risks are first identified. Many hospitals use complex hazard vulnerability assessment tools to weight probability, impact, and preparedness. This process may be more than the average office practice really needs. A primary care practice group might achieve the same objective by simply sitting down with office staff to assess events that have actually happened (e.g., severe weather) and events that might happen (e.g., a violent patient). What possibilities make the staff nervous? Other sources might be emergency preparedness personnel at the local hospital or officials from municipal or city services (e.g., fire chief), who can indicate what they have identified as top risks. Once specific risks have been identified, the practice can begin to either reduce the likelihood of the event happening (e.g., develop data system backup or emergency power generation) or reduce the impact of the event (e.g., add hurricane-resistant shutters). It may be possible to consider risks when designing new structures (e.g., restricting access) or to change existing structures (e.g., by moving generators out of low-lying areas that could flood).

In the preparedness phase, preparing or updating plans for specific events and training personnel through drills and exercises make staff as ready as possible. Top risks can be addressed by developing a very simple plan and then conducting a short drill after office hours in which the staff “walks through” the event detail by detail. Is the response realistic? For example, if the decision is made to call someone in particular, is the telephone number available? Contact information for staff and for outside agencies such as local emergency services and vendors should be updated frequently and kept in hard copy as well as in the office computer system. Stockpiling resources that might be in short supply is not always easy with today’s cost constraints, but keeping a few critical items on hand, such as personal protective equipment (PPE), potable water, and flashlights, might be lifesaving.

In the response phase, hospitals and governmental agencies are required to use an incident command system. Although the practice may not use a formal Federal Emergency Management Agency (FEMA)–style ICS in the office, the designation of one clear commander and delineation of other specific roles, regardless of what they are called, will save time and prevent confusion during an urgent response. All staff members should know their own individual role during a crisis (e.g., leadership, patient care and movement, communications, logistics); preplanning ensures that the response will focus on the most critical tasks without duplication of effort and without wasted time.

During the recovery phase, while returning to “normal,” a debriefing and review of the event is undertaken to gather feedback from participants at all levels. In the quality improvement process that follows, suggestions for improvement are channeled into corrective actions that are tracked for completion, and the cycle of four phases begins again.

The Critical Role of Primary Care Practices in Large-Scale Disasters

There is no well-defined or standard role for primary care practices during disasters as yet; defining that role is a process that may ultimately be left to community-level planners. What is clear is that the basic health care needs of patients do not stop during a disaster. Primary care is often likely to be a critical component in meeting the majority of patient health care needs, at times even more so than acute care (as in the case study on Hurricane Katrina later in this chapter). However, primary care is typically the least planned; the majority of planning efforts and resources focus on acute care needs. Community health centers are probably not well prepared yet and are often not part of community plans.⁴ The U.S. in general is probably not prepared for a catastrophic event that would require a coordinated health care system response, and the development of health care coalitions has been described as the single most important step in preparing the U.S. health care system to respond more effectively.⁵ Grant monies have been designated to support development of community planning efforts, and it is suggested that coalitions should include not only hospitals and extended care facilities, but community health centers and physician office practices as well.¹ Health care coalitions should also include health departments, emergency management agencies, and emergency medical services as well as community responders such as Medical Reserve Corps. In many locations the inclusion of additional health care entities such as specialty hospitals, long-term care facilities, dialysis centers, freestanding clinics, and surgical centers has been valuable.¹ Because of the relatively autonomous nature of their practices, it is unlikely that primary care providers will respond in a uniform way. Federal planning is far more likely to address aggregate organizations such as medical societies or associations than individual primary care practitioners, and the conclusion of one study was that full coordination of physicians is not possible under the current U.S. health care system.² However, community planners may be able to consider the resource of primary care physicians, nurses, and practices more effectively than the federal government, and community planners are more likely to incorporate them into a coherent and realistic plan. Primary care providers will almost certainly continue to address a variety of primary care needs to their own patients, to vulnerable populations, and to patients with specific needs.