Coordinated Interfacility Planning
Introduction
Communitywide or regional emergencies can often pose significant challenges for healthcare institutions. Hospitals and long-term care facilities which may not have significant contact on a daily basis or which, in some cases, actually view one another as competitors will all have to shoulder the burden of disaster response. They may do this in isolation from their neighbors, much as some of them do every day, but the response will be much better for all concerned if they can work together. Unfortunately, there are often significant barriers to coordinated responses. Some of these may have occurred deliberately, as with the tendency to view other hospitals as competitors.1 It can also be quite accidental because when advance planning and preparedness activities occur in a “silo,” hospitals often make conscious choices, such as communications technologies, which actually make work easier within their own facility, but which also make coordinated response more difficult.
This chapter will focus on the ideal of coordinated responses to disasters by all of the healthcare facilities within a community. It will also examine those issues which can create potential barriers to coordinated response and how and why these barriers can sometimes occur. The chapter will examine strategies used by the Emergency Manager to overcome such barriers as a part of day-to-day practice. Finally, it will examine some best practices, aimed at ensuring that healthcare providers can coordinate their activities quickly and easily to respond to a disaster, when this is required.
On completion of this chapter, the student should be able to describe the advantages of interfacility coordination by healthcare facilities for the purpose of disaster response. The student should also be able to describe the potential barriers to interfacility coordination, as well as effective strategies which may be available to overcome such barriers, including day-to-day practices which can be incorporated into the practice of Emergency Management within a healthcare facility.
Working With Your Neighbors
The first steps toward working with other healthcare facilities in the region is getting to know them. That may sound strange; no doubt most people probably believe that either the other facility’s resources are obvious or that they can’t be too different from one facility to the next. In fact, one facility probably knows a lot less about neighboring facilities than they think, and differences in philosophy and methodology which are not immediately obvious may nevertheless be profound. Working together to address disaster response, with formal coordination arrangements, is a highly desirable outcome, but not one which is ordinarily easy to achieve. In order to achieve this goal, a certain amount of simple will is desired; there are attitudes, philosophies, and conflicting priorities to be overcome, and there are also some barriers, which are not inconsiderable, which will also need to be overcome by the Emergency Managers of all of the participating facilities.
Potential Barriers
Attitudes and Philosophies
There are two key problems with respect to attitude which are encountered almost universally by Emergency Managers, regardless of what setting they are practicing in. The first of these is that Emergency Management activities are less important than the core business of the organization. The second is that the required resources are already in place, negating any need for further action. Many Chief Executive Officers in healthcare fail to see the direct connection between business continuity, a process which most understand, and Emergency Management, which most, unfortunately, do not.
Many CEOs see the building of the business, in this case, a hospital, as being their core concern in an often intensely competitive environment. Indeed, there are some, including those in Britain’s National Health Service, who believe that the competitive environment may actually improve service quality.2 While the development of a hospital which is resilient—that is to say that it can quickly and effectively recover from any impact from an adverse event and continue to provide quality service—should be a priority, many CEOs become distracted by the competition itself. It has even been said that among CEOs, resiliency will not be considered important until it can be shown to be a competitive advantage!
Another challenge is the troublesome combination of competing demands and limited resources. A healthcare facility is a business, like any other, and money is important. Moreover, medical technologies are in a constant state of flux; each new iteration of technology, an MRI Scanner, for example, typically has an obsolescence window of around five to seven years, and the physical plant which houses these technologies typically has a similar lifespan.3 Such technological change devours a good deal of a healthcare facility’s available resources, but without them, the facility loses its “state-of-the-art” designation, and therefore, some of its competitive edge.
Each department is going to have its own ideas, programs, and both physical and staffing requirements. The leadership of each department puts a great deal of time and effort into obtaining what their department requires, with meticulously researched and written proposals and business plans, and presentations to senior management, often supported by vendors with a vested interest in selling their product. Those needs are often seen as immediate, and many department heads, upon successfully inaugurating a new technology in their department, immediately commence the next five-year plan for its replacement.
When faced with this type of challenge, the healthcare-based Emergency Manager, whose presentation skills were, at least at one time, “we should probably do this…just in case this occurs,” has a real problem. When facing such stridently competing priorities for limited resources, the CEO is very likely to develop an attitude of “why should I use limited and much-needed resources to address something which, frankly, might never happen?” Indeed, the education of many senior managers actually trains them to consider what will happen if they do nothing, as a part of the risk management process.4
In fact, sooner or later, something adverse, and no one can actually predict precisely what, is going to happen; that is inevitable, and we just don’t know what or when! When an adverse event does occur, how well the local hospital is able to respond to the event, recover, and continue to provide for the needs of the community will become a central point of discussion regarding the facility’s reputation for years to come. As such, the event will either play a huge role in garnering both community support and fundraising efforts or these key issues will be damaged because of it.
Such results are not impossible; consider the example of a local hospital literally destroyed by a direct tornado strike, which was able to set up and operate a temporary full-service emergency room in improvised facilities within about two hours, while the facility itself was still being evacuated, and a temporary hospital, in modular facilities, within a week.5 That hospital will be forever held dear in the minds of local residents and will be the target of both direct donations and fund-raising efforts for years to come! The challenge is for the Emergency Manager to convince the CEO and senior management that such large-scale resources, and large-scale integration and cooperation with facilities which are viewed as competitors, are both worthwhile and appropriate.
Lack of Coordination
The lack of coordination between healthcare facilities during a crisis is typically either the result of communications failures or of a fundamental disconnect in information and work direction caused by differing Command and Control systems.6 To illustrate, if in one hospital a variant of the incident management system model is in place, but in the neighboring hospital, the crisis is run by the vice-president/nursing and a group of nursing unit administrators, how are these two groups going to figure out the lines of communications and the process flow required to make any type of real coordination even feasible? Without a common Command and Control model, formal coordination remains difficult, at best.
While coordination between healthcare facilities is desirable, the ability of a healthcare facility to coordinate their activities with those of the emergency services and of the community at large is also every bit as important. The time to begin to establish robust communications between all of the agencies involved is not during a major incident. Such discussions should begin months or even years in advance. The best way to accomplish this is through regionally coordinated training with common models and through ongoing interagency dialog resulting from regular interagency planning meetings and discussions.7
Figure 3.1 Healthcare Emergency Managers activate a hospital’s Emergency Management Plan
The incident command system has humble beginnings, as a model for the coordination of fire service activities, across a fireground. The incident management/incident command systems, in their various iterations including both HICS and HECCS, have found their way into broad usage across a range of vastly different service providers, specifically because they permit highly effective coordination between organizations which may not even have a day-to-day dialog.8 Truthfully, while many practitioners may have specific model preferences, it doesn’t truly matter which Command and Control model is used, as long as it is used consistently and by all involved in the incident.
Interfacility Communications
Communications failures are one of the greatest single challenges to safety in contemporary hospitals, even on a day-to-day basis. The Joint Commission lists “Communications Failures” as a leading root cause of adverse events occurring in the hospitals which it serves, over a period of years.9 Not all communication is technology based, but in a disaster situation in which multiple hospitals and other healthcare providers are attempting to share critical information while lacking interoperable communications networks or communications protocols, the potential for disastrous errors is greatly increased.
With respect to communications failures, these are most often the result of a failure to have formal emergency communications arrangements in place, in advance of any disaster event. That being said, communications failure is almost always a risk factor in disasters of all types.10 In many cases, it becomes a matter of not understanding the limitations of various communications technologies, not having robust backup systems in place, or even simply not agreeing in advance on how facilities will contact each other during any crisis.
To illustrate, if the organizations elect to use telephones, have they considered what might occur if the telephone network fails or is overwhelmed? The telephone networks in most developed countries can only accommodate the simultaneous use of about 20 percent of the telephones on the network, and in developing countries, this capacity is often much lower. If the facilities are contemplating simply telephoning one another, those calls will go through a switchboard, generally at both ends of the call. If the switchboard is overwhelmed at either end of the call, communications will fail.
If the facilities are using Voice Over Internet Protocol (VoIP) telephony, they are dependent upon the continued functioning of their Internet Service Provider to maintain communications.11 Neither cellular (mobile) or the so-called “smart” phones provide a reasonable alternative, since both are entirely dependent upon the main telephone network. Choices can be made, along with robust backup strategies, but they need to be agreed upon in advance. Without effective communications, there can be no effective coordination. The challenge is to make appropriate choices, to agree upon their use, to develop backup systems, and to test all of these in advance.
Credentialing of Staff
The process of allowing new professional staff to work inside your facility is not a simple one. Contrary to public belief, a given hospital cannot simply permit an unknown physician or nurse to arrive at the facility and begin treating patients, even during a disaster! There are huge potential liability issues which may be involved. When a new physician or nurse, or a similar professional, applies to join the staff of a given healthcare facility, a complex and detailed background check always occurs.12 Did this person actually graduate from a recognized medical/nursing school? Have they passed state/provincial licensing examinations? Do they actually have the specialty training that they claim to have? Have references been discussed with previous employers? Have there been any incidents of professional misconduct or professional discipline by their licensing body? If they have worked in another jurisdiction, has that jurisdiction also been checked? Has a police background check been conducted? This may seem somewhat excessive, but it is absolutely necessary, in order to protect the patients, other staff members, and the hospital from fraudulent, incompetent, or undesirable practitioners.13
This may sound extreme, but in fact, in most jurisdictions, the processes described occur every time that a new member of the professional staff is employed, or, in the case of physicians, joins the staff as a contractor. This process is absolutely central to the ability of the facility to demonstrate due diligence, should anything ever go wrong, and they find themselves in litigation. It is also a central condition to most liability and medical malpractice insurance policies, which healthcare facilities are often required by law to have in place.
Such comprehensive background checks can take two or more weeks to complete. As a result, they cannot take place during the time of occurrence of a disaster. This can often pose a major barrier to the sharing of staff by multiple facilities during a crisis. If a nurse, for example, is employed at two hospitals, each has completed their own background credentialing process, and so, that one particular nurse may work in either facility, but apart from that, it is nearly impossible for one hospital to simply loan nurses or physicians to another hospital, even during a crisis. For such arrangements to be effective, they would require extensive advance discussion, formal agreements, and probably an advance process of the cross-credentialing of each facility’s staff by each of the other facilities involved in the agreement.
Figure 3.2 Credentialing is a complex and detailed task, but an essential one. It cannot occur effectively in the middle of a crisis response
Exploring Solutions
In truth, the failures of healthcare systems to successfully perform advance integration of their respective emergency response systems are more common than most would wish to believe. Such failure is typically the directly result of healthcare facilities failing to place priorities on emergency preparedness activities and on their normal practice of viewing other healthcare facilities as potential competitors, and, as a result, the development and creation of those preparedness activities which do occur within carefully guarded silos. In some cases, there appears to be an attitude that the disclosure of potential vulnerabilities to a competitor places the facility at a competitive disadvantage.
In fact, the full and frank sharing of such information, along with collaboration to address those vulnerabilities, tends to make a facility less, rather than more, vulnerable to the effects of an adverse event. Through the sharing of knowledge and through collaboration with colleagues at other facilities, the healthcare-based Emergency Manager can provide the facility with leadership in integrating preparedness activities and can become a force for change within each facility.
Common Operating Systems
The management of emergencies is primarily about four issues: Command and Control, communications, coordination of resources, and supply chains. These four issues do not change significantly inside of a healthcare facility, and these issues will often form some of the potential barriers to successful coordination between healthcare facilities. They are, therefore, a good starting point from which the Emergency Manager, along with colleagues at other facilities, may begin to overcome those barriers to cooperation and coordination, which often exist between the various healthcare facilities in the same region.
Command and Control Models
The first of these, Command and Control, is often the easiest to overcome; if all facilities are using the same Command and Control model, usually a variant of the incident management system, then the model itself can assist with coordination. Command and Control models will be discussed in considerable detail elsewhere in this series; however, for now, it is sufficient to say that when all facilities use the same Command and Control model, they will populate the same Key Roles (e.g., logistics), within each Hospital Command Center and conduct their business in more or less the same manner. The potential exists for those Key Roles to become highly effective points of information exchange and coordination, by simply engaging in regular dialog with each other at the Key Role level.14 If there are four hospitals in a community which is responding to a disaster, why shouldn’t the public information leads from all four Hospital Command Centers conduct a cooperative and coordinated media plan, with the media and the public receiving exactly the same information, regardless of which source it came from? Examples of this same level of coordination are possible between those in virtually any of the Key Roles.
Communications
With respect to communications, the issue is not so much differences in technology as an agreement to communicate specific information with other healthcare stakeholders on a regular basis. This can occur using any variety of technology from telephones to digital messaging; the key is for all to agree to use the same system. As but one example, in more than one hospital, the author has encountered the use of BlackBerry devices to achieve and coordinate all messaging, both internal and external. These devices were selected because of their tremendous flexibility, including the storage of their plan, Job Action Sheets, and all telephone number lists on each individual device, thereby ensuring that any manager with a device could run the entire incident.15
The use of the Facebook Messenger, WhatsApp, or Zoom software permits teleconferencing and even videoconferencing in a reasonably secure environment. The ability to conference multiple devices permitted virtual “meetings” and the ready exchange of information, and this particular system, as of this writing, has as high a level of security as any mobile device-based system in the world. Such devices can also be conferenced with similar devices in other hospitals, in order to enhance communications and to make communications networks more resilient.
High technology is not always the easiest solution. Occasionally, simple solutions just work better! In Toronto, Canada, all of the hospitals and some other healthcare stakeholders (e.g., Public Health) in the region are equipped with a UHF trunking radio, operating on a network belonging to Toronto Paramedic Service, which permits all of the healthcare stakeholders to communicate among them on a private channel during a crisis. Each radio is installed, not, as one might expect, in the emergency department, but in the room designated as the Hospital Command Center for each facility. It is connected to the facility’s emergency power system, and a full-scale network test occurs once each month. The intent is to provide local healthcare stakeholders with a sound method of both exchanging information and coordinating activities, even during a regionwide electrical power failure!
In many facilities, emergency backup communications can be provided by local amateur radio operators. This is an often-overlooked community resource, and the members of organizations, such as the Amateur Radio Emergency Service (ARES), community-minded volunteers, are often willing to come into a hospital and set up robust backup emergency communications during a crisis. This can permit hospitals to maintain linkages with other healthcare providers, emergency services, and the municipal Emergency Operations Center. These amateurs can provide, at a minimum, two-way voice communication, but many can also move data, and some, even video. Such arrangements require advance negotiation, and while the volunteer will typically bring the radio equipment, the facility will have to preinstall emergency power connections and a suitable antenna.
Figure 3.3 Although older technology, radio amateurs can provide an immensely useful service to hospitals, particularly during a crisis or an exercise
In many facilities and regions, the development of a simple system of “back channel” telephone numbers operates just as effectively. Each facility or organization has a designated telephone number, or series of telephone numbers, which are unpublished and which are not routed through the facility switchboards. Such telephone numbers have the “Caller ID” feature blocked, and the actual telephone numbers are closely guarded by all involved. In this manner, even when switchboards are overwhelmed, it remains possible for each hospital to directly and immediately contact another Hospital Command Center, the municipal Emergency Operations Center, emergency services, and public utilities! In many circumstances, “low-tech” approaches are often more amenable to use during a crisis. Success in interfacility crisis communications actually has very little to do with the degree of technology. The key to successfully overcoming crisis communications barriers is for all agencies to agree in advance to use a single system for the sharing of information.
Resource Management
Resource coordination may be more of a challenge. In fact, the biggest challenge in this regard may simply be a matter of improving the collective understanding of precisely which resources a given facility does or does not possess. From a clinical perspective, there is often sufficient understanding for one facility to understand which services are available at another facility or, at least, they often think that they do. Local hospital networks often evolve along the lines of primary, secondary, and tertiary care facilities, with level and complexity of care available increasing at each stage, from the relatively small, local community hospital which offers basic services at the primary level, to university-affiliated teaching hospitals offering a broad range of advanced services, at the tertiary level.
This system is, however, changing in some important ways. In many communities, particularly in North America, the concept of a “general” hospital is starting to disappear, as technology and economics frequently force individual hospitals into more specialized roles.16 To illustrate, it has been argued that in many communities, the experience of the emergency physicians in dealing with myocardial infarction (heart attack) is eroding, as paramedics begin to use more advanced diagnostics in the field, identifying patients with specific needs and by-passing the traditional stop in the emergency department, in order to transport the patient as quickly as possible to an interventional cardiologist, who can actually fix the patient’s medical problem.17 As a result, emergency physicians simply don’t see very many of this type of patient anymore, unless they happen to walk in.
Similar initiatives are in place for trauma patients, burn patients, stroke patients, obstetrics patients, and pediatric patients, in many centers. Indeed, if current trends continue, the average emergency department may ultimately evolve into something of an advance-level family practice clinic. This is not so far-fetched a notion; in many parts of Europe, actual emergency departments in some hospitals are either minimal or nonexistent. In many cases, there is no recognized specialty in emergency medicine, but “emergency doctors” (often anesthesiologists or surgeons) respond on appropriate calls with the ambulance, stabilize the patient in the field, and then have them transported to the hospital as a direct admission. Increasingly, the old assumptions that “my local hospital can handle anything” have become erroneous, and it is increasingly necessary to have a clear understanding of which types of services are normally available, which types are unavailable, and which types the hospital is prepared to offer specifically during a crisis.
What might be less understood is what nonclinical resources a given hospital might have that might be accessed by another hospital during a crisis. Does one hospital have an out-patient program which has caused it to acquire passenger vans or mini-buses? Such resources are also often found in long-term care facilities, which are often ignored by hospitals for planning purposes. Does one hospital have a particular service available in-house that the other hospitals in the network do not? This might include an in-house information technology department, where other hospitals have contracted this service out. Such resources might include a standing inventory of patient care equipment, although in the age of “just-in-time” inventory control, such resources are becoming increasingly rare. Does one hospital have an in-house linen laundry system, while all of the others are dependent on a delivery system which may be affected by the current crisis? The list can go on, reaching into many facilities and many in-house departments which Emergency Managers might not normally consider. All of these somewhat obscure services are resources which might need to be shared with other facilities during a crisis, and so, the capabilities and the limitations of all must be clearly understood in advance.
A key step to the creation of a truly integrated emergency response by a healthcare system is the development of an ability by all participating facilities within each network to begin to conduct their emergency preparedness planning in a cooperative and coordinated manner. When facilities begin to plan together, the opportunity to eliminate many of the potential barriers to success is created. Unnecessary duplication of services is created when services can be potentially shared, staff training can become standardized, and staff training and exercises may be conducted jointly; and with that standardization resulting in reduced deviation from procedure and increased elimination of errors—both key features of the Six Sigma management model. While not the primary considerations, it may well be the case that time wasted on the unnecessary duplication of services and also money wasted on the unnecessary duplication resources, as well as on both staff training and exercises, may also be saved, a key attribute of Lean for Healthcare.
Resource Sharing
The savings possible through the use of formal resource-sharing programs and arrangements should be immediately obvious; a facility which is permitted to share a resource from another facility may not need to acquire that resource for itself, or to pay the full cost of the maintenance of that resource, between uses. In some healthcare jurisdictions, particularly in the United States and Canada, there is evolution of the healthcare system from large numbers of individual hospitals operating independently, into larger corporate entities, or pseudo-governmental agencies sometimes called regional health authorities, which operate as a single corporate entity with multiple operating sites (the hospitals).
One tremendous advantage to this model is that by having a single employer of record operating multiple sites, combined with a single credentialing system and a single insurance carrier, it can become much easier to coordinate Emergency Management across multiple sites within a region. There is also a trend toward the replacement of the use of multiple individuals at various worksites spending a smaller part of each day on Emergency Management activities, to a full-time individual or individuals, operating at a corporate level, and providing guidance and expertise to all of the operating sites. There are clear advantages to the practice of resource sharing, although the precise form will vary from one organization to the next, in terms of what has been included in such arrangements and what has not been included.
Personnel
The exchange of professional personnel between facilities has already been discussed at length in this chapter and will not be further belabored. Suffice it to say that in any system with a single corporate entity operating multiple service delivery sites as a single employer of record, the free movement of professional staff between the various operating sites as needed is a relatively simple matter. In systems with multiple hospitals and clinics within a region, operating as multiple individual employers of record, it becomes much more complex to move staff from one facility to another, even in times of need, without a considerable amount of advance discussions, signed agreements, advance cross-credentialing processes, and the approval of liability, worker’s compensation, and medical malpractice insurance carriers.
Materiel and Other Resources
The voluntary sharing of some resources is not at all problematic; if such resources are readily available, one hospital may be able to freely share bed linens, food, or, in some cases, cleaning supplies. One hospital may agree to provide information technology support staff to another hospital which normally contracts out such services, in some circumstances. There are, however, limitations to what could potentially be shared, even during a crisis, without careful advance planning. To illustrate, one hospital is using intravenous solutions and supplies from one manufacturer, while the next closest hospital is using the same type of equipment from a different manufacturer. In a crisis, one hospital would be prevented from sharing its inventory of intravenous equipment with the other hospital, because the two sets of equipment are incompatible with one another. They cannot be used together, and the staff of the receiving facility has not received training in the use of the equipment from the other facility.
The issue of most hospitals using “just-in-time” inventory management is also a major factor, as administrators pare away surplus inventory wherever they can in order to eliminate waste and save money, without much consideration of the needs generated by a disaster.18 This problem could conceivably be overcome, either through the advance training of the staff of both facilities or through an orchestrated advance decision for both hospitals to use equipment from the same manufacturer.
There are any number of resource-sharing issues which would face similar challenges, and almost all could potentially be overcome through the use of coordinated, cooperative resource acquisition planning, conducted in advance. These include such resources as the hospital pharmacy, medical equipment management, medical electronics, and other types of medical devices, such as ventilators. There are already individuals with specific expertise in such matters in most hospitals; the Emergency Manager does not need to be able to operate the supply chain, simply to understand it, and to find potential opportunities for improvement and cooperation, conducted under the mantle of Emergency Management.
Sharing Workload
Hospitals are particularly vulnerable to unscheduled demands for service. While there is probably a public perception that the local hospital stands ready and waiting, with every resource required to cope with an emergency, this is not necessarily the case. Hospitals, and their resources, such as diagnostic equipment and operating theaters, tend to be very heavily scheduled, and while some buffers are probably in place for unscheduled events, this does not include major emergency events. Many hospitals operate on a daily basis at, or even beyond, their capacity to provide care and the impact of such events has the potential to throw even a well-ordered hospital into chaos relatively quickly. This is immediately worsened, when a single hospital bears the brunt of the patient load generated by the entire event by itself, with a need to reschedule diagnostic procedures and surgeries and to find beds for new patients, in a facility which is already full.
Fortunately, this problem does not need to create as severe an impact if local hospitals are willing to cooperate with one another. Historically, there has existed a tendency for healthcare facilities to conduct their emergency planning activities in silos; this is primarily due to the unfortunate tendency to view one another as competitors. Advance planning is required, and all of the local hospitals will need to be brought to the table. Whenever possible, the time to decide what to do should not occur in the middle of the crisis.
With such planning, it is entirely possible to arrive at an agreement as to precisely how the victims of a mass-casualty incident will be distributed, whether based upon simple numbers or upon levels of clinical acuity. It is also possible to arrive at a plan to assist “first-impact” hospitals by agreeing to receive and continue the care of some of their existing in-patients, in order to make space for disaster victims. Another essential player in this problem-solving discussion is the local EMS system; paramedics don’t particularly want to overwhelm a particular facility, and if alternatives are being explored, they will generally be happy to participate; after all, they have an Emergency Plan to write, as well.
Balanced Emergency Patient Distribution
At a mass-casualty incident, the local EMS system will be primarily responsible for the assignment of a destination hospital for each patient. This function is usually performed by a transport officer, taking into consideration clinical issues which have been identified during the field triage and treatment process. The process usually also attempts to consider each hospital’s treatment capabilities, local policies, and regulations, and the amount and type of transportation resources which are immediately available. Bear in mind that EMS, like the hospital, has limited resources available and must cope with not only the current crisis, but every other emergency occurring simultaneously within the community. Similarly, while the care of paramedics is usually excellent over the short term, asking them to manage patients with complex treatment requirements over an extended period is very likely to exceed their scope of practice. As a result, it may be unrealistic and inappropriate to expect that they will transport clinically acute patients over large distances without stopping at a closer hospital for stabilization of the patient.
It is also appropriate to remember that in many mass-casualty situations, many of the victims are not transported to hospital by EMS; they arrive in a variety of modes of transport, often untriaged, untreated, and without any prior decontamination.19 With those conditions in mind, and an appropriate advance agreement in place, EMS systems are generally quite willing to attempt to distribute the load as evenly as possible, across several local hospitals, and that distribution may be based upon simple numbers or upon clinical acuity.
Even when this does not occur through EMS, usually because of normal transportation arrangements and protocols, it is almost certainly going to be necessary for the various facilities and agencies to arrive at a reasonable arrangement for the accessing of in-patient beds. This will normally occur through the redistribution, including the decanting, of existing in-patients, in order to make space for the influx of victims who are in more immediate need of acute care beds. This means that not only the local acute care facilities will be affected, but there will be a secondary effect as the existing in-patients are either decanted to more distant facilities or discharged to long-term care or care in the community. Arrangements will be required with the providers of all of these services, and the best time to achieve them is in advance, so that they can be incorporated into all Emergency Response Plans.
Figure 3.4 The management of any mass-casualty event is a complex process, likely to require extensive interfacility cooperation and the redistribution of patients across the entire continuum of care
Distribution of disaster patients according to clinical issues is one potential option, but it is a complex one. In an age in which some hospitals attempt to specialize, there is an increasing, but somewhat erroneous, assumption that the specialty resource will receive all patients which fall into its area of specialization. Trauma Centers are an excellent case in point; on a daily basis it is perfectly reasonable to assume that all trauma patients will be transported to that location. However, in a mass-casualty event, it is equally likely that the local Trauma Center will very quickly exceed its treatment capacity for trauma patients, forcing community hospitals back into the “trauma business.” This is a situation which can also occur for other areas of specialization, such as burns.
Instead, it may be more appropriate to classify hospitals according to both distance from the disaster event and clinical treatment capabilities. “First impact” hospitals would be those in the closest proximity to the event, thereby necessitating the shortest transport times to definitive care for those victims with the highest levels of clinical acuity. “Second impact” hospitals would be those further away, and hopefully, dealing with the lower acuity patients, and receiving higher acuity cases only when the first impact hospitals exceeded their capacity. “Predesignated” hospitals would provide specialty care, such as Trauma Centers, for as long as they were able, with their overflow being passed to the first impact hospitals. A final classification, “overflow” hospitals, would be those furthest away, and their role would be to accept redirected routine emergency patient traffic in order to permit the first impact hospitals to deal with the crisis, and also any in-patients being decanted from the first impact hospitals, or stabilized disaster patients who were being transferred for admission, to make space for victims in the first impact hospitals. With the exception of the “predesignated” hospitals, the actual role of each hospital in the network would be determined in each new event, according to its physical proximity to the disaster event.
It may be useful and appropriate to map out the entire prehospital patient distribution scheme in advance. Tools such as Value Stream Mapping and spatial data plotting could contribute substantially to this process. Such a model would require the agreement and cooperation of EMS, all regional hospitals, and other local healthcare stakeholders. This research, planning, and approval of the required agreements would need to be completed in advance of any emergency event, with healthcare Emergency Managers likely to play an important role in both leading and guiding a representative planning group.
Receiving Decanted In-Patients
All hospitals are essentially boxes of finite size, even during a disaster! All hospitals have the potential to reach a point of patient “saturation,” particularly during a disaster event. Space will eventually be required for many of the victims to be treated as in-patients, particularly after they have cleared the “bottlenecks” in the emergency department, diagnostic procedures, and surgery. The space required may involve an intensive care setting or a less clinically intense setting. The management of this problem is essentially an exercise in surge capacity, at each stage along the continuum of care. As such, it may benefit directly from a joint examination of crisis bed management, using such methodologies as Value Stream Mapping, in order to find new efficiencies in the process of patient flow. Such activities should be conducted jointly by the various facilities in the regional hospital network, using those with clinical expertise, bed management expertise, and the Emergency Manager.
There are really only two options for the management of such patients. One may stabilize these patients, and then transfer them by ambulance to a more distant facility with both space available and the ability to treat that particular patient’s condition. As an alternative, one may consider the transfer of existing low-acuity in-patients. This would include those in-patients on elective admissions, those awaiting long-term care placements, or those expected to be discharged to care in the community within the next 48 hours. These patients could potentially be moved from the first impact hospitals to more distant hospitals or other venues of care, in order to create in-patient space for those victims of the disaster who require it. While admittedly complex and disruptive, the latter is generally the safer means of managing this issue, since those patients with the lowest clinical acuity and the least treatment requirements are those being transported, while those with the higher clinical acuity and treatment requirements consistently remain in the safer environment. Such bed management methodologies need to be determined in advance, and they should be the subject of both advance dialog and formal agreements between all of the facilities involved.
Methods of Fostering Integration
Healthcare facilities are unlikely to work together unless they first begin by talking together. In order to achieve the required objectives, all must be shown how cooperation is in their mutual interest, despite their normal, and somewhat outdated, positioning as competitors. The most likely keys to fostering this type of self-serving cooperation would include minimizing business disruptions and the reduction of costs, as well as the elimination of waste and the elimination of errors. All of these issues are already generally fairly high on the “radar” of most healthcare Chief Executive Officers.
The introduction of mainstream business management techniques, such as Lean for Healthcare and Six Sigma, are likely to add substantially to the interest of senior managers in such an initiative, and the techniques of Project Management are likely to contribute to the success of related projects. Committee work, although time-consuming, is clearly necessary in order to build an atmosphere of cooperation and consensus, because people are much more likely to cooperate with those with whom they already enjoy a relationship. Indeed, it may be possible for the Emergency Managers of the various facilities to harness some of that traditional competitive attitude and energy in order to move related projects along the path to completion and implementation more quickly and efficiently.
The development of a regional healthcare Emergency Preparedness Committee is generally a good place at which to begin. Under the guidance of a working group consisting of the facilities’ own Emergency Managers, a preparedness framework can be developed, in which various major issues can be discussed. These may include, but are not limited to, a comprehensive HIRA for the regional healthcare network, a common Command and Control model, integrated communications, mutual support agreements, jointly conducted in-service education and emergency exercises, and negotiated agreements regarding patient distribution and specific facility roles during a disaster.
Don’t forget to include long-term care in the discussion; their plans are likely to affect acute care facilities, and they can provide a valuable resource for receiving decanted patients, during an emergency. As a first step, consider having all of the healthcare agencies in the region share a copy of their own Emergency Plan with one another; these can greatly improve understanding and can provide an invaluable resource to each Hospital Command Center, during a large-scale crisis. From the perspective of the Emergency Manager, all of this can often be conducted under the banner of being able to demonstrate community partnerships as a part of the accreditation process.
Conclusion
In many parts of the world, healthcare providers tend to view each other as competitors. Depending on the type of healthcare system, this may take the form of good-natured competitiveness or it can be a “no nonsense” serious challenge for market share by two or more large business entities. In either case, in a disaster response, such challenges must be set aside, in order to permit a coordinated and cooperative response aimed at benefiting the greatest number of injured victims. The Emergency Manager is uniquely situated within the healthcare facility to overcome those barriers discreetly and quietly to collaboration, to become a force for change within their own facility, and to put technologies, lines of communication, resources, and procedures into place which have the potential to permit highly effective coordination during times of crisis, between facilities which view themselves as competitors on a daily basis. Working together can be made a “win–win” situation for healthcare facilities and will undoubtedly benefit the victims of any disaster.
Student Projects
Student Project #1
Select a single hospital as the subject hospital and conduct an inventory of available onsite clinical and physical plant maintenance resources. Identify any resource-sharing arrangements with other hospitals which are already in place. Identify all other hospitals which are located within a 30-minute drive of the subject hospital, and identify any clinical (e.g., intensive care unit) or physical plant maintenance (e.g., IT department) resources which are not normally available in the subject hospital, which might be required during any emergency event. Draft a plan for disaster cooperation between all of the hospitals in question. Be sure to identify potential barriers to cooperation and to propose potential solutions to these problems. Be sure to cite and reference as required, in order to demonstrate that sufficient appropriate research has occurred.
Student Project #2
Create a final draft of a formal mutual assistance agreement, to be entered into between three acute care hospitals and two long-term care facilities operating within a single county, within an identified jurisdiction, such as a state or a province. Be sure to include specific information on activation, Command and Control, interfacility communications, sharing of resources, resolution of disputes, and procedures for standing down. Ensure that all aspects of the mutual assistance agreement are in full compliance with all relevant Emergency Management and healthcare legislation in the jurisdiction selected. Be sure to cite and reference as required, in order to demonstrate that sufficient appropriate research has occurred.
Test Your Knowledge
Take your time. Read each question carefully and select the most correct answer for each. The correct answers appear at the end of the section. If you score less than 80 percent (8 correct answers) you should reread this chapter.
1. Some emergency response issues which create substantial barriers to coordinating the responses of multiple healthcare facilities include:
(a) Different Command and Control systems
(b) Lack of interoperable communications
(c) Conflicting in-house policies
(d) All of the above
2. Issues which provide barriers to the free movement of professional staff from one hospital to another include insurance requirements and:
(a) Credentialing of staff
(b) Legislative barriers
(c) Policy barriers
(d) Both (b) and (c)
3. Issues which can potentially create unforeseen problems when hospitals attempt to cooperate during a crisis are that they frequently:
(a) View each other as competitors
(b) Have unrealistic expectations of each other
(c) Lack a complete understanding of each other’s available resources
(d) All of the above
4. Regionwide cooperation by those Emergency Managers working with healthcare facilities can provide:
(a) Effective joint exercises and training
(b) Reduced operating costs
(c) A good public image
(d) All of the above
5. An advantage of using a Command and Control model within a group of healthcare facilities, such as the incident management system, is that it can:
(a) Provide a common response framework
(b) Provide effective points of interfacility information sharing
(c) Provide effective points of resource coordination
(d) All of the above
6. Balanced distribution of patients from a mass-casualty incident can ensure that patients obtain improved times to treatment and:
(a) Individual hospitals are less overwhelmed and can provide better care
(b) Transport times for patients improve
(c) Patients with serious injuries are sent to the most advanced hospitals
(d) All of the above
7. An unfortunate reality of Trauma Centers is that they have finite capacities, and as soon as those capacities are exceeded:
(a) More staff will be called in to work in improvised spaces
(b) Other surrounding hospitals will have to begin treating trauma patients
(c) Patients will need to be transported to more distant Trauma Centers
(d) Both (a) and (c)
8. An unfortunate reality of Emergency Management in healthcare is that every time a healthcare facility must be evacuated, or must decant stable in-patients in order to receive disaster patients, their actions may generate:
(a) Increases in local demand for service
(b) Staffing shortages
(c) A “de facto” mass-casualty incident for surrounding facilities
(d) Both (a) and (b)
9. Regional Healthcare Emergency Preparedness Committees, composed of the Emergency Managers from all healthcare facilities in a given region, may result in:
(a) Improved interfacility coordination during a crisis
(b) Improved understanding of each facility’s capabilities and limitations
(c) Improved standardization of Emergency Response Plans
(d) All of the above
10. An essential requirement of any mutual assistance agreement negotiated between various types of healthcare facilities is that the agreement must:
(a) Comply with all relevant local laws and regulations
(b) Be signed by each facility’s Chief Executive Officer
(c) Be approved by local government
(d) All of the above
1. (d)
2. (a)
3. (d)
4. (a)
5. (d)
6. (a)
7. (b)
8. (c)
9. (d)
10. (a)
Additional Reading
The author recommends the following exceptionally good titles as supplemental readings, which will help to enhance the student’s knowledge of those topics covered in this chapter:
Abkowitz, M. Fall 2008. Lessons Learned the Hard Way: What Disasters Can Teach Us About Planning, Communication, and Luck. Vanderbilt Magazine, Vanderbilt University. www.vanderbilt.edu/magazines/vanderbilt-magazine/2008/10/lessons-learned-the-hard-way/ (accessed online February 04, 2014).
CNA. 2009. Medical Staff Credentialing: Eight Strategies for Safer Physician and Provider Privileging. CNA, Chicago: Vantage Point magazine, 09:3. (accessed online February 04, 2014).
Donahue, A.K. and R.V. Tuohy. July 2006. “Lessons We Don’t Learn: A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them.” Journal of the Naval Postgraduate School Center for Homeland Defence and Security, .pdf document. www.hsaj.org/?fullarticle=2.2.4 (accessed online February 04, 2014).
FEMA. 2004. NIMS and the Incident Command System: A Position Paper. Washington: US Federal Emergency Management Agency. www.fema.gov/txt/nims/nims_ics_position_paper.txt (accessed online February 04, 2014).
Risk and Compromise Tool. 2012. On-Pace, Ohio State University webpage. http://onpace.osu.edu/posts/documents/Risk%20and%20Compromise%20Tool.pdf (accessed online February 04, 2014).