In April, the world was enthralled by news of influenza H1N1, the new “swine flu” strain that quickly spread through Mexico and the world. With this latest threat of a pandemic, hospital leaders no doubt asked the question that has haunted them since September 11, 2001: are we prepared?

Emergency preparedness has become so much a part of the vernacular that healthcare leaders no longer ask what if an incident occurs but when and what. What kind of emergencies might occur—a terrorist attack, bioterrorism, a natural disaster? What training is necessary? What is the best use of limited resources?

“I always tell people one thing, and I learned it in the military: hope is not a plan,” said Dr. Joshua Kugler, medical director and director of emergency medicine at South Nassau Communities Hospital in Oceanside, NY. 

One can never be too prepared for the unknown, so Kugler and Paul Breslin, senior principal in the strategy and planning practice of Noblis Health Innovation, offer these tips to maximize hospital resources.

Rethink leadership. “I think it pays to be a leader,” said Kugler, who also serves on the state Department of Health Advisory Committee. Be the first on your block (or your region or community) to study a solution. “There is never enough money, so you need to look at grants that are provided through the government. When you’re a leader, you’re often funded.”

Rethink the big picture. Healthcare facilities do not operate in a bubble. Hospitals may be the first receivers in a large-scale emergency, but they are generally not the first responders. Emergency plans should include both.

“Hospital leaders should make sure they’re investing their preparedness training efforts and dollars into a single, coordinated community plan. Because that is probably what is going to be most important.” Breslin said. “The community should have the disaster plan, but the hospital may take the leadership role in convening those planning efforts.” 

Individual facility plans are important, too, but they’re not enough. “Take the lesson of Katrina: 80% of the hospitals were under water, so their plan didn’t help out that much,” Breslin said.

Rethink HVAs. Each hazard in a given facility should be evaluated annually using a hazard vulnerability analysis (HVA), according to several state-level preparedness agencies. For example, what will happen if phone lines are knocked down or the emergency department is flooded? 

An airtight HVA forms the basis of a strong mass-casualty plan, Kugler said. “The plan needs to be scalable, flexible (because the first person on the scene might not be the most experienced), and durable. It can’t have holes in it.” From federal and state government to community agencies and each facility, emergency preparedness plans must extend all the way down to individual departments. 

Rethink roles. A mass-casualty plan must function regardless of individual availability. “When something happens, everyone needs to able to break the glass, pull that plan out, and say, ‘What do we do now?’” Kugler said. “The environmental workers at the hospital don’t need to know the entire plan for a mass-casualty incident, but they need to be a part of it because they could be your front-line people in a disaster. For example, in Katrina, there were issues with flooding, and who’s going to take care of that?” 

Rethink operations. “The greatest good for the greatest number of people is the operational mantra for mass-casualty incidents,” Kugler said. Operations during a mass-casualty incident may look very different from normal operations, he warned. 

In times of crisis, hospitals must put aside their open-arms policy of treating everyone and think in broader terms. “It’s antithetical,” Kugler said. “We can’t guarantee that our sickest people are going to be managed the same way as they would during a normal situation.”

Triage follows different protocols during mass-casualty incidents, for example. “That type of triage is something I learned in the military but has become civilianized,” said Kugler, who achieved the rank of lieutenant commander before leaving the Navy for civilian life. “You don’t necessarily let everybody in,” he said. “You may leave the sickest people to die.”

Evacuation plans may look different, too. In a mass-casualty event, the healthiest patients are evacuated first. “That’s important because the number of resources it takes to move a patient who is on a ventilator is much greater than for people who can walk out on their own,” Kugler said.  

Rethink facility use. In a perfect world, every hospital would rebuild its trauma centers to maximize efficiency during an admissions surge. Short of that, there are small steps every hospital can take to increase functionality, no matter how tight the budget, Breslin said. 

A good first step is to review the outcomes and recommendations from Project ER One, a federally funded, publicly accessible project based at Washington Hospital Center in Washington, DC. For instance, with some minor modifications, an ED may be able to add bed capacity in hallways. 

If an update is in the budget, the space should be designed with mass casualties in mind, Breslin said. “If you use a slightly larger footprint than today’s standards, it would allow you to put two people in a single room and one outside the room in the hallway if needed. A 12-bed pod designed this way could give you 24 additional beds in the ED during a surge event.”

Space isn’t the only consideration, of course. Hospitals must acquire the necessary equipment and have an implementation plan in place. “You should have those beds and supplies shrink-wrapped, if you will, and in a ready room so that you can have them up in two hours,” Breslin said. 

When weighing expenditures, consider dual functionality, Kugler suggested. An entrance canopy could be used for parking on a daily basis and be converted to a wash-down area during a chemical or bioterrorism event. 

Rethink training. Although some things will change in a mass-casualty event, familiarity is a good hedge against errors, Breslin said. “If I drive the same car every day, and then I have to go through a toll booth in a rental car, I may not know how to get the window down,” he said. Backup equipment, hookups, and emergency communication devices should be familiar to staff members.

Although drills help with familiarity and are necessary, they’re also costly. Technology can help, Breslin said. Games like Hazmat: Hotzone and simulations like those used in the 3D emergency training room at Stanford University create opportunities to practice multiple scenarios and learn from the outcomes. 

Rethink communications. Hospital leaders should keep in mind all three forms of communication: reliable multi-agency and internal communications systems, communication of plans to everyone in the organization, and communication with the public.

That third level of communication is the one most likely to be overlooked, Kugler said. But keeping the public informed of emergency plans is key to building trust and operating smoothly during a crisis. 

What will happen if the “worried well” throng to the local hospital after a chemical spill, only to find that the doors are closed and personnel are conducting triage in the front entrance? Advance warning of such a plan may calm nerves during a crisis.

“When resources are strained and people are strained, who can rise to the top with a plan that works?” said Kugler. “They need to know that your main interest is their well-being.” 


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