You work in a small city that has several nearby colleges. Many students and faculty come from around the globe, including Southeast Asia where yet another flu strain seems to be developing. Early reports indicate the severity of the illness and affected population to be potentially greater than that of nH1N1 in 2009.

At 10 am on August 27, a handful of patients are referred from the college’s Health Clinic to your hospital’s emergency department (ED), with fever, cough, sore throat, and muscle aches months before the normal start of the influenza season. A few are presenting with exacerbations of their asthma.

By evening the ED is overflowing with patients presenting with typical flu-like symptoms. A handful of patients in acute respiratory distress are arriving by ambulance. The EMT says that this is the sixth case and third hospital to which he has transported such a patient today.

The pattern recurs and worsens the following day. Half of the ED patients are experiencing what appears to be primary viral pneumonia and those admitted the previous day are developing multiorgan failure. Many are transferred to the intensive care unit (ICU) and require mechanical ventilation. Meanwhile, patients have overflowed from the ED into the hallways as they await diagnosis, treatment, and final disposition.

Three days into this event, all of the nearby hospitals are reporting an influx of patients with similar symptoms. Their EDs are overcrowded, every inpatient bed is filled, and the night shift—already sparse—is short staffed because some health care workers (HCWs) are afraid to come to work due to the mysterious infectious outbreak being reported on the television news.

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  Critical care providers must be aware of challenges for the ICU, hospital, and community in disaster preparation and response. Failure to fully understand and appreciate the applicable concepts of disaster medicine will impede the provision of optimal critical patient care in a disaster.

  
  
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  Hazard Vulnerability Analysis is a tool to aid in hospital and ICU emergency planning in terms of likelihood and risk to demand ratios for hospital services. Given these likely events, hospitals and ICUs must then develop and test Emergency Operations Plans.

  
  
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  Preparing and exercising plans challenge hospitals and ICUs that already suffer from fiscal and time constraints for high risk, but low probability events. However, a variety of funding sources, exercise development resources, and modeling applications exist to aid in medical surge planning relevant to critical care.

  
  
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  Incidents such as intentional explosions and disease outbreaks will likely have a direct, though vastly different, impact upon demand for hospital-based critical care resources. Acute traumatic events tend to surge demand for surgical services with short ICU stays, whereas pandemic flu, for instance, will more likely isolate its effects in the ICU for a prolonged period of time.

  
  
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  The “stuff,” “staff,” and “space” paradigm provides three key methods to surge critical care resources during a disaster response. Streamlining and simplifying inventory to meet common critical care issues such as respiratory failure and shock, cross-training staff who have critical care providers overseeing a tiered team, and finally expanding the ICU into other areas of convenience inside a hospital, together provides an effective response strategy.

  
  
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  Understanding the process of hospital and community emergency planning lends to greater scarce critical care resource management in actual catastrophe. An ICU does not, nor can it, manage a surge of patients in isolation.

Critical care providers must be prepared to handle mass casualties resulting from all types of natural and man-made disasters. Hurricanes, floods, other weather-related incidents, wildfires, and earthquakes occur both seasonally and sporadically in various parts of the world. Hazardous material spills, power outages, or transportation accidents can occur as well, or in concert with naturally occurring events, as took place in the 2011 Japan earthquake. Man-made events can also occur as a result of terrorists’ attacks, such as occurred with the Aum Shinrikyo cult’s 1995 release of sarin gas in the Tokyo subway where 12 people were killed and 5000 injured,¹ and in the 2005 London underground station and bus bombings where 56 people were killed.² Although predicted to cause few direct casualties, terrorists could also disperse nuclear material by placing radioactive materials in a conventional explosive; this “dirty bomb” would likely result in more chaos and fear than direct patient trauma. Of course a “backpack” or improvised nuclear detonation by a suicide bomber would cause catastrophic casualties with significant loss of infrastructure. Finally, the threat of emerging infectious diseases, such as the 2003 SARS outbreak³ or the 2009 nH1N1 pandemic,⁴ could also result in large numbers of medical, critically ill patients. All of these disasters have the potential for a rapid influx of patients requiring immediate critical care, and in some cases, long-term critical care.

Lacking specific planning and exercising, critical hospital functions and the ability to care for patients from a catastrophe may be severely limited, resulting in further injury or loss of life. For example, as hospitals increasingly depend on electronic medical records to provide services, a power system failure or computer virus could halt patient services if back-up systems are not in place. Without an emergency generator, flooding could result in a power outage throughout the facility and intensive care unit (ICU) patients would be left without functioning ventilators.⁵ Some events may cause hospitals to close when their services are needed most, either as a result of overextending their capacity or physical structural damage. Moreover, the medical response would be ineffective if the disaster response is not planned prior to a disaster, causing many victims going without potentially lifesaving medical care as a result of chaos and confusion in the response effort.

Hospitals possess limited capital and staff time to spend conducting comprehensive disaster response drills or emergency planning and preparedness. However, these efforts do afford other benefits to hospital functionality outside of the ability to effectively respond to an actual mass casualty event. Such activities support routine patient-care activities through improved communications, enhanced use of infection control (IC) precautions, improved interdepartmental coordination and patient tracking, and optimized working relationships with external community partners such as Emergency Medical Services, Public Health, emergency management agencies, and other hospitals. These enterprises all serve the hospital in both its day-to-day operations as well as its integration into the community.

All emergencies and catastrophes begin as local events. Some disasters require a rapid response, such as nerve agent exposure where victims may develop symptoms within minutes before dying of respiratory arrest. Other emergencies may impede transportation to and from an affected area. Patient movement around a city may be prevented because of the fear of spreading a contagious agent. Finally, although disasters are multidimensional events, hospitals are the lynchpin of the definitive medical effort because they are always open. Thus hospitals must be prepared to function independently early in a disaster and continue to support their essential ongoing activities as well as care for the surge of patients from the incident.

Critical care resources may be particularly vulnerable during catastrophes. State and federal assets are poised to assist and respond, but depending on the extent of the event and other confounding variables (such as weather), local capabilities must be able to function independently for some time. These entities may provide some critical care equipment and supplies, but no specific state or federal teams or response systems are ready to provide critical care to large numbers of civilian victims of a terrorist attack in the first 24 to 48 hours. The US’ Strategic National Stockpile (SNS) implemented by the Centers for Disease Control and Prevention (CDC) could take up to 12 hours to reach the hospital—a delay that is likely to be too long in the event of a chemical attack. The SNS cache includes several critical care supplies, such as emergency airway management and intravenous (IV) supplies, but it does not include cardiopulmonary monitoring equipment, remote monitoring equipment for ventilators, diagnostic equipment, closed suction devices, or medical gases.⁶ Additionally, there could be logistical problems regarding the distribution of assets to hospitals once the local and/or state authorities receive them. Therefore, all hospitals must have some internal capacity to augment critical care.

Every hospital and ICU must undertake catastrophe planning, not only because disasters may impact any facility, but also because in the United States, it is an accreditation requirement for hospitals under The Joint Commission (TJC). These standards, started in 2001, require hospitals to develop and maintain a written Emergency Operations Plan covering the following areas of emergency management:

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   Communication

   
   
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   Resources and assets

   
   
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   Safety and security

   
   
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   Staff responsibilities

   
   
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   Utilities management

   
   
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   Patient and clinical support activities

   
   
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   Regular testing and evaluation of the plan⁷

Semiannual evaluation of the plan is required in the form of operational exercises. For hospitals that offer emergency services or are community-designated disaster receiving stations, each exercise shall use one of the following two scenarios.

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  An influx of simulated patients

  
  
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  An escalating event in which the local community cannot support the hospital⁸

A distinct challenge for hospitals and ICUs is: For what disaster should they prepare? Trying to develop contingencies for all possibilities becomes an overwhelming and expensive enterprise. A hazard vulnerability analysis (HVA) is an effective tool to help hospitals determine the likelihood, potential impact, and current vulnerabilities to events. TJC defines an HVA as the identification of “potential emergencies that could affect demand for the hospital’s services or its ability to provide those services, the likelihood of those events occurring, and the consequences of those events.”⁸ The HVA tool developed by the American Hospital Association’s American Society for Healthcare Engineering designates emergencies as natural, technological, and human events and then rates them in terms of the probability of occurrence, risks posed, and hospital’s level of preparedness.⁹

Working through this process with community partners helps hospitals and ICUs in their planning. While no plan can truly be “all hazards” in nature, key processes identified in developing the plan can translate across a variety of catastrophes, such as command and control, communications systems, etc. This allows organizations to be flexible enough to respond to emergencies of all types and to meet established TJC standards for care provision.

In working with communities, hospitals must plan their response efforts in concert with the HVA of the community and state. Similarly, ICUs should also work with hospital emergency management committees to determine the highly probable events for which they should plan. Casualty patterns and victims’ medical needs generally can be predicted based on the types of hazards identified in the HVA (Table 9-1).

Reviewing a handful of recent intentional explosions offers a general picture of casualty patterns and medical needs of victims in order to demonstrate the type of injuries and care needs following such attacks. For example, in 1995, a terrorist attack destroyed the Alfred P. Murrah Federal Building. What came to be known as the Oklahoma City Bombing resulted in 759 casualties and 168 deaths. Eighty-three victims, 11 of whom died, were admitted to the hospital.¹⁰ The following year, a bomb exploded in the Centennial Olympic Park in Atlanta, Georgia, during the Summer Olympic games. This terrorist attack resulted in 111 injured people and two deaths. Twenty-four individuals, 22 of whom died, were admitted to the hospital.¹¹ Terrorists crashing two airplanes into the World Trade Center on September 11, 2001, resulted in 3825 casualties and 2726 deaths.¹² Of the 181 victims admitted to the hospital, five died.

In a conventional explosion, the majority of patients will have trauma injuries (Table 9-2), with 30% having an Injury Severity Score of greater than 16. Some of these critically injured patients die before they can be stabilized enough to be admitted to the hospital. Such patients will result in many emergency department (ED) visits, with approximately 30% becoming ICU patients.¹³ Burns that occur, unless associated with fire, tend to be superficial thermal flash burns.¹⁴

Within 90 minutes following a sudden impact event like an explosion, 50% to 80% of acute casualties will likely arrive. However, the initial wave of patients will be minimally injured self-referrals who leave the disaster scene by their own accord. The most common injuries are eye injuries, sprains, strains, minor wounds, and ear damage, whereas the most severe injuries are fractures, burns, lacerations, and crush injuries. The hospital closest to the catastrophe will be the most impacted, with ED, surgical, and mental health services being most affected. Other surrounding hospitals usually receive few or no casualties. Disaster recovery will likely begin within hours, days, or weeks.¹⁴ Following the collapse of the World Trade Center in 2001, 448 victims were treated in a 24-hour period at New York Downtown Hospital, the closest one to the event. The hospital, which transferred only 21 patients, was able to stay open.¹⁵

When trying to predict the number of victims who will present after a mass casualty trauma event, it is important to remember that such patients typically arrive quickly and that approximately half of all casualties will arrive at the hospital within a 1-hour window. To predict the total number of victims a hospital can expect one can double the number of casualties the hospital receives in the first hour (Table 9-3).¹⁴