Principles of Hospital Principles of Hospital Disaster PlanningDisaster Planning

• The purpose of this lecture is to outline the basic principles of hospital disaster planning.

• It differs from those in other textbooks on disaster and emergency medicine, as the emphasis is not so much on the clinical aspects of preparedness but rather on the organizational, social, and political aspects.

• This material also focuses not just on what ought to happen but rather on what actually

happens in disasters and why it happens.

• Disaster planning is only as good as the assumptions on which it is based. Unfortunately, many of these assumptions have been shown to be inaccurate or false when they have been subjected to empirical assessment.

• A great deal of planning is based on what is to be logically expected, but what is logical is not always what happens. To avoid this problem to the extent that one can, the information found in this chapter has been culled from field research studies of hundreds of domestic disasters over the last few decades.

• This material will address primarily domestic, peacetime disasters. It points out more problems than solutions, which might prove somewhat frustrating to the disaster medical planner. Today there are not definitive answers presented, an accurate perception of the problems will bring the solutions closer. In the meantime, some of the proposed solutions must be treated like hypotheses that still require testing.

Why is it Necessary for Hospitals to Why is it Necessary for Hospitals to Plan Specifically for Disasters?Plan Specifically for Disasters?

• Hospitals take care of emergencies every day, so why is additional planning specifically for disasters necessary?

• Some have argued that disasters are just like daily emergencies, only larger. Therefore, they conclude that the best disaster response is merely an expansion of the routine emergency response, supplemented by the mobilization of extra personnel, supplies, bed space, and equipment.

• It’s shown that this strategy is not successful because disasters are not simply large emergencies. Instead, disasters pose unique problems that require different strategies.

• Disasters are not only quantitatively different, but they are also qualitatively different. For example, disasters tend to disrupt normal communications systems (e.g., telephones and cellular telephones), damage transportation routes, and disable normal response facilities. It’s well-known: disaster response involves working with different people, solving different problems, and using different resources than those for routine emergencies.

OOne should recognize that planning ne should recognize that planning and response are differentand response are different

• Planning is an organized effort to anticipate what is likely to occur and to develop reasonable and cost-effective countermeasures. Response is the process of dealing with what actually happens, regardless of whether it was anticipated.

• When planning is effective, ad hoc, fly-by-the-seat-of-your-pants responses are reduced. However, the benefits of planning are relative, not absolute.

• Utopian planning efforts that seek to address every possible disaster contingency are simply not realistic. Even if these types of efforts were possible, the planners would never have the funding to implement them.

• It’s importantly to identify for planners the most common problems and tasks they will face in virtually any disaster.

Some believe that every disaster is Some believe that every disaster is unique, meaning that effectiveunique, meaning that effective planning is not even possibleplanning is not even possible

• However, empirical disaster research studies have identified a number of problems and tasks that appear to occur with predictable regularity, regardless of the disaster. These problems and tasks are the most amenable to planning. For example, almost every major disaster requires collecting information about the disaster and sharing it with the multiple agencies and institutions that become involved in the response.

• Other tasks include warning and evacuation, resource sharing, widespread search and rescue, triage, patient transport that efficiently utilizes area hospital assets, dealing with the press, and overall coordination of the response.

• Effective planning involves identifying and planning for what is likely to happen in disasters.

• It also requires procedures for planned, coordinated improvisation to deal with those contingencies that have not been anticipated in the plan.

Erik Auf Der HeideErik Auf Der Heide proposed the term: proposed the term: Paper Plan SyndromePaper Plan Syndrome

• Just because a hospital has completed a written plan does not mean the hospital is prepared for a disaster. Although a written plan is important, it is but one requirement for preparedness. In fact, a written plan can be an illusion of preparedness if other requirements are neglected. This illusion has been called

the paper plan syndrome

To avoid the creation of impotent paper To avoid the creation of impotent paper plans, the following must be true of the plans, the following must be true of the

planning:planning: • Based on valid assumptions about what happens in

disasters • Based on interorganizational perspective (Often,

hospitals, as well as other emergency and disaster response organizations, plan in isolation, rather than collaborating with other agencies likely to become involved in the response [e.g., ambulance services, emergency management agencies, blood banks, dispatchers, law enforcement agencies, fire departments, health departments, Red Cross and moon personnel, news media, and other hospitals].)

• Accompanied by the provision of resources (time, funding, supplies, space, equipment, and personnel) to carry out the plans.

• Associated with an effective training program so that users are familiar with the plan.

• Acceptable to the end users (If the plan users are involved in the planning process, they are more likely to be familiar with the final product; to consider it practical, realistic, and legitimate; and, most importantly, to use it.)

• Failure to comply with these prerequisites may contribute to the development of disaster plans that are unworkable in practice, and it may explain why so often the disaster response differs from what was prescribed in the plan.

Importance of the Planning ProcessImportance of the Planning Process

• A frequently overlooked but important factor in disaster planning is the planning process. Often, the process of planning is more important than the written document that results from it. This is not only because those who participate in the planning process are more likely to accept the final product as legitimate and practical but also because of the personal contacts that result. A number of researchers have observed that predisaster contacts among members of emergency response organizations result in smoother operations when disaster strikes.

• Organizations and their personnel are more likely to interface successfully if they do not have to do so with total strangers. Furthermore, in the process of planning, the participants develop a trust in one another, and they also become more familiar with the roles of other individuals and organizations in the response. Finally, during the planning process, one learns how one's actions in a disaster might enhance or detract from the ability of others to carry out crucial activities.

Importance of Administrative Commitment Importance of Administrative Commitment and the Provision of the Resources and the Provision of the Resources

Necessary to Carry out the PlanNecessary to Carry out the Plan

• Success in any organizational endeavor hinges on the extent to which the chief executive officer is committed to that success; disaster preparedness is no exception. To gain the attention, respect, and cooperation of organization members, disaster planning needs to be given the necessary status, authority, and support.

• Unfortunately, the disaster planning task is often relegated to a position of low status within the administrative hierarchy and is isolated from any existing sources of political power and from priority-setting, budgeting, and decision-making processes.

• One of the reasons things so often do not go according to plan when disasters strike is the failure to provide the resources (e.g., personnel, time, money, equipment, supplies, and facilities) necessary to make the plan work. Plans might be developed without funding for equipment and supplies. Time and money might not be budgeted for the development of disaster training programs or for the overtime needed for training or drills.

• Persons assigned disaster planning tasks might still be expected to carry out all of their regularly assigned duties, and they may receive little remuneration or recognition for their extra efforts. One should not be surprised that organizations that allow planning to occur in this context get what they pay for.

• If preparedness efforts are to result in more than paper plans, the planning process must be tied to the resources necessary to carry out the mandate.

Complacency toward PlanningComplacency toward Planning

• Hospital disaster planners must face the reality that disaster planning is not always met with enthusiasm.

• Often, getting chief executive officers and organizational members to support disaster preparedness is more difficult than developing the disaster countermeasures themselves.

• A number of reasons can be found for this lack of support for disaster preparedness activities. First, some of those involved in routine emergency responses believe that they already know what to do because they see disaster response as merely an expansion of daily emergency response.

Planning AssumptionsPlanning Assumptions

• The value of planning is in its ability to anticipate the problems that are likely to be faced in a disaster and to develop realistic, cost-effective, and practical countermeasures. It should not be surprising to find that, if likely problems are not anticipated, the plans will not be very useful. Furthermore, if planning is based on invalid assumptions, it may not succeed in guiding an effective response.

Planners might, for example, assume the Planners might, for example, assume the following:following:

• A shortage of supplies and medical personnel will exist.

• Hospitals will receive prompt notification after disaster occurs.

• Responding emergency medical service units will triage the victims, provide stabilizing first aid or medical care, and then distribute casualties in such a manner that no one hospital is inordinately overloaded.

• Patients needing specialized care (e.g., hazardous materials decontamination or burn care) will be sent to hospitals that have the capacity to deal with patients' conditions.

Hospitals might reasonably assume that Hospitals might reasonably assume that these activities will occur because they these activities will occur because they are written in the disaster planare written in the disaster plan

• However, numerous field disaster studies and after-action critiques have demonstrated that these and other planning assumptions, on which hospital disaster planning is based, are often inaccurate or untrue.

• Another common planning assumption is that disasters are similar to daily emergencies, except for the extreme shortages of response resources. In fact, disasters are often defined as emergencies that exceed the available resources to deal with them.

• Although this definition might hold true for disasters in underdeveloped countries or in military conflicts, this is uncommon in domestic peacetime disasters. Numerous events in the United States e.g.,that have been called disasters have not been characterized by severe shortages of community medical resources.

• In a study of 29 mass casualty disasters in the United States and its territories, the Disaster Research Center found that only 6% of the hospitals had supply shortages and that 2% had shortages of personnel. Many hospitals reported that they had more regular staff and medical volunteers than they could effectively use.

Private meaning:Private meaning:

• Resource shortages can occur at any given time or place in a disaster. However, in the United States, more often than not, overall community medical resources are sufficient; but they must be used in different ways than during routine, daily emergencies. One of the reasons that disaster medical resources are not strained as much as one would expect is because disasters in the United States have been relatively small in comparison to those in other parts of the world. In addition, the United States is also comparatively well endowed with medical infrastructure.

Private meaning:Private meaning:

• One factor enhancing available medical resources in disasters is that most hospitals operate on a 24-hour basis. In a crisis, therefore, many hospitals can rapidly double or triple their available staff by calling in off-duty personnel. In fact, most off-duty staff do not have to be formally called back to duty; they will report to their hospitals on their own without being asked. In addition, physicians, nurses, and other medical professionals not on the hospital staff will show up to volunteer their services.

• The assumption that emergency response personnel will abandon their professional responsibilities to attend to their families in disasters contributes to the belief that disasters are resource-deficiency phenomenon.

• However, field studies have not borne out that such professional role abandonment is common. The few who must choose family over professional emergency responsibilities are more than made up for by the large numbers of volunteers and off-duty staff who spontaneously show up and offer help.

Lack of Hospital Notification and Lack of Hospital Notification and Information on CasualtiesInformation on Casualties

• Most community hospital and emergency

medical disaster plans assume that timely and appropriate information will be received from the disaster site. Information on the nature and scope of the disaster will allow responders to prioritize the use of available resources and to mobilize the appropriate numbers and types of resources when and where they are needed.

For the medical response, essential For the medical response, essential information includesinformation includes

• a) estimates of the numbers, types, and severities of illnesses or injuries;

• b) the current abilities of medical facilities (e.g., hospitals) to accept and treat casualties.

• This information can be used to facilitate the distribution of casualties so as to spread the patient load among area hospitals so that no single facility is overwhelmed

• Although most casualties will bring themselves to the closest or most familiar hospitals by nonambulance transport, the availability of the information in the preceding text can still guide the destination of patients transported by ambulances over which local authorities may still have control. For example, if hospitals closest to the scene are being overloaded with patients transported by private vehicles, ambulances can be instructed to avoid those hospitals.

In fact, many hospitals learn about the In fact, many hospitals learn about the disaster from the mass media, the first disaster from the mass media, the first

arriving casualties, or ambulances rather arriving casualties, or ambulances rather than from official sourcesthan from official sources..

• An overall needs assessment is unlikely to

occur when coordination and control at the scene have not been accomplished, and for coordination and control to occur early in a disaster response is rare.

• Compared with the situation in daily emergency responses, overall scene assessment is often complicated in disasters when the scene is very large, when multiple disaster sites exist, when streets are strewn with debris that inhibits access, and when emergency medical agencies have not been integrated into the response.

• The process is further complicated when, as so often happens, multiple agencies with overlapping jurisdictional authority from different levels of government and the private sector respond.

Lack of Interagency Radio Lack of Interagency Radio Communications NetworksCommunications Networks

• Lack of adequate information flow to hospitals might occur because existing radio equipment has been damaged or even because the harried emergency department staff has turned down the volume so as not to be bothered by its incessant noise.

Unfortunately, even if telephone lines are left Unfortunately, even if telephone lines are left intact by the disaster, the circuits will almost intact by the disaster, the circuits will almost

certainly be overloaded and unusablecertainly be overloaded and unusable

• Although emergency response organizations such as hospitals can arrange to receive priority with the telephone company when the telephone lines are jammed, little evidence shows that most hospitals take advantage of this option.

• In recent years, as the use of cellular telephones has greatly increased, cellular telephone connections have become the victim of the same types of communications overload that wire-based telephones encounter in disasters.

• Because wire-based and cellular telephones are unreliable in disasters, interorganizational information flow requires that emergency response organizations have common, mutual aid radio frequencies on which to carry out two-way communications.

Time Course of Casualty Arrival at HospitalsTime Course of Casualty Arrival at Hospitals

• Casualties usually start arriving at hospitals within 30 minutes of the disaster impact, and the majority arrive within 60 to 90 minutes. Early casualty flow is made up mostly of those with minor injuries, probably because they are less likely to be trapped in the rubble or because they can more easily escape or be rescued by bystanders.

• Earthquakes (and other disasters) also interrupt utility services, such as electricity, sewer, water, and telephone lines, to the hospital. However, the 2001 California study could document fewer than 1% of the state's hospital buildings whose contents were adequately anchored or braced and that had sufficient backup power, water, and waste-water systems to operate for 72 hours.

• Because of the lack of timely casualty information from the scene, hospitals might be unaware of the fact that more serious victims are yet to arrive. When these victims do arrive, all the emergency department beds might already be occupied.

Survival versus Time until RescuedSurvival versus Time until Rescued

• Although a few trapped disaster victims have been rescued alive at 5, 10, and even 14 days after impact, this occurs only in exceptional cases. In the 1980 earthquake in southern Italy, for example, 94% of the trapped people who survived were rescued during the first 24 hours. No victims were rescued alive after the third day.

• The 1990 earthquake in the Philippines yielded similar findings -88% survival was seen for those rescued on day 1, 35% on day 2, 9% on day 3, and 0% from day 4 onward.

• In the 1976 earthquake in Tangshan, China, those rescued in the first half-hour had a 99% survival rate, followed by 81% on day 1, 34% on day 2, 38% on day 3, 19% on day 4, and 7.4% on day 5.

• In the 1995 bombing of the Murrah Federal Building in Oklahoma City, all but three of the survivors were rescued alive within 5 hours of the explosion.

• Therefore, one can expect that rescue teams responding to large-scale disasters involving trapped victims will have little impact on survival unless they arrive within 1 or 2 days.

• In other words, the local emergency response is the critical variable in the survival of trapped casualties.

Adapting Plans to Deal with Typical Adapting Plans to Deal with Typical Patterns of Disaster BehaviorPatterns of Disaster Behavior

• Disaster planners and responders can do little to control the efforts of bystanders in disaster situations. Disaster plans are more effective if they are designed around how people tend to behave in disasters. This approach is likely to be more successful than expecting persons to conform to the plan.

• Planners and responders can influence the outcome by anticipating the likely course of bystander actions. For example, ambulances should anticipate that the closest hospitals will get the most patients and should therefore avoid transporting additional patients to these hospitals if possible.

• Hospitals should not expect that patients will be triaged or decontaminated at the disaster site but should instead make provisions to carry out these tasks at the hospital.

Focus on Multiple Trauma PreparednessFocus on Multiple Trauma Preparedness

• The common assumption in medical disaster planning is that the primary medical need will be to deal with large numbers of victims suffering from multiple trauma.

• Approximately half the number of the casualties were admitted more because they had been in the disaster than because of the seriousness of their conditions, and they were discharged the next day. Therefore, only 10% of disaster casualties really required even the most basic inpatient care.

Nontrauma Casualties and Loss of Nontrauma Casualties and Loss of Access to Routine Sources of Medical Access to Routine Sources of Medical

CareCare• In many disasters, most

patients need care for conditions other than trauma is not always appreciated.

• This set of patients might include those who have lost access to their routine sources of custodial care, medical care, mental health care, or prescription medications.

• Although disaster medical planning tends to focus on hospital and EMS readiness, most patients could be cared for in nonhospital settings, such as physicians' offices, clinics, and freestanding urgent care or ambulatory care centers. Unfortunately, these valuable medical assets are often not included in community disaster plans.

Blood DonorsBlood Donors

• Hospitals and blood banks are

often caught off-guard and are

unprepared for the quantities of blood

donors that show up during disaster.

These situation is aggravated when local elected

officials or mass media representatives issue

mass appeals for blood donors, often without

consulting the recipient organizations regarding

the actual need for blood.

Example:Example:• Dallas, Texas DC-10 Crash, 1985. After a DC-10

crashed during a thunderstorm at Dallas-Fort Worth International Airport in 1985, radio stations announced the disaster before adequate medical information was available. These stations suggested that blood would be needed. Four hundred ninety-one blood donors responded to the media's call for blood. This inundated the local hospital's blood bank, causing a problem with crowd control. Personnel had to be diverted from the emergency department to the blood bank to manage the people trying to donate blood. Some donors were actually turned away from the blood bank because personnel were unable to process them at the time.

Example:Example:

• Sioux City United Airlines Crash, 1989. At the time of the Sioux City air crash, the blood supplies at the local hospitals and at the Siouxland Community Blood Bank were adequate to meet all the demands. Although officials made no public appeal for blood donors, more than 400 persons turned out to donate blood. Offers of additional blood from blood centers in Des Moines, Omaha, and other areas much further away were declined.

Hospitals as Disaster VictimsHospitals as Disaster Victims

• Although hospital plans often focus on disasters that may affect the community, insufficient attention is given to the possibility that the hospital itself might become a victim.

• Nonstructural damage can cause injury to hospital occupants, and it can interfere with the ability of the facility to care for patients. Nonstructural damage includes those affecting the nonload-bearing components of the building, such as the windows, ceilings, light fixtures, electrical circuits, water storage tanks, and sewer and water pipes. It also includes the material in the hospital, such as shelves, cabinets and their contents, refrigerators, laboratory supplies and equipment, cardiac monitors, imaging equipment, computers, communications equipment, and cafeteria appliances.

• Numerous case reports illustrate the lack of attention to basic measures to assure hospital survival and function after disasters. Generator failure is frequently mentioned.

• Hospital function has also been compromised by inadequately anchored generators, unanchored generator batteries, damage to the lines carrying natural gas to power the emergency generators, and the loss of water supply to cool emergency generators.

• Generators and generator-switching equipment have failed because they were located in basements subject to flooding. Failures have also resulted from inadequate electrical surge protection, dead batteries, and an inadequate fuel supply for the generators.

• Although the need for backup water provisions is frequently mentioned as a necessity for preparedness, hospitals continue to suffer when water supplies are interrupted.

• Hospital functions that have been interrupted because of their dependence on water include operating room temperature and humidity systems, sterilization equipment, water-cooled refrigerators and freezers, hydrotherapy, x-ray film developers, telephone switchboard and computer mainframe cooling systems, air-conditioning systems, fire sprinkler systems, medical suction, cooling systems for lasers, and emergency generators

• Other factors that have impaired hospital ability to function after disasters, particularly earthquakes, have included unanchored pharmaceutical storage shelves; severed oxygen lines; leaking natural gas lines; boilers with no backup fuel source; broken windows and glass; elevator malfunctions; and thelack of battery backup lighting to stairwells, elevators, operating room corridors, radiology, laboratory, outpatient units, and areas of the emergency department.

Improving Hospital PreparednessImproving Hospital Preparedness

The Joint Commission on Accreditation of Healthcare Organizations promulgates standards for hospital preparedness

These standards require that hospital These standards require that hospital disaster plans include provisions for thedisaster plans include provisions for the

followingfollowing::

• Carrying out a hazard vulnerability assessment• Activating the plan• Integrating the hospital plan with the community disaster

plan• Notifying external authorities that a disaster has occurred• Alerting hospital personnel that the plan has been

activated• Identifying hospital personnel• Housing and transporting staff• Providing for staff family support

• Maintaining supply management (e.g., pharmaceutical agents, medical supplies, food, water, and linen)

• Controlling access, crowds, and traffic• Maintaining media relations• Evacuating and establishing alternative sites for

patient care when necessary• Tracking patients and managing patient

medications and medical records during evacuation

• Establishing and maintaining backup communications and utilities

• Setting up facilities to deal with and isolate patients contaminated by hazardous materials

• Assigning staff responsibilities during disasters• Using a command structure consistent with that

used by the local community in disasters• Training• Evaluating the plan annually

MitigationMitigation• The first duty of the hospital in a disaster is to avoid

becoming a disaster victim. One of the best ways for the hospital not to become a disaster victim is for it not to be in locations where disasters tend to occur.

• Hospitals should not be constructed in areas where recurrent flooding occurs, near earthquake faults, on sandy river bottom soil that amplifies seismic shaking, near coastal areas subject to hurricane winds or storm surge, near chemical plants or storage areas, or in forested areas subject to recurrent wildland fires. When considering the construction of new hospital facilities, the local disaster office can be contacted for information on areas vulnerable to disasters that should be avoided.

• Attention also should be paid to the contents of the hospital building that might be vulnerable to damage in a disaster. For example, hospitals commonly locate heating systems, backup generators, and electrical switching equipment in the basement, the most vulnerable area in the event of flooding or water system leakage.

Do Not Plan in IsolationDo Not Plan in Isolation

• One lesson that is clear from the disaster research literature is that most response problems are due to the lack of interorganizational coordination and communication. However, most hospitals and other emergency response organizations plan as if they existed in isolation. Hospital planners should contact their local municipal or county disaster or emergency management office to find out if a community disaster planning committee exists.

• Such a planning committee can be an effective means of addressing a number of issues related to disaster preparedness. The committee can be the stage for developing not only regional plans for mitigation, response, and recovery but also for the establishment of a joint training program.

Health and medical care responsibilities Health and medical care responsibilities that should be addressed by the that should be addressed by the committee include the following:committee include the following:

• Warning and evacuation• Mitigation activities for health care facilities• Establishment of training programs for health care

providers• Overall coordination of the health sector response• On-scene medical assessment• Overall coordination of site search and rescue• Triage• Hospital notification (including information on numbers,

types, and severities of casualties)

Health and medical care responsibilities Health and medical care responsibilities that should be addressed by the that should be addressed by the committee include the followingcommittee include the following::

(continuation)(continuation)• Inventory of current hospital patient loads and capacity

to receive additional patients• Transport and distribution of casualties• Use of nonhospital facilities for patient care• Health facility recovery activities• Public health and environmental health activities (e.g.,

management of infectious disease outbreaks and chemical spills) and development of messages on disaster-related health issues for the media and the public (e.g., food safety when the power is lost, the effects of hazardous chemicals, and the prevention of chain saw injuries and carbon monoxide poisoning during cleanup and recovery).

• Plan for Communications• Management of Donations and

Volunteers• Working with the News Media • Postimpact Hospital Safety

Assessment• Hospital Evacuation• Hazardous Materials Problems• Triage• Security and Staff Identification• Planned Improvisation• Training, Drills, and Critiques

• The implementation of these plans is unlikely in the absence of an effective training program. Several advantages exist for establishing a joint training program.

• First, disaster responses are more effective when formal and even informal relationships have been previously established among the various responders. Joint training is one strategy for encouraging such relationships.

• Secondly, joint training fosters an understanding not only of what activities and responsibilities need to be carried out but also of how those activities facilitate or inhibit the abilities of others to carry out their responsibilities.

• Finally, a community-wide or statewide training program can reduce the costs of training and can make carrying out training at multiple times and locations economically feasible, so that the training is more available to the potential users.

ConclusionConclusion• Disaster planning is only as effective as the assumptions upon

which it is based. The effectiveness of planning is enhanced when it is based on information that has been empirically verified by systematic field disaster research studies.

• Most disasters cannot be adequately managed merely by mobilizing more supplies, equipment, and personnel. Disaster-related problems have been identified by disaster researchers, and they can be anticipated and planned for.

• Plans must be practical for and familiar to the users. Plans must also be interorganizational, and they must be based on valid information about what happens in disasters. Finally, resources (e.g., time, personnel, funding, facilities, and equipment) must be made available to carry out the plan.

• The process of planning is more important than the written plan because those who participate in the planning process are more likely to accept the end product.

• In disasters, emergency response units will often come from many miles away. For this reason, the establishment of regionwide, or even better, statewide disaster plans, is helpful in promoting a coordinated response.

• The effectiveness of the local response is a key determinant in preventing death and disability. National rescue and medical teams that come from across the country will have little overall impact on casualty survival.

• Disaster planning should include provisions to assure the survival and function of these routine sources of care (e.g., pharmacies, dialysis clinics, home health care agencies, nursing homes, assisted living facilities, and psychiatric facilities.

• When large numbers of casualties are seen and the cause of their symptoms cannot be immediately identified, the best strategy may be to provide a large-scale medical observation capacity until a serious exposure can be ruled out (e.g., observation in an auditorium or gymnasium where a few medical personnel can watch a large number of people with access to rapid medical care if any patient's condition deteriorates).

The End