EXECUTIVE SUMMARY

The COVID-19 pandemic and other recent crises have shown the need for improved disaster planning.

  • Disaster plans should be clear, well-defined, and ready to implement before a crisis even strikes. This includes preparation for surge, triage, and crisis standards of care as well as skills training for case managers and other health professionals.
  • The pandemic bears many similarities to the 2017-2018 influenza epidemic in terms of preparedness and strain.
  • Case managers play a critical role in care transitions during these crises and should create a well-defined plan for patient transitions.

The ongoing COVID-19 pandemic has shed light on hospitals’ and communities’ insufficient disaster preparedness plans. Researchers and healthcare professionals say hospitals need to take more concrete steps to better handle the next crisis, whether it is a hurricane, explosion, wildfire, flood — or another pandemic.

“We know that emergency preparedness is absolutely essential for healthcare organizations,” says Paul D. Biddinger, MD, FACEP, chief preparedness and continuity officer at Mass General Brigham and vice chair for emergency preparedness at Massachusetts General Hospital. “Obviously, with what we’ve seen in the pandemic, but also with hurricanes like Sandy or Katrina, or in other events, we have to be able to surge our ability to provide care in the time of crisis. That’s really hard in a healthcare system that’s always being pushed for maximum efficiency and to eliminate waste.”

For instance, there is no waste in a system maximizing all resources. “From my perspective as an emergency medical planner, that means we have no ability to surge,” he adds.

Since it is not feasible to employ physicians and nurses on the payroll when they are not providing care, or to oversee empty hospital beds when a disaster has not occurred, hospitals need to assess how to deploy their resources and pivot in times of crisis, Biddinger says. This will help hospitals better handle a disaster without adversely affecting patient care.

Hospitals, as well as individual departments such as case management, should create a disaster playbook, says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management nursing at Cleveland Clinic.

Now that every case management department has experienced a national disaster (the COVID-19 pandemic), they understand what skills they need to prepare for the next event, she notes. (See story on case management best practices for disaster preparedness in this issue.)

“Everyone had to learn so much on the fly that no one was prepared for,” Davis says. “Ironically, at the height of the pandemic, case managers in the hospitals were not that busy because patients weren’t coming, and the patients who came in were sick and taking a long time to be discharged.”

The lull in activity did not last long, as some hospitals furloughed staff or case managers and other professionals to COVID-19 units or ICUs. Before long, nearly every hospital in the country experienced a surge in COVID-19 patients.

“It’s now a double whammy because people have resigned or are taking time off,” Davis says. “Our patient activity is increased, so there is stress there.”

Case management leaders need to think about how to best use their available staff and what kinds of skills their case managers need during a disaster. “All of our case managers during the pandemic were retrained to be nurses again, and that in itself was stressful,” Davis adds. “Even though they were never asked to do anything out of their comfort level, it was still stressful.”

The disaster preparedness lessons that emerged during the pandemic were apparent during an earlier flu epidemic, but health systems did not pay enough attention to that crisis, according to the results of a study about the 2017-2018 influenza season.1

“We had actually completed the research prior to the pandemic emerging. But as we were doing the data analysis and writing of the study, which happened during the pandemic, we noted very eerie echoes,” says Gavin H. Harris, MD, assistant professor in the divisions of pulmonary, allergy, and critical care medicine and professor of medicine in the division of infectious diseases at Emory University School of Medicine.

Harris and colleagues read about the problems their research subjects faced with how hospital systems handled the earlier flu crises. They could see the same problems were happening in real time with the COVID-19 crisis.

“We were very interested in how hospitals respond to strain in general. We used the lens of pandemic strain as a good way to analyze the capacity of hospital administration and personnel to see how they might respond,” Harris says.

For example, staffing was strained in terms of how hospitals worked around employee sick call-ins, overtime, and other issues that affect delivery of care.

“The 2017-2018 flu season was the largest epidemic this country had experienced since the H1N1 flu epidemic of 2009,” Harris explains.1

Disasters disrupt daily work and leisure routines for hospital staff responding to the crisis. But this disruption usually is limited and everyone expects to return to those routines within weeks or months.

This did not happen with COVID-19. “The world went from its day-to-day grind to derailment,” says Wyona Freysteinson, PhD, MN, professor of nursing at Nelda C. Stark College of Nursing at Texas Woman’s University. “The world in which nurses had been in dissipated with COVID-19. They had gut-wrenching fear after [watching] newscast videos. They found themselves cooped up in front of computers or in a COVID unit, which was opened without a budget.”

Nurses and other healthcare professionals learned to ration personal protective equipment, which was both infuriating and terrifying, Freysteinson adds.

Disasters can be slow-moving, like the COVID-19 pandemic, or fast-moving, like a large-scale earthquake. The fast-moving disasters do not give a hospital time to prepare staff for emergency conditions, Biddinger notes. With slow-moving disasters, it sometimes is possible to redeploy staff after providing some training for their new role. In the event of a fast-moving crisis, this is not possible.

In some crises, there is no time to train staff before redeploying them, or to create more units to handle the influx of patients, Biddinger adds.

One challenge for hospitals is that people are surviving massively destructive events like never before2, says Michel D. Landry, BScPT, PhD, MBA, aid worker with the World Health Organization and professor in the department of orthopaedic surgery at Duke University.

“We have to start thinking about what happens to people after they survive emergencies,” Landry says. “This is true in COVID-19. We have a whole lot of people who survived with very traumatic, rehabilitation-sensitive conditions.”

Case managers play a crucial role in helping patients transition to rehabilitation and other care after discharge. “We have to have a community-engaged process,” Landry says. “Hospitals have to use the transition of care — a very clear, well-defined process — to transition people.”

Case managers should develop a plan to execute these transitions during a disaster. The worst time to plan for an emergency is when it is happening, Landry adds.

One striking study, which was conducted before COVID-19, showed most physicians and nurse practitioners surveyed said their facilities were unprepared for a recent crisis or disaster.3 For instance, some practitioners included in the study experienced the Boston Marathon bombing crisis as well as a storm disaster around that time, says Karen Donelan, ScD, EdM, Stuart Altman professor and chair of U.S. health policy at Brandeis University and senior scientist at Massachusetts General Hospital.

“One of the things they said after the bombing was that the team they had established in trauma rooms really helped the city cope with that mass casualty,” Donelan says. “We thought that we should ask people around the country if they felt like they were in a team, and if that team was ready for a disaster.”

Researchers also assessed whether teamwork led to better outcomes for patients as well as better safety and coordination. “We saw that people who felt they were working well in a team were more prepared for disaster scenarios,” Donelan says.

Teamwork also is needed between hospitals, emergency services, local governments, and other community entities.

Coordinated efforts between multidisciplinary agencies can strengthen communities’ capacities to respond to mental health and other health needs during a disaster, according to the authors of another recent study.4

“Case managers and others can play an important role in the coordination,” says Aram Dobalian, PhD, JD, MPH, professor and director in the division of health systems management and policy at the University of Memphis. “A lot of the disaster planning focuses on the acute triage needs, particularly in an inpatient hospital setting. Part of this is how do we handle surge capacity, how do we triage patients, and how do we establish crisis standards of care.”

REFERENCES

  1. Harris GH, Rak KJ, Kahn JM, et al. U.S. hospital capacity managers’ experiences and concerns regarding preparedness for seasonal influenza and influenza-like illness. JAMA Netw Open 2021;4:e212382.
  2. Landry MD, Jesus TS, Battle K, et al. Catastrophic sudden-onset disasters are followed by a surge in rehabilitation demand. Arch Phys Med Rehab 2021;102:1031-1033.
  3. Donelan K, DesRoches CM, Guzikowski S, et al. Physician and nurse practitioner roles in emergency, trauma, critical, and intensive care. Nurs Outl 2020;68:591-600.
  4. Wyte-Lake T, Schmitz S, Kornegay RJ, et al. Three case studies of community behavioral health support from the U.S. Department of Veteran’s Affairs after disasters. BMC Public Health 2021;21:639.