By Peter Kim / Special to Healthcare Facilities Today

More than any other resource, agency, or organization, hospitals and medical clinics play a crucial role in decreasing mortality rates during disasters. Viewed as low probability, high impact scenarios, disasters present significant challenges to medical facilities and personnel, necessitating frequent reviews and revisions to disaster and emergency response plans in order to accommodate urgent and widespread causalities in the wake of a disaster.

Whether faced with disasters of a natural or manmade origin, catastrophic events will strain each medical institution differently. A twister that renders a 30 bed hospital suddenly understaffed and overloaded with patients won’t have the same impact on a facility with 2,000 beds, showing the importance of individualized disaster response plans rather than relying on federal, state, or local oversight to plan and implement fully-formed guidelines.

Three main factors represent common shortcomings for hospitals in times of crisis: hospital staffing shortages and disorganization, limitations in experience and capabilities of first receivers, and lack of available facilities to treat and secure incoming patients. 

Hospital staffing problems

Defined by a lack of surge capacity, general nursing shortages, and fear of inter-operational poaching of staff, the current state of hospital staffing in the face of disasters is worrisome. 

In the wake of the SARS outbreak in Canada in 2003, the Ontario Health Coalition submitted the following as part of its report to the SARS commission: 

"The effect of SARS on the health care system in the greater Toronto area was dramatic. At various times during the outbreak, 3 hospitals were closed. Health care workers were at increased risk and many were quarantined, which resulted in severe staff shortages. On Mar. 28, following the closure of a second hospital, new and intensive infection control directives were issued for all hospitals in the greater Toronto area and surrounding area. At SWC the directives included cancellation of all hospital-based outpatient clinics, significant visitor restrictions, mandatory wearing of surgical masks by all staff at all times (and N95 masks in patient care areas), limited hospital entrance and mandatory screening of everyone entering the building (symptom/exposure questionnaire and temperature reading). Health care workers were instructed to work at 1 health care institution only, and off-work contact between health care workers from different institutions was discouraged. The SWC SARS Management Team met daily to implement Ministry of Health directives, organize care of patients with and without SARS and deal with staffing issues. With clinic and operating room closures and quarantined staff, staff redeployment to screening at entrances and other essential services became necessary. After Apr. 17, staff not involved in patient care no longer had to wear masks; however, most of the other infection control directives were kept in place well into the summer months."

Furthermore, the report found that the psychological challenges presented to hospital staff during epidemics, disasters, and other catastrophic events may lead to staffing shortages due to the psychological impact on workers in these positions. 

Another scenario involving a 2004 tsunami in Banda Aceh, Indonesia describes a failure of hospital officials to properly incentivize and care for their staff during times of distress. The provincial health department in Banda Aceh reported that fewer than 25% of their workers arrived following the tsunami, with more than 150 physicians absent. It is possible that a lack of shelter, food, and medical resources for family members of medical professionals in the aftermath of a disaster in which public infrastructure is crippled may have an impact on the hospital's ability to retain physicians and emotionally prepare them to respond to the crisis. 

Inexperienced first receivers

Not only has the number of qualified, well-trained medical professionals dropped substantially over the last decade, the number of nurses and emergency medical staff has dropped as a whole. Almost 126,000 nursing positions remain unfilled despite increases in nursing school graduates and increased openings at hospitals. This may point to an aging population in the profession whose workforce is retiring faster than it is growing. 

More problematic is the lack of general practitioners in emergency rooms and hospitals, as many physicians are moving their practices to private practices or retiring, let alone the specific training for medical professionals to prepare for disasters and widespread emergency scenarios. A projection by the Association of American Medical Colleges puts the number of GPs at 29,800 below capacity - a number they expect to more than double by 2025. 

Young physicians and medical students preparing for a career in medicine have a markedly reduced interest in general clinical care. A survey of 50,000 medical residents conducted from 2009-2011 concluded that only 21% of respondents showed an interest in general internal medicine over a career in a subspecialty function. 

Strategies to attract medical students to general practices have been varied and largely ineffective, with only slight increases in starting salaries over the last decade and high rates of burnout among general practitioners pushing young physicians to subspecialty practices like oncology, dermatology, and radiology. 

Limitations in emergency medical facilities

The annual report by the American College of Emergency Physicians spells doom for the nation's ability to adequately receive and treat patients in the event of disasters. With emergency room visits rising swiftly, the capability of medical institutions to accommodate a sudden and massive surge drops. Furthermore, 75% of emergency physicians surveyed report that their hospitals do not have the surge capacity to handle an epidemic illness or act of terrorism. 

More than 700 hospitals closed from 1998-2008, leaving 90% of Level One tertiary care hospitals operating at 90% capacity or higher. Studies focused on the response to emergency room surges have found lack of suitable facilities is a major detriment to adequately treating a large influx of patients while offering alternatives to traditional care facilities. Options cited include reopening previously closed hospitals, utilizing large public venues, and deploying temporary fabric structures placed adjacent to physical hospitals. 

Conclusion

As the severity of natural disasters and the risk of catastrophic acts of terrorism continue to grow, hospitals, community organizations, and government departments should move to a more detailed, event-specific approach to disaster preparedness, providing specific goals and resources for medical professionals depending on their region, size of institution, and the nature of the disaster - similar to emergency preparation guides for the general public. Disasters of a natural or manmade origin will not cease or become less impactful as more of the world becomes industrialized, leaving a greater onus on the medical community to respond in kind.

Peter Kim is a community and outreach specialist at BLU-MED Response Systems.