Disaster planning: Why aren’t hospitalists at the table?

PARKLAND, PITTSBURGH, LAS VEGAS. Puerto Rico, Houston, the Florida Panhandle. After every manmade and natural disaster, reporters crowd into affected hospitals to detail how local clinicians and administrators responded.

But a new review article on hospital preparedness published in October by the Journal of Hospital Medicine points out that hospitalists for too long have shied away from taking on key responsibilities in preparing their hospitals for just such crises. Instead, they’ve ceded what should be their leadership in disaster planning and management to their emergency and surgical (and sometimes critical care) colleagues.

Hospitalist Jason Persoff, MD, the assistant medical director of emergency preparedness at the University of Colorado Hospital in Aurora, is lead author of that review, which spells out a framework for hospitalist roles in disaster preparedness and response. He has personally learned some tough lessons about emergency preparedness, or the lack thereof.

“What I saw in Joplin was that hospitalists have a big role to play in multi-casualty trauma events.”

~ Jason Persoff, MD
University of Colorado Hospital

In 2011, Dr. Persoff, a long-time storm chaser, was in Joplin, Mo., tracking the tornado that destroyed that city’s St. John’s Regional Medical Center (now Mercy Hospital Joplin). Rushing to the only other functioning hospital in Joplin to help care for hospital patients being evacuated there, he says, “was a transformative moment. That’s when I realized I would be able to combine my passions for severe weather and medicine into one career.” Dr. Persoff spoke to Today’s Hospitalist.

Talk about your experience in Joplin and what it taught you about the need for disaster preparedness.
I realized during that disaster that there was a huge gap between the midlevel-and-above management and the boots on the ground. People outside the emergency room, the ORs and the ICUs didn’t know how to contend with that crisis.

And 14 hours in, when I hit the point of exhaustion, I had no idea to whom I needed to report or transfer patients, or how I fit into the bigger picture. Unless you’re trained, it is very difficult to see where one belongs in a disaster.

But disaster training, for most doctors, isn’t really an option; most people have very little desire to spend hours of CME on that or to keep running drills for events they feel are highly unlikely to occur. The odds of having a disaster in your area are so long that most people’s attitude is, “We’ll figure it out when we have to deal with it.” And that is not an OK answer. Instead, you need a robust system in place that requires almost no training among rank-and-file clinicians to pull it off.

Why haven’t hospitalists been involved in disaster planning?
I think hospitalists’ view of possible disasters is crises like SARS in the early 2000s or Ebola in 2014. They see emerging infectious diseases as the single biggest threat they would need to deal with, and that’s where most hospitalists stop.

But what I saw in Joplin was that hospitalists have a big role to play in multi-casualty trauma events. It became very apparent, for instance, that surgeons were overwhelmed by the number of surgeries they had to do and couldn’t care for patients once they left the anesthesia unit. I saw that as a very important opportunity. There were also patients in the hospital whose doctors could no longer care for them because they were consumed with the influx of new patients.

And in trauma-disaster activations in my own hospital—a bus accident last year, shooting incidents, a chlorine gas spill—the ED becomes over-taxed and patients who have a high probability of being admitted just sit in the ED taking up beds. That’s when hospitalists need to rapidly admit those patients to open up throughput and ED capacity.

Because trauma is outside the scope of internal medicine, most hospitalists don’t see themselves as having a role in responding to it. But we’re the backbone of each of our hospitals, and we have a vital role to play in terms of continuity, disposition, admission and even triage in the ED.

You write in the review that disasters psychologically overwhelm clinicians. Is that because they’re not sure what to do?
It overwhelms them because there is so much to do, and prioritization and triage become big issues. It can also be very hard for doctors to unstick themselves from their standard approach to medicine. During disaster admissions, for instance, I can’t really go through a family history and a review of systems. My goal is to get the patient admitted, treat whatever may be life-threatening, and then circle back—or have someone else circle back—within the next 24 hours to figure out the rest of the pieces.

So what do hospital medicine groups need to put in place so their members will know how to respond?
Communication is the No. 1 area where things break down. To ensure good communication, hospitalists need to first create a means of interacting with a hospital’s incident command structure, which spells out who will command and coordinate an emergency response. They also need to develop a structure within their group that is founded on that incident command system.

And every group needs a hospitalist unit leader, someone who during a disaster will have a lot of responsibility for communications throughout the hospital. I’m now filling that role in my hospital, and we’re figuring out that job description through developing what we call “job action sheets.” We will then create job action sheets for other group members who will be handling parts of our response. These sheets help people understand their role and who they supervise and to whom they respond, and they help guide clinicians’ actions during a crisis.

During a disaster, that unit leader will need to constantly bring information to clinicians. To prepare, doctors need to know there is someone who can get them information and that the information is readily available.

The goal is to teach people how to rapidly find the information they need and then be able to execute on that information with as little training as possible.

Do you store that information electronically?
No, and I’m very much against any electronic storage. In Joplin, all electricity and communication went down. Our plans are on paper, so you can write on them. Ours have fill-in-the-blanks and equations to help people figure out how much they may need to expand. It’s a process where people are writing things down, creating a record that we carry forward for later review. That paper becomes the documentation that we then critique and learn from.

Phyllis Maguire is Executive Editor of Today’s Hospitalist.