When a plane crashes or storm rages, most state and local governments have the infrastructure and planning in place to handle an uptick in needed emergency care. But what about a really big disaster, something on the scale of, say, the Haiti earthquake, the Japan tsunami or another 9/11? Or what if a virus like H1N1 suddenly morphs into a truly murderous disease on the scale of the 1918 flu pandemic? Would your state or town be able to handle the potentially enormous surge of sick or injured?
Probably not, says the Institute of Medicine (IOM). On the state and local levels, catastrophic disaster preparedness is "rudimentary at best," the IOM believes. To help rectify that, the group recently released a report titled Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Sponsored by the U.S. Department of Health and Human Services, U.S. Department of Transportation and U.S. Department of Veterans Affairs, it's an expansion of a similar report issued in 2009, which was hustled out to meet the then-growing concern of a serious H1N1 pandemic that, thankfully, did not reach the level of catastrophe. That time.
"We wanted to incorporate things we could now see in the rearview mirror: H1N1, Haiti, Japan, the Joplin tornadoes. We now had a number of events to study, and each informed and refined our thinking about the best way to move forward," says Dr. Umair A. Shah, M.D., MPH, who is deputy director of public health in Harris County, Texas, and member of the IOM committee that reviews care standards during disasters.
The first study laid out the theory regarding emergency medical response. In this updated version, the authors applied theory to practice.
The theory included developing and implementing crisis standards of care, outlining how the various players should operate in disasters that strain medical capacity and resources. The practice part includes recommendations for creating a systems-based approach to allocating those resources and delivering care during an overwhelming crisis.
On top of guidelines, the report includes tools and templates to help different stakeholders (hospitals and outpatient clinics, public health departments, the emergency medical system, public safety agencies and government offices) identify core functions and responsibilities, and create a working plan that integrates each entity's role seamlessly with the others.
"We created about nine different reports within one report," Shah says. "You can go cover to cover if you want, or you can pick out the module specific to your discipline. We designed it to be practical and user-friendly."
The report stresses the need to include the ultimate end-users -- the general public -- in emergency planning, and provides a model for authorities to use to hold public sessions on crisis planning and disaster response. That's essential, says Shah, to help the public understand why standards of care could change in a disaster, how these standards will be applied, and how legal and regulatory issues may need to adapt in a crisis.
"We held two public sessions, one in Boston and one in Lawrence, Mass., and talked about scenarios such as an earthquake and a deadly virus," he says. "We asked the public what values should be incorporated in decision-making. Should police officers get care before teachers? Should the young be treated before the old? What about palliative care? Who gets the resources first?"
"We were looking for the underlying values that the members of the community felt should be included. There was a lot of resonance with lay people, who we don't give nearly enough credit for getting this stuff."
The ultimate goal for the IOM committee, Shah says, was to make the new report "useful in the field, and not just sit on a shelf. We want state and local governments to realize a lot of work has been done since 2009. This report will really lay the foundation for planning and application."
Planning needs to begin now, he says, because once a disaster happens, it's impossible to retrofit. The IOM committee noted that only a few communities currently have the level of integration necessary to care for an overwhelming number of victims. All levels of government, it says, should begin taking action to ensure a consistent and coordinated approach among those entrusted with emergency response.
"This is not for just an unusually busy Saturday night in the ER, where you know Sunday morning is coming," Shah warns. "This is for a sustained and overwhelming response, where Sunday morning doesn't come for months or perhaps years."
Copies of Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response are available from the National Academies Press. Call 202-334-3313 or 1-800-624-6242 or find it online at www.nap.edu. Additional information is available at www.iom.edu.
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