Public Health Emergency - Leading a Nation Prepared
The first step in developing a healthcare emergency response system is to fully understand the range of potential hazards and their impact, the complexities of healthcare emergency response, and the difficulties of delivering healthcare services during a disaster.
In emergency management, “hazard” refers to the underlying etiology for any type of emergency. A wide range of actual or potential hazards is relevant to healthcare organizations in any locale. Using a Hazard Vulnerability Analysis (HVA – see Chapter 5), healthcare organizations may identify and characterize hazards according to the following attributes:
In a detailed HVA, vulnerability is examined and characterized for the healthcare organization in a manner that provides information for all four phases of Comprehensive Emergency Management – mitigation, preparedness, response, and recovery. Vulnerability is multifaceted and involves the following:
For these reasons, healthcare organizations may characterize hazards as primarily “mass casualty,” and/or “mass effect” (Exhibit 1-1).
Exhibit 1-1. Mass Casualty and Mass Effect Incidents
Mass Casualty Incident: An incident that generates a sufficiently large number of casualties whereby the available healthcare resources, or their management systems, are severely challenged or unable to meet the healthcare needs of the affected population.
Mass Effect Incident: An incident that primarily affects the ability of an organization to continue its normal operations. For healthcare organizations, this can disrupt the delivery of routine healthcare services and hinder their ability to provide needed surge capacity. For example, a hospital’s ability to provide medical care to the victims of an earthquake is compromised if it must focus on relocating current patients because a section of the facility was destroyed.
Adapted from Barbera JA, Macintyre, AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems (2006) Available at: www1.va.gov/emshg/page.cfm?pg=122.
Incident characteristics vary across hazards and even within a specific hazard type. These characteristics should be considered when assessing the value of a Healthcare Coalition to participating healthcare organizations and the local jurisdiction. The following is a partial list of incident characteristics that are relevant to Coalition operations.
Sudden versus slow onset: Mass casualty and mass effect incidents may occur suddenly with extraordinary medical resource needs, or they may evolve slowly and with warning, allowing for more extensive evaluation before instituting response measures. In a slow onset incident (e.g., heat wave), a Healthcare Coalition may facilitate inter-facility action planning and enable healthcare organizations to anticipate mutual aid and other resource needs. In sudden onset incidents, rapid notification to all local and regional healthcare organizations through the Healthcare Coalition may be critical so organizations can respond effectively, support each other, and interact with local jurisdictional authorities.
During sudden onset incidents, many victims reach hospitals (or other healthcare providers) on their own or through the assistance of bystanders, and not by way of Emergency Medical Services (EMS). Therefore, victims may arrive with little or no prior notification and without being matched with the most appropriate facility. The ability of healthcare organizations to rapidly obtain additional resources, provide input to EMS for appropriate patient distribution, and assist each other in matching resources to patient needs may best be addressed through a Healthcare Coalition.
Insidious versus obvious onset: Incident onset may be obvious or insidious, requiring adequate surveillance systems for recognition and determination of the incident size and scope. In the case of the latter, the ability to rapidly gather and synthesize data from healthcare organizations may be important to determining that a dangerous incident is evolving.
Short duration versus prolonged incidents: Preparedness planning and exercises often focus on short duration, high intensity incidents. However, healthcare emergencies can be prolonged with ongoing service needs and continuity of operations issues. It is important for healthcare planners to recognize that a prolonged incient (days to weeks) will almost always have a major impact on the healthcare organization. Increased personnel commitment during a prolonged response can be difficult to sustain given the manpower constraints faced by many healthcare organizations. The financial impact of a prolonged response on a healthcare organization, due to disruption of normal healthcare service delivery, must also be addressed. The Healthcare Coalition can promote access to resources that may be critical to sustaining continuity of operations in addition to addressing surge needs.
Terrorism and other fear-generating hazards: Some mass casualty or mass effect incidents, particularly acts of terrorism such as the anthrax mailings in 2001, result in a large population of concerned, potentially exposed persons. Substantial medical and public health resources must be devoted to evaluate these patients. Victims may require specialized medical and public health capabilities, ranging from population-based mental health interventions to treatment for such issues as chemical burns, inhalational respiratory failure, or radiation syndromes. The ability to share expert advice and establish uniform diagnostic and treatment protocols during response may be as important as acquiring adequate equipment and supplies.
Exhibit 1-2. Example of how expert medical advice can be shared during an emergency
During the 2001 anthrax attacks in the Washington, D.C. metropolitan region, members of the medical community initiated a series of teleconferences to coordinate the clinical management of patients with suspected anthrax across the affected jurisdictions (Washington, D.C., suburban Maryland, and northern Virginia). The calls provided a forum to exchange information on diagnosis and treatment, such as the usefulness
of chest CTs in detecting early signs of inhalational anthrax, the lack of value of nasal swabs in making a diagnosis, and the effectiveness of certain antibiotic treatments. The calls also helped to dispel rumors circulating in the media.
Gursky E, Inglesby TV, and O’Toole T. Anthrax 2001: Observations on the Medical and Public Health Response. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, Volume 1, (2003).
Healthcare organizations’ actions during an emergency or disaster can be complicated by a range of response issues. While the primary responsibility for emergency response lies with the executive leadership of each healthcare organization, the support activities performed by an effective Healthcare Coalition may be very helpful. The following issues should be considered when examining the Healthcare Coalition’s potential roles during incident response.
The need for continuity of healthcare operations despite a hazard impact: Because of the critical services they provide, healthcare organizations can rarely halt operations before or after a hazard impact. They must continue to provide a safe environment for current patients, staff, and visitors.
The need to maintain adequate healthcare service delivery while addressing all aspects of medical surge: Any hazard that directly impacts a healthcare organization will likely produce a range of response issues. Medical care must be provided to hazard victims while maintaining operations for the usual patient population. The organization may also be required to perform other activities, such as participating in risk reduction for potential victims (through advice, prophylaxis, and other health interventions), assisting with mass fatality response, and addressing the psychological needs of patients, staff, and visitors.
The fragility of healthcare organizations’ physical facilities: The following physical attributes of healthcare organizations make them somewhat “fragile” compared to other emergency resources:
The business environment in which healthcare organizations operate day-to-day poses challenges after a hazard impact. Some characteristics of this environment include the following:
The “public-private sector divide” during response: Most healthcare organizations in the U.S. are privately owned. While the overall management of healthcare emergencies is typically a public sector responsibility, the delivery of emergency healthcare services is usually performed by private healthcare organizations. This distinction can complicate the response if not adequately addressed through response planning between the public and private sectors.
The following issues should be considered:
The need for a visibly competent healthcare emergency response: In order to maintain the public’s confidence and promote cooperation during extreme emergencies, the public must be assured that healthcare services are being provided in an equitable and ethically sound manner. The importance of maintaining the public’s confidence has several implications for healthcare systems:
The aforementioned issues should be considered by healthcare emergency planners and public authorities during preparedness planning. None of the issues will likely be obvious to or accepted by the public as legitimate obstacles to effective emergency response.
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