Jason Persoff, MD, SFHM, now a hospitalist at University of Colorado Hospital in Aurora and an amateur storm chaser, got a close look at how natural disasters can impact hospital care when a tornado destroyed St. John’s Regional Medical Center in Joplin, Mo., on May 22, 2011.
Dr. Jason Persoff
He and a colleague who had been following the storm responded to injuries on the highway before reporting for a long day’s service at the other hospital in Joplin, Freeman Hospital West, caring for patients transferred from St. John’s on an impromptu unit without access to their medical records.
“During my medical training, I had done emergency medicine as an EMT, so I was interested in how the system responds to emergencies,” he explained. “At Joplin I learned how it feels when the boots on the ground in a crisis are not connected to an incident command structure.” Another thing he learned was the essential role for hospitalists in a hospital’s response to a crisis – and thus the need to involve them well in advance in the hospital’s planning for future emergencies.
“Disaster preparation – when done right – helps you ‘herd cats’ in a crisis situation,” he said. “The tornado and its wake served as defining moments for me. I used them as the impetus to improve health care’s response to disasters.” Part of that commitment was to help hospitalists understand their part in emergency preparation.1
Dr. Persoff is now the assistant medical director of emergency preparedness at University of Colorado Hospital. He also helped to create a position called physician support supervisor, which is filled by physicians who have held leadership positions in a hospital to help coordinate the disparate needs of all clinicians in a crisis and facilitate rapid response.2
But then along came the COVID pandemic – which in many locales around the world was unprecedented in scope. Dr. Persoff said his hospital was fairly well prepared, after a decade of engagement with emergency planning. It drew on experience with H1N1, also known as swine flu, and the Ebola virus, which killed 11,323 people, primarily in West Africa, from 2013 to 2016, as models. In a matter of days, the CU division of hospital medicine was able to modify and deploy its existing disaster plans to quickly respond to an influx of COVID patients.3
“Basically, what we set out to do was to treat COVID patients as if they were Ebola patients, cordoning them off in a small area of the hospital. That was naive of us,” he said. “We weren’t able to grasp the scale at the outset. It does defy the imagination – how the hospital could fill up with just one type of patient.”
What is disaster planning?
Emergency preparation for hospitals emerged as a recognized medical specialization in the 1970s. Initially it was largely considered the realm of emergency physicians, trauma services, or critical care doctors. Resources such as the World Health Organization, the Federal Emergency Management Agency, and similar groups recommend an all-hazards approach, a broad and flexible strategy for managing emergencies that could include natural disasters – earthquakes, storms, tornadoes, or wildfires – or human-caused events, such as mass shootings or terrorist attacks. The Joint Commission requires accredited hospitals to conduct several disaster drills annually.
The U.S. Hospital Preparedness Program was created in 2002 to enhance the ability of hospitals and health systems to prepare for and respond to bioterrorism attacks on civilians and other public health emergencies, including natural disasters and pandemics. It offers a foundation for national preparedness and a primary source of federal funding for health care system preparedness. The hospital, at the heart of the health care system, is expected to receive the injured and infected, because patients know they can obtain care there.
One of the fundamental tools for crisis response is the incident command system (ICS), which spells out how to quickly establish a command structure and assign responsibility for key tasks as well as overall leadership. The National Incident Management System organizes emergency management across all government levels and the private sector to ensure that the most pressing needs are met and precious resources are used without duplication. ICS is a standardized approach to command, control, and coordination of emergency response using a common hierarchy recognized across organizations, with advance training in how it should be deployed.
A crisis like never before
Nearly every hospital or health system goes through drills for an emergency, said Hassan Khouli, MD, chair of the department of critical care medicine at the Cleveland Clinic, and coauthor of an article in the journal Chest last year outlining 10 principles of emergency preparedness derived from its experience with the COVID pandemic.4 Some of these include: don’t wait; engage a variety of stakeholders; identify sources of truth; and prioritize hospital employees’ safety and well-being.
Dr. Hassan Khouli
Part of the preparation is doing table-top exercises, with case scenarios or actual situations presented, working with clinicians on brainstorming and identifying opportunities for improvement, Dr. Khouli said. “These drills are so important, regardless of what the disaster turns out to be. We’ve done that over the years. We are a large health system, very process and detail oriented. Our emergency incident command structure was activated before we saw our first COVID patient,” he said.
“This was a crisis like never before, with huge amounts of uncertainty,” he noted. “But I believe the Cleveland Clinic system did very well, measured by outcomes such as surveys of health care teams across the system, which gave us reassuring results, and clinical outcomes with lower ICU and hospital mortality rates.”
Dr. Christopher Whinney
Christopher Whinney, MD, SFHM, department chair of hospital medicine at Cleveland Clinic, said hospitalists worked hand in hand with the health system’s incident command structure and took responsibility for managing non-ICU COVID patients at six hospitals in the system.
“Hospitalists had a place at the table, and we collaborated well with incident command, enterprise redeployment committees, and emergency and critical care colleagues,” he noted. Hospitalists were on the leadership team for a number of planning meetings, and key stakeholders for bringing information back to their groups.
“First thing we did was to look at our workforce. The challenge was how to respond to up to a hundred COVID admissions per day – how to mobilize providers and build surge teams that incorporated primary care providers and medical trainees. We onboarded 200 providers to do hospital care within 60 days,” he said.
“We realized that communication with patients and families was a big part of the challenge, so we assigned people with good communication skills to fill this role. While we were fortunate not to get the terrible surges they had in other places, we felt we were prepared for the worst.”