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Most communities unprepared for disasters

A new IOM report urges office-based physicians to join in planning to help treat patients who don’t need hospital care.

By — Posted April 9, 2012

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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.

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ADDITIONAL INFORMATION

How office-based physicians can help when disaster strikes

Disasters may require physician practices and other nonhospital sites to help meet demand for care, yet determining the responsibilities of private physicians and public health authorities can lead to confusion. The Institute of Medicine advises that who does what should be mapped out in advance. Its new report offers a sample of the breakdown:

“Electronic care” (phone triage, expanded patient hotlines, Web-based assessment and prescribing)

Private care sector: Augment and unify phone advice and prescribing systems; update and modify scripted advice for patients.

Public health sector: Set up public lines/resources when demand exceeds available private resources; provide mechanisms for 211, 311 and 911 hotline backup; address prescribing and regulatory issues.

Ambulatory alternate care sites (flu centers, minor trauma care)

Private care sector: Augment existing clinics and open new clinics in other spaces; assist in staffing public health clinics.

Public health sector: Set up clinics in high-incidence/impact areas where health care resources are inadequate; provide site and logistics support and potential Medical Reserve Corps staffing; address regulatory issues.

Nonambulatory alternate care sites (hospital overflow, medical shelter for nonambulatory patients)

Private care sector: Provide policy, medical direction, staffing and special medical material support to site.

Public health sector: Provide site and logistical support in conjunction with emergency management; legal/regulatory protections.

Population-based interventions

Private care sector: Provide vaccinations and prophylaxis in conjunction with public health policy and directives.

Public health sector: Coordinate overall provision of interventions, including public sites and their staffing.

Source: “Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response,” Institute of Medicine, March 21 (link)

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