Health professionals need plans for providing care in a crisis

An IOM report encourages emergency planning to enable thoughtful decision-making when facilities face challenges such as evacuation, patient capacity or equipment shortages.

By — Posted Aug. 12, 2013

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

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.”

Back to top


How the health community can plan for a crisis

To ensure that physicians and other health professionals are prepared to care for patients in a crisis, facilities should develop indicators and triggers. Indicators predict changes in service demand or resource availability, and triggers signal when action is needed. An Institute of Medicine report highlighted examples of possible indicators and triggers and the actions that can be taken.

Public health

Indicator: Epidemiology information.
Trigger: Predicted cases exceed epidemic threshold.
Action: Consider need for medical countermeasures; alternate care site planning; establish awareness among EMS and health care facilities.


Indicator: Emergency department wait times.
Trigger: ED wait times exceed a set number of hours.
Action: Increase staffing; divert patients to clinics; activate plans to accommodate pending admissions rapidly.


Indicator: Patient demand forecasting and epidemiology information.
Trigger : Unable to accommodate the number of requests for appointments or service.
Action: Expand hours and clinic staffing; prioritize home care service provision; increase phone support.

Source: “Crisis Standards of Care: A Toolkit for Indicators and Triggers,” Institute of Medicine, July 31 (link)

Back to top

External links

“Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response,” Institute of Medicine, March 21, 2012 (link)

“Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: Letter Report,” Institute of Medicine, September 2009 (link)

Emergency Preparedness and Response website, Centers for Disease Control and Prevention (link)

Injuries and Mass Casualty Events, CDC (link)

“Crisis Standards of Care: A Toolkit for Indicators and Triggers,” Institute of Medicine, July 31 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn