Health professionals need plans for providing care in a crisis

Unexpected large-scale disasters such as the Boston Marathon bombings in April can leave a health care community scrambling. An Institute of Medicine report says physicians and other health professionals should prepare for such crises that alter how they deliver care.

“There are going to be times when you can't do business as usual and you need to make sure there is a process in place,” said John L. Hick, MD, co-chair of the committee that developed the IOM report, which was issued July 31. “There need to be parameters [that detail] who is authorized to decide [how delivery of care will change] and what triggers those changes.”

The report is the third in a series of IOM papers published since 2009 that are intended to improve health care and delivery of medical services during disasters and public health emergencies. The latest report was developed by a 10-person committee, which included experts in emergency medicine, pediatrics and public health. The paper was not spurred by recent disasters but by research showing that too few health facilities have established indicators and triggers to guide patient care decisions during a crisis.

IOM committee members defined indicators as predictors of change in service demand or resource availability. They said triggers signal when action is needed to address those changes.

Examples of indicators are emergency department wait times and epidemiology information. The triggers that could signal action in those circumstances include wait times that exceed a certain number of hours or an inability to accommodate a high volume of ill patients.

The report encourages health care workers to identify actions that should be taken when the trigger is reached.

“If you haven't thought about how you would allocate resources when you don't have enough … you're more likely in a very stressful situation to make decisions that might seem reasonable at the time, but that in retrospect can't be very well supported,” said Dr. Hick, an emergency medicine physician at Hennepin County Medical Center in Minneapolis.

In developing the report, the committee met with other health professionals in January and sought input from the federal government. Committee members also examined a handful of reports on disaster response.

Talks needed before crisis strikes

The IOM paper also outlines who should participate in conversations about patient care during a crisis and key questions that should be discussed during those meetings. In the outpatient setting, the IOM recommends that talks involve behavioral health professionals, hospice staff, local public health workers and private practice physicians, among others.

Key issues to discuss include evacuation plans, how care will be provided to hospice and home-care patients when roads are impassible and what steps to take when alternate care facilities reach capacity, the report said.

“Many things place us at risk to move us into a setting where patients' medical and health care needs exceed our medical resources,” said Kristi L. Koenig, MD, director of the Center for Disaster Medical Sciences at the University of California, Irvine School of Medicine. “It's difficult to imagine, but it's important to plan for this ahead of time.”

For example, she said a multiple vehicle crash in a rural community that lacks a nearby hospital likely would demand the enactment of an emergency medicine plan. Even in urban areas, an influenza pandemic, natural disaster or a single suspected case of smallpox could overwhelm hospitals and primary care clinics, Dr. Koenig said.

Dr. Hick cautioned physicians, however, against becoming over-reactive in a crisis. For instance, he said, “If you're running out of ventilators, don't start taking people off [them]. First, see what other ventilators you can find in the area.”

He said such “knee-jerk reactions” can be prevented by partaking in the types of thorough discussions recommended by the IOM.

Just as important, development of indicators and triggers helps support physicians' health during a crisis, Dr. Hick said. That level of preparedness gives physicians confidence that they're making the right decisions during a very stressful situation, he added.

“We don't want providers to feel like they're making this up as they go along,” Dr. Hick said. “That's the scariest position to be in.”