Abstract
Background
Disasters—ranging from natural, such as environmental events and pandemics, to accidental and intentional—have significantly increased in recent decades. 1 To effectively care for disaster victims, healthcare systems and providers must prepare for and respond to catastrophic human events while integrating their response into a broader interdisciplinary emergency response system. Hospitalists are at the forefront of disaster response, as hospital medicine expertise is critical in managing the majority of hospitalized patients experiencing both the acute and downstream impacts of disaster, especially from biological pathogens. Indeed, the COVID-19 pandemic highlights the importance of hospital medicine leadership in disaster response throughout all phases of disaster and serves as a catalyst for formalizing the important role of hospital medicine leadership in disaster preparedness and response plans.
Hospital Medicine in Emergency Preparedness
Hospitalists have a fundamental responsibility to proactively prepare for no-notice mass casualty events and be architects to a sustained response to a global pandemic. The defining feature of an “all-hazards” approach is the use of a hospital incident command system (HICS), which creates flexible and scalable responses to meet the needs of disaster response, regardless of the disaster type. 2 Integrating hospitalists into disaster preparedness plans involves training staff on incident command system (ICS) systems, expected hazards, and surge capacity planning.
Staff Training
Integrating hospital medicine into hospital preparedness plans should begin with an understanding of the hospital vulnerability analysis, which assesses the risk of a no-notice event (risk = probability x severity) for planned resource allocation, staff allocation, and drill planning in the event of a potential disaster. 3 Understanding the highest-risk disasters allows for subsequent staff training and surge capacity planning. Depending on regional disaster vulnerabilities, hospital medicine clinicians may need advanced training during disaster drills and “just-in-time” training for specific skills required to manage a new illness or patients needing more advanced critical care or trauma care. The development of high-yield training modules focused on topics such as donning and doffing, chemical injury, radiation injury, trauma, biological threats, psychiatric emergencies, and critical care, would enable hospitalists to join teams caring for disaster victims swiftly and competently.
As staff group sizes increase, however, maintaining readiness for disaster response becomes less feasible. Subspecialization within hospital medicine— as a triagist, medicine consultant, proceduralist, critical care specialist, or biocontainment unit specialist—is already evolving and should be leveraged preemptively to implement disaster response plans effectively. 4 During the initial response phase, preplanned disaster medicine task forces—such as biocontainment teams or surgical comanagement teams—can be rapidly deployed as other team members receive training.2,4 Hospitals frequently localized providers geographically to dedicated COVID-19 units to foster COVID-19-specific expertise among clinicians. 5 This approach to rapid subspecialization could be beneficial across a spectrum of disaster scenarios.
Surge Planning
Hick et al6,7 make consensus recommendations for critical care by identifying conventional, contingency, and crisis standards of care to define a taxonomy of intensive care unit surge capacity based on whether sufficient resources are available to provide conventional hospital care practices. Many hospitals aim to maintain conventional care at 20% above capacity and resort to contingency planning—providing care in nontraditional areas—only if surges exceed 100% above capacity. Infectious pathogens sometimes require that hospitals maintain surge capacity plans for prolonged periods of time. Much of the inpatient surge planning and literature, however, focuses on the use of emergency department and critical care resources. The COVID-19 pandemic saw increasing primary hospital medicine literature on surge planning.8,9 Bowden et al 8 described the critical role of hospitalists in implementing a tiered protocol, thereby increasing bed and staffing capacity by 100%. Altman et al 9 developed on-demand training modules used by 167 ambulatory-based clinicians to prepare for relocation to inpatient medical teams. Such primary hospital medicine research may prove vital to rapidly expand space and staffing during future disasters, enabling hospitals to best maintain functionally equivalent or sufficient care practices during patient surges that require contingency or crisis care planning. This is essential as general medicine inpatient beds generally occupy the most space within hospital systems.
Leveraging the knowledge of hospitalists and frontline workers in regard to medical and staffing needs in particular wards is essential to increase bed capacity and avoid waste. In one team member's experience, expanding the care of medical patients into a previously dedicated psychiatric unit failed to consider the lack of wall outlets for intravenous pumps and oxygen tubing. Kim et al 10 provide an essential list of common equipment and staffing needs for clinician leaders involved in hospital surge planning.
Hospital Medicine in Disaster Response
The management of disaster victims with exposure to infectious agents, as well as radiation and chemical injuries, requires broad expertise. In addition, many victims of natural disasters suffer prolonged hospitalizations 7 and worsening chronic medical problems due to displacement and disrupted care. 11 Hospitalists are well positioned to play an essential and collaborative role—not just in a pandemic setting but also in response to traumatic mass casualty incidents— managing those who are indirectly impacted by disaster due to decompensation of chronic disease. Integrating hospital medicine into efficient disaster response requires knowledge and engagement within HICS, effective reverse triage, effective staffing models, and community partnerships to increase hospital resources and provide safe transitions of care upon discharge to those impacted by disaster (Table).
Table. Roles of Hospital Medicine During COVID-19
Abbreviation: ICU, intensive care unit.
Hospital Incident Command System
Superior working knowledge of command center operations and personnel in various roles of the HICS is a prerequisite for hospitalists to participate actively in disaster preparedness and response plans. Integrating frontline hospital medicine leaders into existing HICS operations hierarchy enables frontline staff to efficiently direct logistics and operations concerns to the appropriate leadership, while maintaining the chain of command essential to a typical ICS structure. As an example of hospital medicine leadership effectiveness in disaster response during the COVID-19 pandemic, Tevis et al 12 founded the physician clinical support supervisor position under the operations branch of HICS. A lead hospitalist in that role ensures that command goals are concordant with hospitalist and other groups' priorities and concerns, serving as a liaison to broker transparent 2-way communication and shared decisionmaking with the incident command staff.
Triage and Patient Flow
Hospitalists have an essential role in improving emergency department and hospital throughput and expanding available units to increase patient capacity during a surge. 2 Hospital medicine involvement with interdisciplinary teams of social workers, care management, and other subspecialties helps facilitate early discharge to alternate care sites that can manage higher-acuity patients. While initial triage determinations often occur prehospital and in the emergency department, reverse triage is where hospital medicine can significantly impact overall hospital flow and capacity.
The term “reverse triage” refers to the expedited discharge of low-risk patients to reallocate hospital resources. 13 Prior research estimates that hospitals can increase bed capacity by 33% to 48% (in community hospitals) by effectively expediting the discharges of lower-acuity patients. 13 At Denver Health, we incorporated a “mass text,” urging all in-house hospitalists to identify patient candidates for expedited discharge during mass casualty incident drills. At some hospitals, hospital medicine clinicians may also staff postdischarge follow-up visits to ensure adequate follow-up for patients needing early hospital discharge.
Other specific examples of hospitalists' involvement in increasing bed capacity include:
Assisting emergency department flow and accurate, rapid triage of nontrauma patients to decompress emergency departments
2
Expanding medical bed capacity to previously nonmedical units through knowledge of patient, equipment, and staff needs Handling medical management of surgical patients during mass trauma
2
Coordinating crisis staffing of the emergency department, step-down units, or intensive care units to improve specialty availability for critically ill patients
14
Staffing postdischarge clinics, alternative care sites,
15
telemedicine, or virtual home hospital visits16,17
Staffing
The movement from response to recovery is fluid, and different medical departments or parts of the community may be in the recovery phase while others are still in the response phase. The COVID-19 pandemic exposed the extreme risk of burnout during a prolonged disaster response. 18 The primary aim of hospitalists within a disaster response is to care for disaster victims; however, lessons learned from COVID-19 also indicate the essential need to prioritize hospital wellness initiatives. The cost of losing hospital-based employees to burnout and preventable mental health crises, and the subsequent need to retrain or rapidly credential new employees, is staggering. The ability of hospital system administrators to retain a list of credentialed clinicians ready to be called into action—including locums or local resources such as physician researchers, volunteers, or retirees—may prove vital to maintaining adequate care in a staffing crisis.
Community Partnerships in Disaster Response
Hospitalists often have clinical, operational, or research relationships and networks within their local and regional communities. Examples of hospital–community partnerships may include those within the regional continuum of care (eg, other area hospitals, urgent care centers, long-term care facilities, pharmacies, home care providers, durable medical equipment vendors, and public health and first responders), as well as with municipal agencies, community and faith-based organizations, homeless service providers, and payers. Leveraging hospitalists' preexisting clinical, operational, or research networks can support and amplify the disaster response within our local communities. The participation of hospitalists on community-wide committees and joint task forces can serve to bridge the hospital and community systems of care and improve awareness and communication regarding emerging threats and available community resources. While leveraging these community partnerships is not unique to hospital medicine, hospitalists' use of such resources to ensure basic patient needs are met during care transitions is essential to transition disaster victims back into the community. Such partnerships may enable effective front- and back-end decompression of the hospital, ensuring that the most critically ill can be managed in the hospital setting while ensuring safe discharge plans for those who are ready for discharge.
Advocates for Equity in Disaster Planning and Response
Disaster disproportionately affects vulnerable populations such as older adults, persons with disabilities, those experiencing chronic medical or psychiatric illness,19,20 and those living in poverty. Disrupted infrastructure affects patient transportation, access to primary care, medications, and other vital services such as dialysis and chemotherapy. 11 Vulnerable populations are also at risk for neglect, abuse, and exploitation during disaster. 19 Those who are older or have disabilities are least able to evacuate during a community disaster response. Unmet needs in the community increase strain on hospital resources as patients present for decompensation of chronic illnesses. 20 As experts in acute and chronic disease management, geriatric care, and the care of vulnerable and marginalized populations, hospitalists play a pivotal role in equitable disaster response by advocating for these unmet needs.
Hospital Medicine in Disaster Recovery
Hospital medicine planning for disaster recovery involves many of the same principles in the initial response planning: fostering collaboration, effective communication with incident command, identifying system failures, resource allocation, and funding allocation as staff and equipment demands change. 21
Specific means for hospital medicine to address hospital and community recovery during disaster include:
Promoting transitions of care by staffing discharge clinics or virtual home hospitals until patients displaced by disaster return to their medical homes 17
Deactivating surge staffing models to normal through work with HICS
Returning emergency department triage and patient flow systems to normal and ensuring the transfer of patients back to units with specific expertise
Advocating for health and hospital policy that mitigates health disparities for those who lost insurance, income, or housing during a disaster
Fostering wellness programs during and after disaster to prevent clinician burnout
Developing quality improvement metrics to evaluate institutional preparedness and response
Restoring functions as they pertain to the hospital's mission: clinical, teaching, and research pillars 21
The National Disaster Recovery Framework, 22 available through the US Federal Emergency Management Agency, advances the concept that recovery extends beyond repairing damaged structures. Recovery requires the restoration of services critical to supporting the physical, emotional, and financial wellbeing of impacted community members. As hospitalists, our role continues beyond defining recovery as a “return to normal hospital operations” and extends to addressing the impact of preexisting health disparities amplified during the disaster to provide better care for the patients in our community.23,24 There is a lack of literature on hospital disaster recovery compared with disaster response and preparedness. However, expertise in transitions of care, quality improvement, patient education, and advocacy makes hospitalists key players in both hospital and community recovery from disaster. It is essential that hospital and hospital medicine recovery plans are initiated in parallel with response plans and built upon existing hospital emergency capabilities, resources, and emergency response plans. 21 Understanding how disaster recovery processes enhance patient care, staff and community wellness, and accurately assess hospital medicine protocols is imperative, as the knowledge gained during disaster recovery forms a foundation for understanding future preparedness needs.
Conclusion
Since the mid-1980s, when the term “disaster medicine” was officially introduced, this specialization has become an intersection of emergency management, emergency medicine, and trauma surgery. Four decades later, we argue that hospital medicine participation in disaster medicine should be indispensable. The active participation of hospitalists in institutional and regional disaster emergency preparedness and response committees is critical to delivering essential patient care during a disaster. Through this participation, hospitalists would become familiar with institutional and regional hazard vulnerabilities and be directly involved in the creation and execution of preparedness and response plans for hospital medicine groups. Such plans and policies will drive an ethical best practice process, guided by emergency preparedness initiatives to prepare hospital personnel and volunteers to serve patients, families, and communities. These plans should align with existing emergency, surgery, and critical care department plans and be transparent and easily accessible to all providers. Once the plans are approved, ensuring their implementation and practice is critical.
Future hospital medicine involvement in all types and phases of disaster management will contribute to a successful and timely hospital management response that aims to decrease morbidity and mortality of victims and improve community and hospitalists' wellness. The ability to effectively prepare for and respond to disaster depends on hospital medicine leadership investment in pursuing quality improvement research and assessment of hospital-based care pathways and policies created during the COVID-19 pandemic to create hospital medicine standards of care during a disaster. During the COVID-19 pandemic, we witnessed the skill and perseverance with which hospitalists stepped in to respond. Perhaps this pandemic will chart the path forward for hospital medicine in disaster preparedness leadership based upon lessons learned from the frontlines by reviewing challenges and strategies, developing broad policies, and planning for the next disaster.