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Hospitalist groups should have disaster response plans
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.
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.
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.”
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.”
Challenges of surge capacity
Every disaster is different, said Srikant Polepalli, MD, associate hospitalist medical director for Staten Island University Hospital in New York, part of the Northwell Health system. He brought the experience of being part of the response to Superstorm Sandy in October 2012 to the COVID pandemic.
“Specifically for hospitalists, the biggest challenge is working on surge capacity for a sudden influx of patients,” he said. “But with Northwell as our umbrella, we can triage and load-balance to move patients from hospital to hospital as needed. With the pandemic, we started with one COVID unit and then expanded to fill the entire hospital.”
Dr. Polepalli was appointed medical director for a temporary field hospital installed at South Beach Psychiatric Center, also in Staten Island. “We were able to acquire help and bring in people ranging from hospitalists to ER physicians, travel nurses, operation managers and the National Guard. Our command center did a phenomenal job of allocating and obtaining resources. It helped to have a structure that was already established and to rely on the resources of the health system,” Dr. Polepalli said. Not every hospital has a structure like Northwell’s.
“We’re not out of the pandemic yet, but we’ll continue with disaster drills and planning,” he said. “We must continue to adapt and have converted our temporary facilities to COVID testing centers, antibody infusion centers, and vaccination centers.”
For Alfred Burger, MD, SFHM, a hospitalist at Mount Sinai’s Beth Israel campus in New York, hospital medicine, now in its maturing phase, is still feeling its way through hospital and health care system transformation.
“My group is an academic, multicampus hospitalist group employed by the hospital system. When I meet other hospitalists at SHM conferences, whether they come from privately owned, corporately owned, or contracted models, they vary widely in terms of how involved the hospitalists are in crisis planning and their ability to respond to crises. At large academic medical centers like ours, one or more doctors is tasked with being involved in preparing for the next disaster,” he said.
“I think we responded the best we could, although it was difficult as we lost many patients to COVID. We were trying to save lives using the tools we knew from treating pneumonias and other forms of acute inflammatory lung injuries. We used every bit of our training in situations where no one had the right answers. But disasters teach us how to be flexible and pivot on the fly, and what to do when things don’t go our way.”
What is disaster response?
Medical response to a disaster essentially boils down to three main things: stuff, staff, and space, Dr. Persoff said. Those are the cornerstones of an emergency plan.
“There is not a hazard that exists that you can’t take an all-hazards approach to dealing with fundamental realities on the ground. No plan can be comprehensive enough to deal with all the intricacies of an emergency. But many plans can have the bones of a response that will allow you to face adverse circumstances,” he said.
“We actually became quite efficient early on in the pandemic, able to adapt in the moment. We were able to build an effective bridge between workers on the ground and our incident command structure, which seemed to reduce a lot of stress and create situational awareness. We implemented ICS as soon as we heard that China was building a COVID hospital, back in February of 2020.”
When one thinks about mass trauma, such as a 747 crash, Dr. Persoff said, the need is to treat burn victims and trauma victims in large numbers. At that point, the ED downstairs is filled with medical patients. Hospital medicine can rapidly admit those patients to clear out room in the ED. Surgeons are also dedicated to rapidly treating those patients, but what about patients who are on the floor following their surgeries? Hospitalists can offer consultations or primary management so the surgeons can stay in the OR, and the same in the ICU, while safely discharging hospitalized patients in a timely manner to make room for incoming patients.
“The lessons of COVID have been hard-taught and hard-earned. No good plan survives contact with the enemy,” he said. “But I think we’ll be better prepared for the next pandemic.”
Maria Frank, MD, FACP, SFHM, a hospitalist at Denver Health who chairs SHM’s Disaster Management Special Interest Group, says she got the bug for disaster preparation during postresidency training as an internist in emergency medicine. “I’m also the medical director for our biocontainment unit, created for infections like Ebola.” SHM’s SIG, which has 150 members, is now writing a review article on disaster planning for the field.
“I got a call on Dec. 27, 2019, about this new pneumonia, and they said, ‘We don’t know what it is, but it’s a coronavirus,’” she recalled. “When I got off the phone, I said, ‘Let’s make sure our response plan works and we have enough of everything on hand.’” Dr. Frank said she was expecting something more like SARS (severe acute respiratory syndrome). “When they called the public health emergency of international concern for COVID, I was at a Centers for Disease Control and Prevention meeting in Atlanta. It really wasn’t a surprise for us.”
All hospitals plan for disasters, although they use different names and have different levels of commitment, Dr. Frank said. What’s not consistent is the participation of hospitalists. “Even when a disaster is 100% trauma related, consider a hospital like mine that has at least four times as many hospitalists as surgeons at any given time. The hospitalists need to take overall management for the patients who aren’t actually in the operating room.”
Time to debrief
Dr. Frank recommends debriefing on the hospital’s and the hospitalist group’s experience with COVID. “Look at the biggest challenges your group faced. Was it staffing, or time off, or the need for day care? Was it burnout, lack of knowledge, lack of [personal protective equipment]?” Each hospital could use its own COVID experience to work on identifying the challenges and the problems, she said. “I’d encourage each department and division to do this exercise individually. Then come together to find common ground with other departments in the hospital.”
This debriefing exercise isn’t just for doctors – it’s also for nurses, environmental services, security, and many other departments, she said. “COVID showed us how crisis response is a group effort. What will bring us together is to learn the challenges each of us faced. It was amazing to see hospitalists doing what they do best.” Post pandemic, hospitalists should also consider getting involved in research and publications, in order to share their lessons.
“One of the things we learned is that hospitalists are very versatile,” Dr. Frank added. But it’s also good for the group to have members specialize, for example, in biocontainment. “We are experts in discharging patients, in patient flow and operations, in coordinating complex medical care. So we would naturally take the lead in, for example, opening a geographic unit or collaborating with other specialists to create innovative models. That’s our job. It’s essential that we’re involved well in advance.”
COVID may be a once-in-a-lifetime experience, but there will be other disasters to come, she said. “If your hospital doesn’t have a disaster plan for hospitalists, get involved in establishing one. Each hospitalist group should have its own response plan. Talk to your peers at other hospitals, and get involved at the institutional level. I’m happy to share our plan; just contact me.” Readers can contact Dr. Frank at [email protected].
References
1. Persoff J et al. The role of hospital medicine in emergency preparedness: A framework for hospitalist leadership in disaster preparedness, response and recovery. J Hosp Med. 2018 Oct;13(10):713-7. doi: 10.12788/jhm.3073.
2. Persoff J et al. Expanding the hospital incident command system with a physician-centric role during a pandemic: The role of the physician clinical support supervisor. J Hosp Adm. 2020;9(3):7-10. doi: 10.5430/jha.v9n3p7.
3. Bowden K et al. Harnessing the power of hospitalists in operational disaster planning: COVID-19. J Gen Intern Med. 2020 Sep;35(9):273-7. doi: 10.1007/s11606-020-05952-6.
4. Orsini E et al. Lessons on outbreak preparedness from the Cleveland Clinic. Chest. 2020;158(5):2090-6. doi: 10.1016/j.chest.2020.06.009.
Hospitalist groups should have disaster response plans
Hospitalist groups should have disaster response plans
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.
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.
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.”
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.”
Challenges of surge capacity
Every disaster is different, said Srikant Polepalli, MD, associate hospitalist medical director for Staten Island University Hospital in New York, part of the Northwell Health system. He brought the experience of being part of the response to Superstorm Sandy in October 2012 to the COVID pandemic.
“Specifically for hospitalists, the biggest challenge is working on surge capacity for a sudden influx of patients,” he said. “But with Northwell as our umbrella, we can triage and load-balance to move patients from hospital to hospital as needed. With the pandemic, we started with one COVID unit and then expanded to fill the entire hospital.”
Dr. Polepalli was appointed medical director for a temporary field hospital installed at South Beach Psychiatric Center, also in Staten Island. “We were able to acquire help and bring in people ranging from hospitalists to ER physicians, travel nurses, operation managers and the National Guard. Our command center did a phenomenal job of allocating and obtaining resources. It helped to have a structure that was already established and to rely on the resources of the health system,” Dr. Polepalli said. Not every hospital has a structure like Northwell’s.
“We’re not out of the pandemic yet, but we’ll continue with disaster drills and planning,” he said. “We must continue to adapt and have converted our temporary facilities to COVID testing centers, antibody infusion centers, and vaccination centers.”
For Alfred Burger, MD, SFHM, a hospitalist at Mount Sinai’s Beth Israel campus in New York, hospital medicine, now in its maturing phase, is still feeling its way through hospital and health care system transformation.
“My group is an academic, multicampus hospitalist group employed by the hospital system. When I meet other hospitalists at SHM conferences, whether they come from privately owned, corporately owned, or contracted models, they vary widely in terms of how involved the hospitalists are in crisis planning and their ability to respond to crises. At large academic medical centers like ours, one or more doctors is tasked with being involved in preparing for the next disaster,” he said.
“I think we responded the best we could, although it was difficult as we lost many patients to COVID. We were trying to save lives using the tools we knew from treating pneumonias and other forms of acute inflammatory lung injuries. We used every bit of our training in situations where no one had the right answers. But disasters teach us how to be flexible and pivot on the fly, and what to do when things don’t go our way.”
What is disaster response?
Medical response to a disaster essentially boils down to three main things: stuff, staff, and space, Dr. Persoff said. Those are the cornerstones of an emergency plan.
“There is not a hazard that exists that you can’t take an all-hazards approach to dealing with fundamental realities on the ground. No plan can be comprehensive enough to deal with all the intricacies of an emergency. But many plans can have the bones of a response that will allow you to face adverse circumstances,” he said.
“We actually became quite efficient early on in the pandemic, able to adapt in the moment. We were able to build an effective bridge between workers on the ground and our incident command structure, which seemed to reduce a lot of stress and create situational awareness. We implemented ICS as soon as we heard that China was building a COVID hospital, back in February of 2020.”
When one thinks about mass trauma, such as a 747 crash, Dr. Persoff said, the need is to treat burn victims and trauma victims in large numbers. At that point, the ED downstairs is filled with medical patients. Hospital medicine can rapidly admit those patients to clear out room in the ED. Surgeons are also dedicated to rapidly treating those patients, but what about patients who are on the floor following their surgeries? Hospitalists can offer consultations or primary management so the surgeons can stay in the OR, and the same in the ICU, while safely discharging hospitalized patients in a timely manner to make room for incoming patients.
“The lessons of COVID have been hard-taught and hard-earned. No good plan survives contact with the enemy,” he said. “But I think we’ll be better prepared for the next pandemic.”
Maria Frank, MD, FACP, SFHM, a hospitalist at Denver Health who chairs SHM’s Disaster Management Special Interest Group, says she got the bug for disaster preparation during postresidency training as an internist in emergency medicine. “I’m also the medical director for our biocontainment unit, created for infections like Ebola.” SHM’s SIG, which has 150 members, is now writing a review article on disaster planning for the field.
“I got a call on Dec. 27, 2019, about this new pneumonia, and they said, ‘We don’t know what it is, but it’s a coronavirus,’” she recalled. “When I got off the phone, I said, ‘Let’s make sure our response plan works and we have enough of everything on hand.’” Dr. Frank said she was expecting something more like SARS (severe acute respiratory syndrome). “When they called the public health emergency of international concern for COVID, I was at a Centers for Disease Control and Prevention meeting in Atlanta. It really wasn’t a surprise for us.”
All hospitals plan for disasters, although they use different names and have different levels of commitment, Dr. Frank said. What’s not consistent is the participation of hospitalists. “Even when a disaster is 100% trauma related, consider a hospital like mine that has at least four times as many hospitalists as surgeons at any given time. The hospitalists need to take overall management for the patients who aren’t actually in the operating room.”
Time to debrief
Dr. Frank recommends debriefing on the hospital’s and the hospitalist group’s experience with COVID. “Look at the biggest challenges your group faced. Was it staffing, or time off, or the need for day care? Was it burnout, lack of knowledge, lack of [personal protective equipment]?” Each hospital could use its own COVID experience to work on identifying the challenges and the problems, she said. “I’d encourage each department and division to do this exercise individually. Then come together to find common ground with other departments in the hospital.”
This debriefing exercise isn’t just for doctors – it’s also for nurses, environmental services, security, and many other departments, she said. “COVID showed us how crisis response is a group effort. What will bring us together is to learn the challenges each of us faced. It was amazing to see hospitalists doing what they do best.” Post pandemic, hospitalists should also consider getting involved in research and publications, in order to share their lessons.
“One of the things we learned is that hospitalists are very versatile,” Dr. Frank added. But it’s also good for the group to have members specialize, for example, in biocontainment. “We are experts in discharging patients, in patient flow and operations, in coordinating complex medical care. So we would naturally take the lead in, for example, opening a geographic unit or collaborating with other specialists to create innovative models. That’s our job. It’s essential that we’re involved well in advance.”
COVID may be a once-in-a-lifetime experience, but there will be other disasters to come, she said. “If your hospital doesn’t have a disaster plan for hospitalists, get involved in establishing one. Each hospitalist group should have its own response plan. Talk to your peers at other hospitals, and get involved at the institutional level. I’m happy to share our plan; just contact me.” Readers can contact Dr. Frank at [email protected].
References
1. Persoff J et al. The role of hospital medicine in emergency preparedness: A framework for hospitalist leadership in disaster preparedness, response and recovery. J Hosp Med. 2018 Oct;13(10):713-7. doi: 10.12788/jhm.3073.
2. Persoff J et al. Expanding the hospital incident command system with a physician-centric role during a pandemic: The role of the physician clinical support supervisor. J Hosp Adm. 2020;9(3):7-10. doi: 10.5430/jha.v9n3p7.
3. Bowden K et al. Harnessing the power of hospitalists in operational disaster planning: COVID-19. J Gen Intern Med. 2020 Sep;35(9):273-7. doi: 10.1007/s11606-020-05952-6.
4. Orsini E et al. Lessons on outbreak preparedness from the Cleveland Clinic. Chest. 2020;158(5):2090-6. doi: 10.1016/j.chest.2020.06.009.
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.
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.
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.”
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.”
Challenges of surge capacity
Every disaster is different, said Srikant Polepalli, MD, associate hospitalist medical director for Staten Island University Hospital in New York, part of the Northwell Health system. He brought the experience of being part of the response to Superstorm Sandy in October 2012 to the COVID pandemic.
“Specifically for hospitalists, the biggest challenge is working on surge capacity for a sudden influx of patients,” he said. “But with Northwell as our umbrella, we can triage and load-balance to move patients from hospital to hospital as needed. With the pandemic, we started with one COVID unit and then expanded to fill the entire hospital.”
Dr. Polepalli was appointed medical director for a temporary field hospital installed at South Beach Psychiatric Center, also in Staten Island. “We were able to acquire help and bring in people ranging from hospitalists to ER physicians, travel nurses, operation managers and the National Guard. Our command center did a phenomenal job of allocating and obtaining resources. It helped to have a structure that was already established and to rely on the resources of the health system,” Dr. Polepalli said. Not every hospital has a structure like Northwell’s.
“We’re not out of the pandemic yet, but we’ll continue with disaster drills and planning,” he said. “We must continue to adapt and have converted our temporary facilities to COVID testing centers, antibody infusion centers, and vaccination centers.”
For Alfred Burger, MD, SFHM, a hospitalist at Mount Sinai’s Beth Israel campus in New York, hospital medicine, now in its maturing phase, is still feeling its way through hospital and health care system transformation.
“My group is an academic, multicampus hospitalist group employed by the hospital system. When I meet other hospitalists at SHM conferences, whether they come from privately owned, corporately owned, or contracted models, they vary widely in terms of how involved the hospitalists are in crisis planning and their ability to respond to crises. At large academic medical centers like ours, one or more doctors is tasked with being involved in preparing for the next disaster,” he said.
“I think we responded the best we could, although it was difficult as we lost many patients to COVID. We were trying to save lives using the tools we knew from treating pneumonias and other forms of acute inflammatory lung injuries. We used every bit of our training in situations where no one had the right answers. But disasters teach us how to be flexible and pivot on the fly, and what to do when things don’t go our way.”
What is disaster response?
Medical response to a disaster essentially boils down to three main things: stuff, staff, and space, Dr. Persoff said. Those are the cornerstones of an emergency plan.
“There is not a hazard that exists that you can’t take an all-hazards approach to dealing with fundamental realities on the ground. No plan can be comprehensive enough to deal with all the intricacies of an emergency. But many plans can have the bones of a response that will allow you to face adverse circumstances,” he said.
“We actually became quite efficient early on in the pandemic, able to adapt in the moment. We were able to build an effective bridge between workers on the ground and our incident command structure, which seemed to reduce a lot of stress and create situational awareness. We implemented ICS as soon as we heard that China was building a COVID hospital, back in February of 2020.”
When one thinks about mass trauma, such as a 747 crash, Dr. Persoff said, the need is to treat burn victims and trauma victims in large numbers. At that point, the ED downstairs is filled with medical patients. Hospital medicine can rapidly admit those patients to clear out room in the ED. Surgeons are also dedicated to rapidly treating those patients, but what about patients who are on the floor following their surgeries? Hospitalists can offer consultations or primary management so the surgeons can stay in the OR, and the same in the ICU, while safely discharging hospitalized patients in a timely manner to make room for incoming patients.
“The lessons of COVID have been hard-taught and hard-earned. No good plan survives contact with the enemy,” he said. “But I think we’ll be better prepared for the next pandemic.”
Maria Frank, MD, FACP, SFHM, a hospitalist at Denver Health who chairs SHM’s Disaster Management Special Interest Group, says she got the bug for disaster preparation during postresidency training as an internist in emergency medicine. “I’m also the medical director for our biocontainment unit, created for infections like Ebola.” SHM’s SIG, which has 150 members, is now writing a review article on disaster planning for the field.
“I got a call on Dec. 27, 2019, about this new pneumonia, and they said, ‘We don’t know what it is, but it’s a coronavirus,’” she recalled. “When I got off the phone, I said, ‘Let’s make sure our response plan works and we have enough of everything on hand.’” Dr. Frank said she was expecting something more like SARS (severe acute respiratory syndrome). “When they called the public health emergency of international concern for COVID, I was at a Centers for Disease Control and Prevention meeting in Atlanta. It really wasn’t a surprise for us.”
All hospitals plan for disasters, although they use different names and have different levels of commitment, Dr. Frank said. What’s not consistent is the participation of hospitalists. “Even when a disaster is 100% trauma related, consider a hospital like mine that has at least four times as many hospitalists as surgeons at any given time. The hospitalists need to take overall management for the patients who aren’t actually in the operating room.”
Time to debrief
Dr. Frank recommends debriefing on the hospital’s and the hospitalist group’s experience with COVID. “Look at the biggest challenges your group faced. Was it staffing, or time off, or the need for day care? Was it burnout, lack of knowledge, lack of [personal protective equipment]?” Each hospital could use its own COVID experience to work on identifying the challenges and the problems, she said. “I’d encourage each department and division to do this exercise individually. Then come together to find common ground with other departments in the hospital.”
This debriefing exercise isn’t just for doctors – it’s also for nurses, environmental services, security, and many other departments, she said. “COVID showed us how crisis response is a group effort. What will bring us together is to learn the challenges each of us faced. It was amazing to see hospitalists doing what they do best.” Post pandemic, hospitalists should also consider getting involved in research and publications, in order to share their lessons.
“One of the things we learned is that hospitalists are very versatile,” Dr. Frank added. But it’s also good for the group to have members specialize, for example, in biocontainment. “We are experts in discharging patients, in patient flow and operations, in coordinating complex medical care. So we would naturally take the lead in, for example, opening a geographic unit or collaborating with other specialists to create innovative models. That’s our job. It’s essential that we’re involved well in advance.”
COVID may be a once-in-a-lifetime experience, but there will be other disasters to come, she said. “If your hospital doesn’t have a disaster plan for hospitalists, get involved in establishing one. Each hospitalist group should have its own response plan. Talk to your peers at other hospitals, and get involved at the institutional level. I’m happy to share our plan; just contact me.” Readers can contact Dr. Frank at [email protected].
References
1. Persoff J et al. The role of hospital medicine in emergency preparedness: A framework for hospitalist leadership in disaster preparedness, response and recovery. J Hosp Med. 2018 Oct;13(10):713-7. doi: 10.12788/jhm.3073.
2. Persoff J et al. Expanding the hospital incident command system with a physician-centric role during a pandemic: The role of the physician clinical support supervisor. J Hosp Adm. 2020;9(3):7-10. doi: 10.5430/jha.v9n3p7.
3. Bowden K et al. Harnessing the power of hospitalists in operational disaster planning: COVID-19. J Gen Intern Med. 2020 Sep;35(9):273-7. doi: 10.1007/s11606-020-05952-6.
4. Orsini E et al. Lessons on outbreak preparedness from the Cleveland Clinic. Chest. 2020;158(5):2090-6. doi: 10.1016/j.chest.2020.06.009.