Disaster has been defined in numerous terms. But in essence, disaster is a disruption of function that causes the ability of the affected community to overcome using its resources. Pandemics are considered progressive occurrences with one causal organism, but various reasons for expanding from local infectious outbreak to a global pandemic. Unlike natural disasters, which most often have definitive onset and known number of immediately affected populations, epidemics most often begin sporadically and increase based on the route of transmission, infectivity, and mitigation efforts. This variability can complicate all stages of the disaster cycle ( Fig. 1 ).
All disaster preparedness begins with basic concepts. Chance of the hazard or event happening to an area and the vulnerability of that community in the event of that event. This is termed the hazard vulnerability analysis (HVA). Novel infectious outbreaks such as coronavirus disease 2019 (COVID-19) are difficult because transmission, at-risk population, natural history, and effective public health policies are unclear early in the course. This leads to short or even nonexistent time to do an HVA. Before COVID-19, the 2019 U.S. National Health Security Preparedness Index, which assesses the ability to provide health care during large-scale public health threats, reported a significant gap in the U.S. health-care system to maintain quality health care during and after such an event. This chapter gives the authors’ perspective of how our systems approach disaster planning to the COVID-19 pandemic. Both health systems have multiple hospitals that overlap in Pennsylvania, which experienced a surge of COVID-19 patients early in the United States. The University of Pittsburgh Medical Center (UPMC) is urban based, while Geisinger Medical Center is rural based. Both systems’ hospitals and their communities are historically interconnected.
Proper preparation, resource allocation, and education contribute to variability and disaster response. Several studies from natural disasters show that resiliency and collaboration can support recovery efforts for communities. Some communities face unique challenges such as rural locations with geographic variability, funding, coordination, and cooperation among local networks. The capacity and capability of a community and health system to respond to emergencies determine preparedness. Capacity is defined as having enough personnel and supplies, while capability has the correct resources. Appropriate and timely resource allocation and mobilization are essential steps to ensure preparedness. Unlike natural disasters, epidemics can be prolonged and put extreme pressure on the health systems making mitigation or “flattening the curve” paramount to maintaining capacity and capability.
From prior disaster research and recent COVID-19 experience, several themes emerge. There is extensive variability across the national, local, and organizational levels in addressing preparedness policies. Despite this variability, there is a clear need for essential aspects of preparedness, including assessing resources (stuff/space), training for providers (staff), and increased communication/collaboration across networks/programs. The inadequate response, failure to triage, and lapses in communication are common systemic barriers to significant incidents.
The initial assessment must also include the identification of all stakeholders. The stakeholders include the community, the health-care system, and the local/state/national networks. Each stakeholder group has systemic and organizational structures established to aid in disaster response. In the community, this includes federal, state, and local governments and the community residents.
Community
The community requires information and education about their role in preparation and response. Public health networks and the existing health-care system strive to work in concert to orchestrate disaster response. The success of a coordinated response and action plan is dependent on the strength and stability of the existing networks. Information and education are essential for the community to participate in their protection. Infection control and public health initiatives need to be accurate and timely communicated. Dissemination of precise information must include national and local health-care efforts to support public health. Additional measures by local government and primary care providers can help the community.
Geisinger has a robust connection with the community, given the population that it serves. Through social media and other public forums, Geisinger engages the community. Their participation through public health initiatives, such as universal mitigation strategies, and following local visiting policies are essential to combat surge. Geisinger leadership held community town halls throughout the pandemic to engage the public. Additional challenges to community preparedness are the dissemination of accurate and timely information. During an election year, the political climate can affect the tenor and quality of information that reaches the community. Public health initiatives should strike a neutral tone and be rooted in evidence and science. In the end, the public depends on its health-care system and the institution’s preparations.
Health care
Stuff
Health-care preparedness is the analysis and preparation of what is required and anticipated opportunities to plan. Disaster planning includes mobilization of necessary resources. The effective systemic response must have a coordinated and collaborative model to expect future surge. The importance of recognizing the current state versus the predicted future state is essential. Pandemic preparation at our institutions was a multipronged approach. The capability of our existing network to flex and respond requires the understanding of the supply chain and the available resources.
Resources and the delivery of care to patients demand accuracy. Supplies such as equipment, oxygen, and medications must be available as an alternative solution. The disruption of the supply chain during a disaster period also needs to be anticipated. Each department assessed current supplies and leadership focused on policies and procedures to implement throughout the network. For example, our existing triage policy was reviewed and updated by a multidisciplinary team of critical care leadership, physicians, and medical ethicists. Past analysis of disaster preparedness helps inform and prioritize activities that maximize a hospital’s capability to respond.
Health-care delivery and estimates for surge capacity are required. Models exist to assist officials both nationally and locally for surge planning tools (PACER). Strategies to improve capacity such as (1) opening unlicensed beds, (2) canceling elective admissions, and (3) implementing reverse triage were all used simultaneously in preparation for the pandemic surge. At the network level, daily communication and collaboration supported our response to meet current needs for intensive care unit (ICU) level of care.
Staff
In the Society of Critical Care Medicine’s ICU Readiness Report to evaluate the state of ICU preparedness during the height of the COVID-19 pandemic in March 2020, 82% of respondents reported ICU shortages and bed capacity and 58% reported issues with adequate ICU staffing. Proactive planning for ICU staffing augmentation is paramount to the successful response to a local surge in ICU and critical care patient volumes. Each hospital system must design a system which caters to their personnel needs in terms of physicians, advanced practice providers (APPs), and nursing staff, among others. There will be an array of capabilities based on preexisting personnel, but plans should incorporate contingency plans to add additional personnel who are either present in the hospital working in different roles or with the use of outside personnel via ICU telemedicine. Institutions must have a framework to plan for increased capacity with the proportional expansion of staff and stuff. A framework was recently published, suggesting a tiered/graded system provides adequate staffing structure to respond. The local surge planning involves unit closures and redeployment of employees.
UPMC is a 40-hospital system ranging from rural to tertiary/quaternary academic centers in Pennsylvania, New York, and Western Maryland. They designed and rolled out a system-level ICU pandemic surge staffing algorithmic plan for implementation when “normal” ICU resources were exhausted and the potential for 100%–200% surge increase in patient volume occurs (reference). The plan was developed to ensure that local needs were balanced with system resource supply. A tiered-provider strategy was used by the hospitals to allow for adequate ICU and critical care coverage by physicians and nurses who had some experience in managing acutely ill patients. The first step in designing any staffing plan is to ascertain what were the existing staffing and then determine how this could be augmented with additional providers including tele-ICU medicine capabilities. UPMC used a tiered staffing algorithm designating “Tier 1” providers as critical care providers including telemedicine critical care providers. “Tier 2” providers were identified as those physicians with prior/remote critical care training, experience and skills, other airway capable providers (e.g., certified registered nurse anesthetists), and those who were non-airway providers but were ICU-capable providers (e.g., APPs). A “flex” tier, if available, could be a separate procedure team specifically for intubations, bronchoscopies, central and arterial lines, prone positioning, etc. This flex team could free up procedural time for those critical providers in the ICU and on the ward to focus on clinical management. In Fig. 2 , the tiered staffing strategy shows how critical care including mechanical ventilator management be administered to four groups of 24 patients with a team managed by a critical care-trained physician. In Fig. 3 , a more detailed outline is presented for the progression from Tier 1 to Tier 3 providers with the possible additional of tele-ICU support as well as the additional of a potential procedural team.
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