The Role of Hospital Medicine in Emergency Preparedness: A Framework for Hospitalist Leadership in Disaster Preparedness, Response, and Recovery
Recent high-profile mass casualty events illustrate the unique challenges that such occurrences pose to normal hospital operations. These events create patient surges that overwhelm hospital resources, space, and staff. However, in most healthcare systems, hospitalists currently show no integration within emergency planning or incident response. This review aims to provide hospitalists with an overview of disaster management principles so that they can engage their hospitals’ disaster management system with a working fluency in emergency management and the incident command system. This review also proposes a framework for hospitalist involvement in preparation, response, and coordination during periods of crisis.
© 2018 Society of Hospital Medicine
Recent events, domestically and globally, have highlighted the numerous complex challenges that disasters and mass casualty incidents (MCIs) impose on hospitals. Mass casualty events result from natural phenomena (eg, hurricanes, tornadoes, and wildfires), accidents (eg, plane crashes, building collapses, and toxic waste spills), or man-made crises (eg, terrorism).1-4 These events feature the potential to cause an acute surge of patients, which can overwhelm available hospital resources and personnel. Mass effect incidents are sustained crises, which often occur due to loss of infrastructure, epidemic infectious diseases, or need for hospital evacuations, and can completely overtax local and regional resources, thus requiring federal and state coordination.5
Hospital disaster response plans have traditionally centered on responses by the emergency department (ED) and associated surgical services to mass trauma-type events, without commensurate involvement of other hospital departments in either incident management operations or the planning process for mass effect incidents.6,7 In particular, the role of hospitalists in the leadership structure of various hospital disaster command structures remains undefined.8 However, recent disasters suggest that hospitalist involvement will highly benefit hospital emergency preparedness.9 Hospitalists possess specialized expertise in patient triage and disposition; medical comanagement with surgical services; coordination of complex medical care (usually with continuous 24/7 in-house coverage); integration with the full spectrum of affiliated services, such as case management or patient rehabilitation; and quality improvement research.10-12 At our institution, hospitalists are involved in the direct care of over 60% of the patients admitted across all medical and surgical services. Thus, we believe that hospitalists are uniquely qualified to offer leadership in disaster preparation, response, and recovery if integrated into hospitals’ incident command architectures. For example, although numerous acute patient surges are due to trauma MCIs, hospitalists may nevertheless act as the primary care providers in disasters that are medical in nature or that require rapid hospital evacuation and patient transfer (Table 1).
Although truly large-scale disasters are uncommon, several recent incidents exemplify scenarios with remarkably extreme acute patient surges (defined as >20% of normal patient volumes), which completely overwhelm a hospital’s capacity to maintain normal operations and require response from all available medical personnel, ideally in a preplanned and organized manner.13 The Las Vegas shooting on October 1, 2017, for example, resulted in 546 trauma victims, inundating two local hospitals and one regional facility.14,15 In another case, the deadliest tornado in modern US history struck Joplin, Missouri on May 22, 2011, destroying one of the two hospitals in the city and leaving an estimated 1,371 people injured, many of whom were presented to the one remaining area hospital.16 One of our team members (J.P.), a storm chaser from out-of-town, reported to the remaining functioning hospital and oversaw an impromptu hospital unit that received patients from the damaged hospital, ultimately caring for approximately 40 patients with a combination of medical and surgical issues from presentation through eventual disposition or transfer to outlying hospitals.17 Such incidents illustrate that during trauma events, hospitalists play critical roles for continuity of care for hospitalized disaster victims.
Therefore, we propose a means for incorporating hospitalists into the coordinated hospital disaster response effort, first by providing hospitalists with an overview of disaster management principles to allow their engagement with hospitals’ disaster management system with working fluency and second, by proposing a framework for hospitalist involvement in hospital emergency response. These recommendations stem from our experience and from similar recommendations from a number of evidence-based articles on intensive care medicine, disaster preparedness, and emergency medicine literature cited in this article. To our knowledge, no evidence-based literature discusses hospital medicine or internal medicine specific to emergency preparedness. We aim to change such condition with this article.
