By Dr.Daniel Kollek and Carl Jarvis
Seven years ago I was asked to write an article for a hospital management magazine on disaster preparedness. The question was: “Are we ready?” Now, while preparing this review, I thought it might be appropriate to see how things have changed since. Unfortunately, problems still remain. I may have been saved some re-writing, but my preference would have been to tell you a different story.
It would be unfair to say there’s been no effort or improvement since 2010; there have been changes. New hospital builds now incorporate de-contamination into some of their emergency departments: large gatherings such as Toronto’s G20 served as a springboard to improve hospital readiness: some cities such as Montréal – driven by dedicated local leadership – conducted more frequent disaster exercises: and disaster content is showing up more frequently at ”mainstream” conferences. Leading major centres (including Ottawa and McGill University hospitals), are changing their corporate emergency preparedness structure to a clinical-administrative dyad model to help bridge the gap between those with clinical and those with organizational skills (more on this divide later). That said, the core issues remain unchanged. Hospitals are not performing formal risk assessments and disaster plans are not reviewed and measured against formal standards. Where functional hospital disaster plans do exist, they’re rarely exercised, with poor integration between hospitals and pre-hospital/ disaster site response.
So what’s impeding change?
The recurrent theme remains that when one is further away from the actual delivery of disaster care, the better prepared the system is perceived to be. The discrepancy of readiness perception between high and mid-level administration and frontline caregivers stems from a variety of reasons. The simplest explanation is the gap in training and expertise (and in some situations actual physical distance) between the administrator and the individuals mandated to deliver disaster-setting care.
As a striking example of this, in 2010, the Canadian Association of Emergency Physicians contacted provincial health ministers across the country to voice concern about the healthcare system’s ability to respond to disaster. Uniformly, the provincial health ministers who responded (8 of 10) stated that their provinces were prepared. This despite any scientific data to support their opinion.
Unfortunately, the reality at the front lines is not so rosy. Front- line providers have repeatedly expressed serious concerns about the ability of healthcare systems, and specifically healthcare facilities, to respond in a disaster. Staff are inadequately trained, despite the existence of competency lists and curricula. U.S. data show a wide variability between regions and facilities. Canadian data, while limited for reasons that will be expanded on further, also show there are both regional and topic specific areas of strengths and weaknesses for specific types of events.
One reason for this lack of preparedness is the perception that attacks such as those in London, Manchester, Paris, Brussels and Nice will never happen here. There is no basis for this belief, even if it were true. From the receiving hospital’s viewpoint, it doesn’t matter whether the patient’s injury was the result of a malicious terror attack or an accident. Claiming a low terror risk is no protection from other accidents and, even if it were, Canada is not at particularly lower risk than other western nations.
Disasters do strike. The question is not “if and why” but “when and where”. A Wikipedia search, for example, will reveal that in 2016 alone, there were 61 significant train derailments globally, of which 13 were in North America. The chances of someone being involved in an accident are far higher than a terror event, so the argument that terror events are uncommon provides no justification for lack of readiness for mass casualties.
Another oft-quoted reason for not having a disaster assessment tool is that disasters are so variable that it’s impossible to test our readiness for them.
While it’s true that disasters may vary, the general response to disasters is uniform and is frequently termed “all hazards” preparedness. Since, at least in general terms, we know the response we need to deliver, we can develop protocols and test our ability to do so. For example, Israeli hospitals – likely the world leaders in preparedness for dealing with disasters – have developed standard operating procedures that facilitate the management of mass casualty incidents. This is as applicable to a bus crash as to a less likely terror event (more on this later). Since there are standards against which to measure performance, it is possible to define what constitutes an organized response to a disaster and equally possible to develop an ongoing process of quality improvement.
Incidentally, the statement that there’s a large variability in potential disasters leads one to ask why hospitals don’t routinely perform risk assessment to determine which disasters may befall them. Currently, there is no evidence that any formal risk assessment tool has been deployed across hospitals in Canada.
It doesn’t help that, particularly in healthcare, disaster preparedness is an “orphan” entity. Healthcare professionals have extremely limited training in disaster preparedness: disaster management experts have almost no expertise in healthcare, and there is no overarching authority able to bridge the gap between the two. This diffusion of responsibility exists at all levels, but reaches an extreme at the federal level. The Minister of Public Safety has the expertise and tools for disaster response, while the Ministry of Health has significant knowledge of health care issues at its disposal, yet both lack each other’s proficiency..
Political considerations are another possible reason we’re ill equipped. So far as previous Federal administrations are concerned, disaster preparedness isn’t a voter “hot button” issue and therefore receives limited support from elected officials. Further, the federal-provincial divide on healthcare issues is problematic. Front-line delivery is a provincial mandate, and this makes it difficult for federal agencies such as the Public Health Agency of Canada (PHAC), to effect change at the provincial level despite very significant effort, much goodwill and solid expertise on their part,.
The final reason high-level healthcare leadership thinks we’re ready for disasters is that nobody has actually checked. There has been no formal, replicable and evidence-based assessment of disaster preparedness at healthcare facilities in Canada . If we do not measure our inabilities, we will not be able to remedy them. This underpins all other problems.
This is despite the fact Canadian tools do exist for both risk and readiness assessment. With support from the PHAC, The Centre for Excellence in Emergency Preparedness (CEEP) has developed and presented such tools in multiple forums since 2003. These were even offered free of charge to Accreditation Canada, a for-profit company that sells its product (certification) to hospitals and systems that choose to participate. Accreditation Canada develops their checklists, with standards they themselves derive, based on a general agreement between their clients (hospitals) and Accreditation’s opinion of which systems are needed to meet a target goal. The company has no evidence based clinical standard of preparedness for Mass Casualty Incident (MCI) events and they declined the offer of an outside tool. As a result, a Canadian hospital can be accredited without any in-depth disaster-readiness.
Why the reluctance to formally and scientifically assess hospitals for disaster preparedness? The obvious (never-voiced) risk is, should a deficiency be found, deniability is no longer plausible – and resources would be needed to repair the gaps. An additional argument for the lack of formal disaster readiness assessment is the lack of a standard of care. Canada has no national clinical standards for emergency preparedness. This was the unfortunate conclusion of a 2013 conference in Ottawa sponsored by PHAC, and the situation hasn’t changed since.
It’s true that there are regulatory and accreditation standards (as mentioned above). There are also occupational health standards, and, for some specific scenarios, clinical best practices. Disasters however, despite the fact that they cause morbidity and mortality like any other disease, are the only clinical scenario with no guidelines. As a result the argument is made that, because there are no guidelines, we cannot prepare adequately. This is circular logic. Until we start developing and testing plans as well as measuring outcomes of events and exercises, we’ll never know what works in our system, never develop guidelines and never learn what we should aspire to.
In the meantime, rather than bemoan a lack of Canadian disaster response standards, we should be learning from other countries. Through the offices of American friends of MDA (the Israeli pre-hospital system), Israel offers annual courses on how to prepare the hospital and pre-hospital system for disaster. Closer to home, the rapid intake of patients at Boston hospitals during the 2013 marathon bombing, the almost immediate mobilization of 60 ambulances in Manchester to the Ariana Grande attack this year, or the rapid deployment of outreach care during the attacks in Paris recently provide further examples of how this can be done – and done well. In an interview with CMAJ (Canadian Medical Association Journal) Dr. Ron Walls, Chief of Emergency at Boston’s Brigham and Women’s Hospital is quoted as saying:
“We had drilled this exact scenario, this idea of having a bomb going off in a mass gathering in town. Nobody is ever prepared for this, but we were prepared. I would just suggest to people that if they think these drills are silly or unnecessary or that this can’t happen — it can happen.”
Canadian hospitals need to learn from these examples, develop adequate plans and, above all, exercise their response. There’s no substitute for real world practice. In the United States, disaster-readiness is tied to Federal funding so an unprepared hospital suffers a financial impact. No such legislation exists in this country.
The situation is even worse when considering events with contamination. Occupational health standards do exist for staff caring for patients in hazardous materials (hazmat) situations. At the very least, staff are not supposed to put themselves in harm’s way when safety measures (equipment, training, and drills) could reasonably be undertaken to keep them safe. We have to recognize that the lack of preparedness for contaminated casualties is a choice some hospitals have made. Many hospitals are so far below that basic level of due diligence that the only safe option for nurses and physicians confronted with a contaminated casualty would be to stand by and wait for a hazmat team to arrive. Indeed while some Canadian hospitals have undertaken innovative programs to train their staff in managing such casualties others have chosen to contract out their decontamination,
The final reason hospitals have not assessed their readiness is the most understandable. Faced with pressing and immediate issues, including hospital overcrowding and budget management, potential problems such as disasters are seen as deferrable concerns. The irony is that, with our alternate level of care (ALC) statistics, our blocked emergency departments and overwhelmed pre-hospital services, the disaster is upon us already.
We are blinded to it because it arrived with a whimper, not a bang.
Even more ironic is the fact that good disaster preparedness may prove helpful in dealing with overcrowding. Because disaster response is an organization-wide process, its improvement has an impact on the entire hospital. If disaster is defined as an event that outstrips the organization’s ability to deliver healthcare, preparedness is a method of “vaccination”. Processes discovered to be useful in expediting care in a disaster situation raise the threshold not only under these conditions, but can easily find their way into the general day-to-day function of the organization. Hospitals that function well prior to an event may have even less need to invoke their disaster plan to begin with.
Beyond the morbidity and mortality that disasters can engender, these events pose another risk to healthcare facilities and systems. High-profile lack of preparedness puts hospitals at risk for both reputational damage and lawsuits. In today’s 24/7-news-cycle-mobile-phone-video world, disasters and the response to them are very visible to the public. An organization that responds poorly to a severe event can tarnish its reputation for an extremely long period of time. Any mention of the Federal [U.S.] Emergency Management Agency (FEMA) today immediately brings to mind their mismanaged response to Hurricane Katrina, while all the good works FEMA performed in the past are forgotten.
Preparing for disasters is a daunting task. Topics to cover can include risk and hazard vulnerability analysis: general readiness assessment and mitigation: incident management systems and communication: triage: hospital emergency surge capacity: integration of volunteers into the disaster response: caring for populations at-risk (specifically pediatrics, geriatrics and mental health): integrating hospital response with pre-hospital care and external support (such as disaster medical assistance teams): and medico-legal issues. We can draw some comfort from the fact that much of this material already exists in the literature and that Canada has experts who can deliver education and assessment on these topics.
It’s incumbent on hospitals to take the initiative on disaster preparedness, as this issue falls between the cracks of the healthcare and public safety systems. It lacks clear ownership and is often forgotten or deferred in the presence of more visible and pressing topics, such as hospital overcrowding and budget crunches
The first two steps are for hospitals to perform formal risk and readiness assessments. Once these are completed, the task of remedying identified gaps, planning for the high-impact or high-probability risks, and conducting drills will be far more manageable. Until these assessments are undertaken, plans developed and exercises practiced, we are all at risk of being found unprepared when the disaster – whatever it may be – strikes.
Dr. Daniel Kollek is an Emergency Physician, Director of the Centre For Excellence in Emergency Preparedness and Associate Professor at McMaster University in Hamilton Ontario. Dr. Carl Jarvis is an emergency physician in Halifax NS, and is the medical director for emergency preparedness at EHS (the provincial EMS system).
Further information on the Centre for Excellence in Emergency Preparedness can be obtained at www.ceep.ca or by contacting admin@ceep.ca.