Emergency Preparedness: It Takes a Village
"When people think of disasters, they tend to think of hospitals," says Chris Martin, of Seattle's Harborview Medical Center. Part of Martin's job as the hospital's administrative director of emergency services is to imagine worst-case scenarios—a big earthquake, pandemic influenza, or a chemical attack—and get ready for them.
For Martin, it doesn't take a great deal of imagination. In December 2006, the Pacific Northwest experienced a devastating storm, with 80-mile-per-hour winds uprooting scores of trees in the heavily wooded area and leaving a million people without power. In the end, the storm claimed 14 lives.
Seven of the area's 17 hospitals had to run on backup generators that left them unable to perform crucial procedures, such as CT scans and cardiac catheterizations. Harborview stayed up and running, and like other local hospitals it became a refuge for people needing to fill prescriptions (no pharmacies were open) or just looking for a hot meal and a place to shelter from the freezing temperatures. Further straining capacity, some patients resisted being discharged to their cold, dark houses.
The first night after the wind storm, Harborview's ED began to see people arriving with symptoms of carbon monoxide poisoning; they were bringing their charcoal heaters indoors to cook and stay warm, or using generators that weren't exhausting fumes. Staff worked with translators to treat the many Somali, Korean, and Russian victims.
"It sometimes took us days to sort out who was who," recalls Martin, "but I can say we never misplaced a specimen." After the first 24 hours, poisoning cases dropped off, thanks to communication efforts by the public health department and translator community, and by Harborview staff members, who asked family members of the victims to notify their friends about the dangers. In the end, there were eight deaths from carbon monoxide poisoning.
Hospital Collaboration
Seattle's hospitals were able to respond effectively to the wind storm because they had a history of working together.
Harboview, Washington State's only Level I trauma center, acts as Seattle's disaster control hospital. During the wind storm, they canvassed other hospitals to assess their capacity to receive patients and made determinations about where to send ambulances based on geography and availability. They took advantage of a Web-based reporting system, which they use on a daily basis to manage patient flow across hospitals (see screenshot below).
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"Everyone wanted to be responsive," says Martin, "but we all needed to know that every hospital was taking its fair share of patients. We functioned because we were able to work together."
In the days after the storm, hospitals held group conference calls with public health department officials, who then worked with the power company to prioritize restoration efforts on critical areas, including nursing homes, pharmacies, and the laundry facility that services all of Seattle's hospitals.
King County Healthcare Coalition
After the terrorist attacks and anthrax mailings of 2001, the federal government began allocating money to help the public health system prepare for attacks—to upgrade surveillance, deal with large numbers of casualties, and build communications between hospitals. Recently, the federal government has said that it will require jurisdictions to pursue collaborative efforts in emergency preparedness in order to receive funds, though there are no specific mandates as to what the collaborations should look like.
In terms of coalition building, Seattle is ahead of the curve—perhaps because of its experience in 1999 as host to the tumultuous World Trade Organization Ministerial Conference. Area hospitals have been pooling their federal disaster funds and holding monthly sessions to discuss joint strategies for years.
In 2005, community leaders formed the King County Healthcare Coalition, a voluntary organization that aims to build relationships and infrastructure to meet the medical needs of the community during a large-scale emergency. Members come from across the health care continuum, including ambulatory and specialty care, mental health care, long-term and home health care, and hospital and long-term care providers. The coalition is housed under the auspices of the Seattle and King County Public Health Department.
While similar groups have been formed in Washington, D.C., northern Virginia, Houston, Oregon, Minnesota, and Florida's Palm Beach County, Seattle's coalition is frequently cited as the national model.
All of Seattle's hospitals have joined the coalition. Coalition staff provides them with consultation and technical assistance on training exercises, resource acquisition, critical infrastructure enhancement, and regional planning opportunities. Hospitals pool their federal funds to help pay for these staff members. In addition, the funds are used to cover the costs of joint training; the purchase of new equipment, such as decontamination showers; and other efforts, with a hospital committee making spending decisions.
The coalition's Regional Medical Resource Center will monitor capacity and supplies among the community's health care facilities and coordinate deployment and communication during emergencies. Hospitals are also asking retired nurses or physicians to sign up for a "personnel pool" to supplement health care workers, if needed.
Planning for Pandemics
One of the focuses of the coalition has been on planning for an infectious disease outbreak.
"Hospitals felt they had done a lot of planning around earthquakes and terrorism," explains Martin. "But an infectious disease outbreak would be a very different kind of emergency." While most of the casualties from an earthquake or terrorist attack would come all at once, she notes, a pandemic could lead to spikes in the number of patients over a long period of time.
Coalition members have done a number of "tabletop" drills to consider the case of pandemic influenza. Would the county institute social distancing measures, such as canceling sports games or public events? How would they decide who would get the available ventilators and antiretroviral drugs? How would they ensure staff members' safety and keep them coming to work?
This year, the coalition members will perform a functional training exercise to test plans for deploying antiretroviral drugs from the strategic national stockpile.
"Rationing care is a huge issue," says Martin. "We think that the more you talk about it, the more prepared you will be to make decisions when they're needed."
Advice for Hospital Leaders
What can hospitals do to help coordinate their responses during a large-scale emergency?
Improve patient flow in the emergency department. If emergency departments don't function smoothly on "normal" days, says Martin, "nothing's going to work in the event of a disaster. It has to be about continually improving operations, and incorporating procedures and protocols on an everyday basis that can be ramped up in the event of a disaster." She suggests that hospitals might make emergency preparedness part of regular training or incorporate it into staff competency reviews.
Build relationships with other hospitals. Seattle's healthcare coalition grew out of longstanding relationships between hospitals. "Hospitals have gotten more mileage out of pooling their resources than they would have on their own," says Cynthia Dold, M.P.P., M.P.H., the King County Healthcare Coalition program manager. "For example, we've been able to hire the technical experts we need to help hospitals address Joint Commission standards around emergency preparedness."
Reach out to community health care providers. During the wind storm, Seattle's Public Health Emergency Operations Center rapidly organized a shelter to prevent nursing home residents and others with medical needs from overwhelming hospitals. This experience confirmed coalition members' belief that emergency planning needs to involve all parts of the health care system—not just hospitals.
To help others learn from their experience thus far, the King County Healthcare Coalition has created an emergency preparedness toolkit, which can be used to support the development of a health care coalition, or as a topic-specific reference to complement existing health response planning.
King County's coalition has received a federal grant to develop further resources that can be used by communities around the country. "There will be a lot more lessons and tools coming out of these coalitions," says Dold. "The idea is not to reinvent the wheel, but to enable communities to learn from each other.”
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Chris Martin, RN
Director of Emergency Services
Harborview Medical Center
