Daniel KolleK Hospital Disaster Readiness: Why Are …

1 Daniel KolleK Hospital Disaster readiness : why are We Unprepared? Urgency in the Emergency: In Support of National Standards of Emergency care 34 34. I. t is a recurrent theme that the further away one is from lack of formal, replicable, and evidence-based Disaster pre- the actual delivery of Disaster care , the better prepared paredness assessment underpins all other problems in that one perceives the system to be. At the extreme, recent if we do not measure our inabilities, we will not be able to correspondence from the Canadian Association of Emer- remedy them. gency Physicians to the provincial health ministers across Canada voiced concern about the health care system's ability Why Is Hospital readiness Not Assessed? to respond to Disaster . Uniformly, all health ministers in the provinces that responded (8 of 10) stated that their provinces One of the oft-quoted reasons for not having a Disaster asses- were prepared.

2 Sment tool is that disasters are so variable that it is impossible to design a uniform assessment tool for readiness . While it is Unfortunately, the reality at the front lines is not so rosy. Front- true that disasters may be variable, the response to disasters line providers have repeatedly expressed serious concerns about is far more uniform. Israeli hospitals, likely the world leaders the ability of health care systems, and spe- in preparedness for dealing with disasters, cifically health care facilities, to respond in have developed standard operating pro- a Disaster (Kanter & Moran, 2007; KolleK , Processes that are cedures that facilitate the management of 2003; KolleK & Cwinn, 2009; Tachibanai, discovered to be useful mass casualty incidents. Not only do these Takemura, Sone, Segami, & Kato, 2005).

3 In expediting care in a procedures allow for an organized response Staff is inadequately trained despite the to a Disaster , they also allow for an ongoing existence of competency lists and curri- Disaster situation can process of quality improvement since there cula (Hsu et al., 2006; Tachibanai et al., easily find their way are standards against which to measure 2005). data shows that there is a into the day-to-day performance (Adini, Goldberg, Laor, Cohen, large amount of variability between & Bar-Dayan, 2007). regions and facilities (Higgins, Wainright, function of the Lu, & Carrico, 2004). Canadian data, organization. Incidentally, the statement that there is a while limited for reasons that will be large variability in potential disasters leads expanded on further, also shows that one to ask why hospitals do not routinely there are areas of strength and weakness and that there is both perform risk assessment to determine which disasters may regional variability and variability in preparedness for specific befall them.

4 Currently in Canada, there is no evidence that types of events. any formal risk assessment tool has been deployed across hospitals, despite the fact that such tools, specifically This discrepancy between high- and middle-level adminis- Canadian tools, do exist. tration's perception of readiness and frontline caregivers' per- ception of a lack thereof stems from three key reasons. The Another reason for the lack of formal assessment is the lack first and simplest of these is the distance, both geographic and of a standard of care . This was alluded to earlier and stems in terms of training and expertise, between the administrator from the misperception that each type of Disaster requires its and the individuals actually delivering the care in a Disaster own unique plan and that a standard of care must be derived setting.

5 For each. Recent thinking in the Disaster world has for years focused on an all hazards approach as opposed to individual Second is the fact that, particularly in health care , Disaster plans. The all hazards approach requires a basic plan that is preparedness is an orphan entity. Health care professionals then adapted for specific events. This basic plan is the back- have extremely limited training in Disaster preparedness bone of the Hospital Disaster response and can and should be (Bagatell & Wiese, 2008; Hsu et al., 2006), Disaster management measured against a standard of care . experts have almost no expertise in health care , and there is no overarching authority that is able to bridge the gap between The third reason for not performing formal readiness assess- these two groups.

6 This diffusion of responsibility exists at all ments is that, while the literature is replete with calls for the levels, but reaches an extreme at the federal level. The development of such a tool (Barbera, Yeatts, & Macintyre, Minister of Public Safety has the expertise and the tools for 2009; Lazar, Cagliuso Sr., & Gebbie, 2009; McCarthy, Brews- Disaster response and the Minister of Health has at her disposal ter, Hsu, Macintyre, & Kelen, 2009), the perception is that significant expertise in health care issues, yet both of them are nothing is available or what is available is not validated (Jen- lacking in the expertise of the other. kins, Kelen, Sauer, Fredericksen, & McCarthy, 2009; Kaji, Langford, & Lewis, 2008; Kaji & Lewis, 2008). This percep- The third reason is the absence of any formal assessment of tion is incorrect because tools, specifically Canadian tools, do health care facility Disaster preparedness in Canada.

7 This exist for both risk and readiness assessment. With support from 35. KATIE LAFERTY. management, potential problems such as disasters are seen as deferrable concerns. This opinion exists despite the ability of Disaster preparedness to help with overall efficiency. The irony is that, with our alternate level of care (ALC) statistics, our blocked emergency departments, and our overwhelmed pre- Hospital services, the Disaster is upon us already. We are blin- ded to it because it arrived with a whimper, not a bang. Disaster Preparedness Improves Overall Quality of care While the likelihood of a Disaster occurring is small, the im- pact of a Disaster can be extremely significant. First and fore- most, there is a direct health care impact on the population, be it from mass trauma, an infectious agent, a chemical release, weather patterns, or other causes.

8 Disasters can also have an impact on the ability of the Hospital to function. As the workload increases, the staff themselves may become ill and fear within the health care community may grow. Last, the re- putation of an organization that responds poorly to disasters is tarnished for an extremely long period of time. Tragedies such as the 2004 Indian Ocean tsunami or Hurricane Katrina in 2005, shown on 24/7 news channels, provide an eyewitness account of Disaster management or lack thereof in our global village world (Jenkins et al., 2009). Any mention of the Fe- deral [ ] Emergency Management Agency (FEMA) today immediately brings to mind the response to Hurricane Katrina while all good works that FEMA had performed in the past are forgotten. Thus, beyond the immediate impact on the popula- tion, the Hospital staff, and the Hospital 's ability to function, the impact of a Disaster on the public relations image of the Hospital can be in and of itself disastrous and sustained for a very long term.

9 Standardizing approaches to surge management during disas- ters is the first step in quality improvement. Because Disaster response is an organization-wide process, this improvement has an impact on the entire Hospital . Processes that are dis- covered to be useful in expediting care in a Disaster situation can easily find their way into the day-to-day function of the the Public Health Agency of Canada (PHAC), the Centre organization. If Disaster is defined as an event that outstrips for Excellence in Emergency Preparedness (CEEP) has deve- the organization's ability to deliver health care , preparedness loped such tools and has presented them in multiple forums is a method of vaccination, raising the threshold not only in since 2003. Two proposals to put these interactive tools online Disaster periods but also in normal day-to-day function.

10 Hospi- to have them available to hospitals have been made to the tals that function well prior to an event may have less need to Chemical, Biological, Radiological-Nuclear, and Explosives invoke their Disaster plan to begin with. Research and Technology Initiative (CRTI), but these were not approved. Areas for Review and Training The final reason that hospitals have not assessed their Since 2001, the Centre for Excellence in Emergency readiness is the most understandable. Faced with pressing and Preparedness has been called upon to provide both research immediate issues such as Hospital overcrowding and budget and education on a variety of Disaster topics. Over time, recur- 36. rent themes emerge and their importance is supported by what little research exists in the Canadian context.