Chapter 9. Preparedness for Catastrophe

• The intensive care unit medical director should play an active role in each hospital's disaster planning.
• The Joint Commission on Accreditation of Healthcare Organizations requires that each hospital develop, implement, and regularly test a disaster plan.
• A hazard vulnerability analysis should be conducted by each hospital to identify threats to care of patients specific to its region.
• Preparation should coordinate all community resources and not be focused on a single ICU or hospital.
• Each ICU medical director should identify his or her role within the emergency command structure (typically the hospital emergency incident command system).
• Back-up methods of communication such as walkie-talkies should be acquired and tested to ensure reliable communication between the ICU and the hospital command center.
• A pool of potential volunteer ICU medical personnel should be identified prior to a disaster and mechanisms put into place to provide emergency credentialing.
• An active disaster education program should be created to keep all ICU personnel up to date.
• Participation in realistic disaster exercises is important to identify problems within each hospital's plan and to reinforce education.

Hospitals today are faced with a daunting task: to prepare for community disasters that could bring a large number of injured or ill patients to their doorsteps. Since September 11, 2001, the threats to a community and its hospitals seem endless. In addition to the terrible events surrounding the World Trade Towers collapse, a more insidious attack occurred in the form of anthrax delivered through the mail. Health care workers have died as a result of severe acute respiratory syndrome (SARS), which represents an emerging, highly contagious infectious disease. Natural disasters have wreaked havoc on numerous health care facilities, and have jeopardized patient well-being.

During a disaster, hospitals serve as a refuge for the injured and ill. Unfortunately, the ability of health care organizations to prepare for these would-be crises is jeopardized by current financial constraints. To many hospital administrators, maintaining facility solvency at their current rate of reimbursement is the real threat, while expending funds for disaster preparedness seems less essential. Hospitals must operate in a fiscally efficient manner, operating near full capacity. The ability of a typical hospital system to absorb large numbers of injured patients during an emergency either acutely, or over a more prolonged period of time, is extremely limited. More importantly, there has been little outside financial support to fund hospital disaster preparedness efforts.

First responders (police, fire department, and EMS) remain the primary focus for most ongoing disaster preparedness efforts. However, as mandated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), all hospitals must have a functional disaster plan. As we learned during the recent SARS dilemma, the intensive care unit (ICU) is a key element of a hospital's response to large-scale incidents. In addition to emerging infectious diseases, trauma, bioterrorism, chemical attack, and radiation-induced injury are possible occurrences. Unfortunately, there is little written in the medical literature about the effects on structure and function of an ICU during a disaster.1,2 As one example, during a biological weapons attack or an outbreak of a highly contagious disease, the ICU physician will be called on to recognize the syndrome and initiate the appropriate investigation and therapy. Therefore, the ICU medical director must be intimately involved with the hospital disaster committee to ensure the optimal use of this limited resource, and to ensure that the proper training and equipment are accomplished and available. The purpose of this chapter is to educate the intensivist on the general components of a hospital disaster plan, to detail where an intensive care unit fits into the hospital preparedness plan, and to review what predisaster preparation initiatives an ICU should conduct.

The definition of a disaster is imprecise. Many different definitions are published, and an appropriate definition should be broad enough to be applicable to most situations. Frederick C. Cuny defines disaster as “a situation resulting from an environmental phenomenon or armed conflict that produced stress, personal injury, physical damage, and economic disruption of great magnitude.”3 By this definition, a disaster includes a wide range of events and outcomes. A disaster can occur outside the hospital or inside the facility, and can be the result of a naturally-occurring phenomenon, an unintentional accident, or an intentional act. A mass casualty incident (MCI) occurs when the requirements to care for multiple casualties overwhelm the normal capacity of the health care system.

Given recent events, it is self-evident that hospitals must be prepared for an MCI. In the U.S., the standards for hospital accreditation as set forth by the JCAHO4 (revised standards effective January 1, 2001) serves as a foundation for understanding the minimal components required in disaster preparation. The JCAHO standards include three components:

1. Environment of care (EC) standard EC.1.4 requires a hospital to develop a management plan that addresses the response to emergencies affecting the EC.

2. EC standard EC.2.4 requires the hospital to implement the emergency management plan.

3. EC standard EC.2.9.1 requires the hospital to execute the plan by participating in emergency management drills.

The development of a hospital disaster plan must address four phases of emergency management: mitigation, preparedness, response, and recovery. Mitigation refers to the identification of potential emergencies that could affect a hospital, and implementing a plan to support the most vulnerable areas. The JCAHO also requires that a hazard vulnerability analysis (HVA) be conducted. An HVA is a formal assessment of the potential threats to the normal delivery of health care. This analysis should include plans for internal disasters such as fire and loss of power, as well as external disasters that could result in large numbers of patients coming to a hospital. To assist a hospital to evaluate their vulnerabilities, the American Society for Healthcare Engineering has developed a hazard vulnerability assessment tool that is available through their website.5

Preparedness is self-explanatory, and includes obtaining supplies and equipment, making arrangements with vendors and outside medical facilities to enable the urgent acquisition of supplies, and educating and preparing the hospital staff through literature, lectures, and drills. Response includes the predetermined actions of the medical staff in the event of a disaster, and the actions that management takes to initiate the plan, set up the command structure, and initiate communications with first responders. Recovery focuses on returning to normal operations and restoring needed services.

A hospital emergency response plan must be coordinated with community emergency management planning. After the HVA has been accomplished for both the hospital and the community, there should be coordination between organizations regarding which potential hazards are given hierarchical planning priority. The flooding disaster of the Texas Medical Center (TMC) in Houston in June 2001 underscores the need for specific plans for operations and evacuation of hospitals at risk, and the need for a coordinated community response. This was especially true for all critical care functions within the TMC complex. JCAHO standard EC.1.4 highly recommends that hospitals within a geographic area know and share the names, roles, and contact numbers of all leaders in their local/regional emergency command structure. Resources such as hospital personnel staffing should be closely coordinated so that no person is committed to two facilities at one time.

The incident command system (ICS) is a leadership structure that was envisioned to alleviate the traditional problems of poor communications and poor planning during a disaster. It was originally developed in 1970 in response to problems experienced in the management of wildfires in Southern California. During a multiple casualty event, every hospital must be closely linked with the community's command structure. It is helpful for the hospital and ICU leadership to understand the basic premises of the ICS in order to function within it more effectively. The ICS is built on the following basic principles:

1. Common terminology.

2. Modular organization with a unified command structure starting with an incident commander. The incident commander will delegate duties to different functional areas as the situation unfolds. These functional areas will have written consolidated action plans following established strategic objectives.

3. Integrated communications.

4. Manageable span-of-control in which the number of individuals that report to a supervisor is established at a range of three to seven.

5. Predesignated incident facilities with areas for command post, search and rescue, decontamination, transport, and the press.

6. Comprehensive resource management.6

During a disaster, the subordinate leaders/representatives under the incident commander would likely include the fire department, emergency medical systems, public health organizations, law enforcement, and environmental agencies. Each of these functions is expected to keep a representative at the central command center. The on-site grouping of each of these liaison representatives dramatically improves communication and coordination of responders. A hospital should know in advance who to contact within the community command structure in order to obtain information about incoming casualties, who to convey information to regarding available hospital capabilities, and who to communicate with about the ongoing needs of their facility. The official point of contact for most hospitals will likely be the emergency medical systems commander.

A version of the ICS has been adapted for hospitals and is called the hospital emergency incident command system (HEICS).7 Utilizing this system provides a seamless interface with the community command structure. Many hospitals are utilizing some form of the HEICS, and the HEICS document contains a proposed hospital command structure (Fig. 9-1). Job action sheets are provided that clearly define the responsibilities for each team member within the command structure. An intensivist may be asked to fill one of several roles. One proposed responsibility for the medical director of the ICU during a time of mass casualties would be as the medical care director. The medical care director coordinates patient care throughout the hospital and would optimize utilization of ICU beds and capability that becomes such a limited resource during surges in numbers of high acuity patients. The HEICS also defines the role of the critical care unit leader, who may be a nursing supervisor or a physician. An example of the associated job action sheet is provided (Fig. 9-2).

Finally, it is important to develop plans for maintaining ICU security during a disaster, as well as a means of communicating the status of patients with families and members of the media. Plans for securing the ICU should be made in cooperation with the safety and security officer identified within the HEICS. Ideally, a single point of entry into the ICU should be established with security present to control access. ICU personnel should be instructed to communicate with the media only with the approval of the public information officer or liaison officer. The public information officer should be consistently updating the media and families of victims and provide appropriate accommodations for them as they wait. This will maximize patient confidentiality and avoid intrusiveness due to lack of information or curiosity.

During a disaster, traditional forms of communication between the various departments of the hospital may become useless. Traditional telephone lines, cellular communications, and pager systems may fail or become overburdened during a time of community crisis. The hospital disaster plan should include an alternative form of communication within the hospital between vital departments and the hospital command center. An ICU must be able to relay bed and personnel availability to the hospital incident commander and must be able to receive information about incoming critically ill patients. Several hospitals now have dedicated walkie-talkie units to facilitate communication during a disaster.8,9 These backup communication systems should be tested as part of any disaster exercise and must be properly maintained.

If a mass casualty event occurs, hospital leaders must be able to calculate the current capacity of their facility, and the incremental number of patients that can be accepted for care. It is estimated that the capacity of a hospital to care for an emergency patient load is approximately 20% of the total bed capacity.10 However, this may represent an overestimation of the ability to care for severely injured patients requiring critical care in a sudden mass casualty event. The actual number of trauma teams needed to resuscitate and stabilize critically injured patients may be a truer determinant of capacity. The total number of patients that can be accepted can then be ascertained, once the percentage of critically injured patients is known.11 The Centers for Disease Control and Prevention (CDC) offers a webpage that provides a mass trauma casualty predictor and predictor of hospital capacity to care for critical casualties. Generally, 50% of all casualties will arrive within the first hour (Fig. 9-3). Of those patients, approximately 33% will be critical casualties. The hospital's capacity to care for these casualties will be determined by the number of available operating rooms staffed with surgery teams.12

In some circumstances, the requirement for medical care during an emergency response outstrips availability. In this circumstance, a form of disaster care rationing may be needed. The process of triage, a word coming from the French trier (to sort, to select), may be required to manage many casualties, and has been incorporated as part of the ICS. Triage sorts the patients, following established guidelines, in order to prioritize their initial management, as well as their evacuation to other facilities, according to the available resources and the type of incident.

Few hospitals maintain a sufficient number of empty beds for “surge capacity” due to cost constraints and the efficiency requirement to operate at or near full capacity. In the event of an emergency, a hospital plan should be in place to define a process for transferring existing ICU patients to other facilities. Agreements with neighboring hospitals should be established to accept predisaster ICU patients in transfer. Restrictions on out-of-ICU vasopressors or mechanical ventilation may need to be temporarily suspended to allow more stable ICU patients to be transferred to a hospital ward.

Not all disasters involve multiple traumas arriving at the hospital over a defined period of time. A bioterrorist act or an epidemic of an emerging infectious disease such as SARS would likely place strain on an ICU's capacity for care over a much more prolonged period. An infectious disease outbreak may mandate that a hospital protect its own employees and other patients first, thereby potentially limiting the capacity to care for all patients requiring critical care. It would be prudent to designate one hospital and ICU in a community or region as the isolation hospital where all confirmed or suspected contagious patients are admitted. This would both consolidate resources in one facility and limit exposure of other patients. The requirements for isolation will depend on the organism involved. Both smallpox and SARS patients would optimally be placed in isolation rooms with negative pressure relative to the surrounding area.13 In most hospitals this resource is limited, and should be considered in determining capacity for care.

The vaccination of health care workers against smallpox has been controversial due to concerns about side effects from the vaccine and reimbursement of health care costs for those workers who become ill. There are many obvious benefits of having ICU and ancillary personnel who have been vaccinated taking care of patients with smallpox. Hospital personnel safety, limitation of the potential spread of the disease, and confidence of the health care team all would greatly benefit by a pre-exposure vaccine program.

Previously, hospitals planned for a disaster assuming that outside assistance would not be available for up to 72 hours postevent.1 This remains true in many countries; therefore appropriate supplies should be stockpiled in hospitals, pharmacies, and ICUs to sustain relief efforts until help is projected to arrive. As a response to this concern, in 1999 the CDC and the Department of Health and Human Services (HHS) established the National Pharmaceutical Stockpile. The purpose of this program is to resupply essential medical materiel such as drugs, antidotes, and surgical supplies, to any area of the country within 12 hours in the event of a national emergency. Included in these supplies are critical care-related materials such as mechanical ventilators. These assets were successfully deployed during the World Trade Center disaster. Effective in March 2003, the program became known as the Strategic National Stockpile (SNS), and is managed jointly by the Department of Homeland Security (DHS) and the HHS. To receive supplies from the SNS, the affected state's governor must directly request them from the DHS or the CDC.14

Professional organizations are also organizing volunteer personnel to help augment local staffing in the event of a disaster. As one example, the Society of Critical Care Medicine is cataloging the skills that each of its members possesses, and whether these individuals are willing to volunteer to help in times of disaster. In addition, the federal government has responded by creating the USA Freedom Corps as a way to organize volunteers. As a part of the USA Freedom Corps, the Medical Reserve Corps (MRC) is a group of locally organized medical volunteers that would serve in a time of disaster to augment existing medical staff. This program is sponsored by the HHS, and its primary role is to facilitate the establishment of these local organizations.15 Provisions should be made by hospitals to establish a process for emergency credentialing of professional volunteers during times of crisis. State or national licensure bodies could also improve access to help by allowing physicians and nurses who are licensed in one state or region to practice medicine in another under emergency conditions.16

A vital component of ICU preparedness is ongoing medical education that emphasizes clinical situations likely to be seen during a disaster. However, for busy clinical professionals, medical preparedness training does not compete favorably with traditional continuing medical education requirements. Clinicians have limited time and budgets to accomplish these training demands. External funding sources are negligible at this time. As a result, most clinicians lack sufficient knowledge of disaster response. To address this shortfall, the Society of Critical Care Medicine has developed a succinct disaster medicine course that is designed to either accompany their Fundamentals of Critical Care Support Course, or the material can be taught as a separate 5- to 6-hour course. The course is entitled Fundamentals of Disaster Management, and will be accompanied by a seven-chapter handbook. The American Medical Association has recently endorsed two multi-day course offerings called Basic Disaster Life Support and Advanced Disaster Life Support. These courses will offer a more substantial exposure to medical disaster training.

It is beyond the scope of this chapter to provide details on the care of patients who may present to a hospital after a disaster. In today's environment, this can be overwhelming due to the large number of different threats that can face a community. The local hazard vulnerability analysis (HVA) will serve as an initial assessment of which topics should be emphasized. In this way, medical communities can target specific educational goals and then limit training to these highest priorities/risks, at least as a starting point.

The American College of Emergency Physicians has issued an executive summary from their task force on the education and training of its members on the care of casualties of nuclear, biological, or chemical incidents.17 This summary includes a review of six available training courses, and found that none met all the objectives established by the task force. The primary barriers identified to obtaining the educational goals outlined were access to adequate training and ability to retain the knowledge once learned. Therefore the only acceptable method of improving educational retention is to conduct exercise training that involves a broad cross-section of health care professionals in the community.

JCAHO (EC.2.9.1) currently requires a hospital's disaster plan to be tested twice a year, with the tests occurring at least 4 months apart, but not more than 8 months apart. Furthermore, they suggest that if a hospital is formally designated in the community as a disaster receiving station, then at least one drill per year should include simulated patients. One of these drills should also be conducted as part of a community-wide exercise that addresses likely emergencies, again using the HVA as a guide.4

The federal government has assigned a more imminent priority to disaster exercises since the terrorist attacks of September 11, 2001. As one example, the Department of Homeland Security conducted a week-long, $16 million dollar exercise in both Seattle and Chicago in May 2003. This exercise involved a simulated chemical, biologic, and “dirty bomb” attack. The scope of those involved in the exercise ranged from elected civic leaders and other decision makers, to hospitals and health care professionals. Unfortunately, these exercises tend to rediscover the same medical lessons. Specifically, elected civic leader decision making substantially impacts observed medical outcomes. Education and training of civic leaders regarding medical issues can be insufficient. Because of the common focus of these activities on prehospital events, critical care professionals should become actively involved in the planning and participate in these exercises. All medical personnel should know their roles within the HEICS, and then train for disaster in those roles.

In summary, several points should be repeated for emphasis:

1. The current breadth and depth of health care professional education in disaster response has much room for improvement.

2. Our current health care system is underfunded to improve disaster educational standards to optimal levels.

3. Health care professionals are very busy, and have limited time available to devote to disaster medical education.

4. Numerous high-quality courses and training programs are currently available. Further improvement is desirable.

5. Much of our current medical educational focus is on prehospital issues; critical care is required to ensure an effective response to disaster.

6. Effective medical training and education must include elected civic leaders.

7. JCAHO standards and a sensible HVA can be used to target and prioritize the most pressing disaster medical educational needs of a community.