Most communities unprepared for disasters

Many state and local government agencies and health systems are not ready to coordinate the response to a disaster that overwhelms available medical resources and requires a shift in standards of care, said an Institute of Medicine report released in March.

In the event of a catastrophe such as pandemic flu that results in a shortage of ventilators, hard choices will have to be made about who gets the high-tech breathing help. Ethical and legal “crisis standards of care” should be triggered by predefined indicators of disaster, yet few states have taken action to implement such a process, said the IOM report.

“Crisis standards of care means a change in the usual practice of health care governed by the fact that there’s either an excess in the demand for care, or a shortage in supplies or staff and the ability to manage patients,” said Dan Hanfling, MD, vice chair of the IOM committee that produced the report. “The notion is that it would be recognized by a disaster declaration that the standards of care would be shifting along a continuum & from a patient-focused outcome to a population-based outcome. In other words, we’re trying to do the best for the most.”

Such a shift in standards could involve relatively simple steps such as sterilizing and reusing surgical equipment instead of disposing of it after a single use and calling on specialist surgeons to do general surgery. It also could mean gut-wrenching decisions such as withdrawing patients with poor survival odds from ventilator care in favor of those likelier to live.

The IOM report lays out templates that communities can use to drive disaster planning in areas such as state government functions, emergency medical services, hospital care, public engagement and ambulatory care.

The last element — helping office-based physicians and health professionals pitch in when catastrophe strikes — is one that has gotten short shrift in disaster planning, said Dr. Hanfling, an emergency physician who is special adviser on emergency preparedness and response at Inova Fairfax Hospital in Falls Church, Va.

“There’s going to be a need for very robust out-of-hospital care delivery, and that may be home care, it may be office-based care, and it may be care in designated alternate care sites,” he said. “Not all care will be delivered in the ER or the hospital setting.”

The report says public health authorities should work with outpatient physicians to outline what responsibilities they could undertake in the event of disaster, such as administering immunizations, offering patients advice on prevention and handling minor trauma cases.