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IOM: Medical Disaster Planning 'Rudimentary at Best'

 |  By cclark@healthleadersmedia.com  
   March 26, 2012

Years after lessons gleaned from the 9/11 terrorist attacks, Hurricane Katrina, the Joplin tornado, and California wildfires, health systems and government agencies throughout the country are ill-prepared to grapple with major medical catastrophes.

That's the conclusion of a 566-page report from the Institute of Medicine, which calls for communities and health providers across the country to develop "crisis standards of care" (CSC) to respond to catastrophes.

It's necessary "to make sure that emergency medical system teams, public health departments, emergency room management, law enforcement and the healthcare community are all operating off of the same plan," Dan Hanfling, MD, vice-chairman of the report committee, an emergency physician at Inova Health System in Falls Church, VA, explained in an interview.

"What we have seen in the aggregate is a patchwork of capabilities, and we think that there's room for improvement across the board."  Hanfling adds that providers and the populations they serve should all think of these terrible events as "predictable surprises, because we know they're going to happen," and to think ahead of how they should be managed, and of some of the ethical and legal questions they may pose as to the allocation of scarce resources like medical equipment and supplies.

"The capacity and capabilities...required to manage such disaster incidents are in place, albeit in varying states of configuration, maturity, and functionality," the IOM report said. "However, systems to manage the truly catastrophic incidents that are the subject of this report, in which overwhelming numbers of casualties and cascading failures of infrastructure compound the incident, are rudimentary at best.

"As a result, in its renewed deliberations on developing and implementing CSC, the committee recognized the demand for a rigorous systems approach."

Hanfling says there's a lot of "low-hanging fruit," that just hasn't gotten picked.  One area "where we have fallen flat on our face at this point" is that private physicians "have not been effectively integrated" into disaster planning and response, he says.

"Private practitioners are very busy running their offices; they're business people...And in many instances, for them to understand what their specific role and responsibilities might be in a disaster is something that I think we have only begun to address," he says.

The report includes templates that various sectors of health providers can use to model their programs, or compare what they should have with what they do have.  There are templates for state and local government, prehospital emergency medical responders, hospital and acute care facilities, and out-of-hospital and alternate care systems.

For example, the report says, "In states with limited numbers of local health departments and in the approximately one-third of states in which the state health department assumes responsibility for providing local public health services ...the state may need to take a more active role in ensuring appropriate local stakeholder representation in state-level CSC planning, as well as in furthering community and provider engagement."

The report devotes specific attention to EMS personnel, who are often volunteers with full-time jobs and families, but who may be alone in making decisions about where to take patients harmed by a disaster, especially if that disaster has already destroyed hospital base stations that would ordinarily direct them.

Ethical challenges in delivering care during a disaster is another theme in the report.  For example, one of the discussion points deals with considerations of administering mechanical ventilation when there aren't enough licensed personnel for all patients who need it.  Family members of some patients may wish to do it themselves. However, the report says:

"It is ethically inappropriate to allow patients to be ventilated by family members while others without family members do not receive the same support. The facility clinical care committee and ethics committee should determine how to handle these situations, as they are likely to arise and will require a thoughtful response. Additionally, individuals unable to keep up with the physical requirements of bagging may feel that they have contributed to the patient's death."

An entire chapter is devoted to engaging the general public in a conversation about how an entire community should plan for a disaster.

Hanfling says that discussion among members of the IOM committee that wrote the report was informed by the tragedy at Memorial Medical Center in New Orleans, where generators, which were held in the basement, became flooded, resulting in a loss of power and 45 patient deaths.

Tenet Healthcare, which owned the hospital at the time, agreed last August to a $25 million settlement on behalf of 187 patients in the hospital at the time and many others who took shelter there.

The report is actually phase two of a report requested in 2009 by the Department of Health and Human Services after the onset of H1N1 threatened to be a much more lethal pandemic.

It contains tables of subject areas that it suggests each community should address, such as having a plan to deal with mental health and palliative care needs of a population in crisis.

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