The Rationale for a Pessimistic Preparedness Planning Scenario

Imagine for a moment being the quarterback of a football team. There is a big game coming up, but it does not appear on any schedule. Information about the game will be provided at the time of the opening kickoff.  In addition, a game plan must be written without prior knowledge of the opposing team or the identity of its players – but the plan still must conform to the league’s game-plan format and be kept in a large binder in an office where it is all but inaccessible to the players.

The players themselves are a rather large group of individually capable professionals, only some of whom will play in the game but all of whom are required to practice their skills separately. Some do, and some do not. In the best-case situation possible, the receivers run pass routes but do not catch passes; defensive players tackle dummies, but not live running backs. The players may or may not like or even know one another, and no one reviews the game plan until they are on the field. Nevertheless, on the day of the game the players get together in a massive huddle after the kickoff and get their first look at the game plan. A play is then called and the game finally starts in earnest.

One more problem to cope with: If anyone on the team should fumble, miss a tackle, throw an interception, or simply not show up in good physical condition the misplays and mental errors will be televised and there may be fines imposed by the league and/or liabilities imposed against the individual players for their poor performance.

The Dangerous Effects of Casual Afterthoughts

Such is the challenge facing today’s medical-response disaster planner. For various reasons, medical disaster planning is generally an afterthought in a clinical emergency department. For that reason, among others, a relatively junior member of the medical staff is often assigned to write the plan. Lacking both the experience and qualifications needed, the writer of the plan often has no recourse, therefore, but to take previous plans and adapt or amend them to meet current disaster concerns. There are several obvious problems with this approach, most of which fall into several familiar categories: 

  • One size does not fit all: Although the “all hazards” general model used in disaster planning is useful and reasonably effective for communications and command systems, it breaks down in the intricacies of medical responses. No one would want all-hazards surgery perpetrated on himself or herself after suffering an injury. The ability to tailor medical responses to a particular situation is limited by writing a single all-purpose response plan that does not address the specific medical needs of individual patients suffering from any of a broad spectrum of possible injuries. Medical systems probably should develop at least three different types of disaster plans, therefore – namely, a trauma plan, a HAZMAT response plan, and a communicable disease plan. 
  • The failure of translation:  Once an alteration to a plan is made, all those who operated on the old plan must be updated and retrained on the new plan.  For disaster plans in print that are kept at multiple locations, this requirement translates into a matter of constant upkeep. For disaster responses that exist primarily (or exclusively) in the minds of the operating professionals, the retraining is still required. In either case, alterations or changes in the plan are both difficult to disseminate and expensive to carry out.
  • The failure of optimism: Some but not all planners are guilty of planning a “best day” response in which the individual “players” involved can instantaneously extricate themselves from their pre-existing duties and responsibilities and show up at the disaster site properly equipped and briefed.  At present, there is very little guidance of any type for medical professionals to follow who are required to transition from the “chaos” phase of disaster response – in which little or nothing is known about the size and scope of the problem – to an orderly and more effective phase of the response effort. Here there is an obvious medical example that serves as a helpful microcosm of the overall problem: Because the staffing of a hospital is different, both in size and in quality, at different times of the day, the assumptions made by an optimistic planner open some major and glaring gaps during off-peak staffing hours.  

The failure of the optimistic planner is based on the presumption that enough medical personnel, space, and supplies will be available for the number of victims likely to need medical care during a truly major disaster. By not planning for the delivery of care above the usual and customary disaster drill point, the system risks what might be described as “disaster myopia” – i.e., the condition, caused by the unwarranted assumptions of the planner on the scale of the event, of not being able to “see” the extent and scope of larger disasters.        

A Rational Surge Capacity Needed

A major problem that must be addressed openly and honestly is that the nation’s private-sector hospitals By not planning for the delivery of care above the usual disaster drill point, the system risks what might be described as “disaster myopia.” are businesses as well – high-overhead/low-margin businesses, in fact.  Most of the nation’s private-sector hospitals make an estimated 3-5 percent profit margin on their services. Moreover, because of the high daily overhead costs of paying salaries and both buying and maintaining capital equipment, the hospital must operate near capacity in order not to lose money.  As a result, most hospitals must stay within 3-5 percent of their capacity just to break even on a day’s overhead costs.

As a practical example of what this means, a 500-bed hospital would, on a best-day scenario for disaster planning, be breaking even with 95 percent occupancy – which would leave only 25 beds available to accommodate disaster victims. On most days, however, there would be even less capacity in a financially viable hospital system, and some days in which there is 0 percent excess capacity. It should be remembered that a 100-percent capacity hospital is the financial ideal, and hospital administrators take great pains to reach and maintain that goal.

In short, having more than a small number of empty beds available, and the medical staff needed to cope with disasters, is not financially possible for most medical institutions.  Hospital planning that assumes the availability of not only enough beds but also the medical staff needed is a significant, but avoidable, problem. 

Pessimistic/Realistic Options: Delay, Degrade, Deny Care

Instead of relying on optimistic plans for disaster response, medical systems should understand how to manage if the staff does not show up for work, if the re-supply needed does not arrive in time (and/or in the quantities needed), or if a very large number of victims flood existing capability. In other words, medical systems need pessimistic disaster planning.  

However, to create a pessimistic “surge” capacity within medical facilities already operating at or near capacity requires an offsetting degradation of the care provided to patients already in the hospital.  Simply stated, to care for more victims with the same number of staff and beds requires one or more changes from the daily standards and norms of care that would be both medically sound and professionally ethical.  There are three basic strategies that may be employed:

  • Delay Care:  If victims or hospital inpatients are suffering from non-emergent health issues that would not be significantly impaired by the delay of care, they may be asked to return at a later time. Some examples of such conditions: Colds and influenza, certain types of fractures, some lacerations, and elective surgeries.
  • Degrade Care: Should victims require care despite limitations in staffing or available space, so-called “disaster privileges” to practice medicine outside the scope of normal care may be adopted to expand practice responsibilities and available facilities. Examples: Senior nursing staff can make ventilator or medication changes in accordance with established protocols, patient care rooms could be expanded with additional cots, and surgical and critical-care suites could be used interchangeably. 
  • Deny Care: In an extreme situation, care may be denied to a patient or victim – depending on the resources available and the utility of rendering care to that individual or to another. In this scenario, the concept of “medical marginal utility” would be used to determine where medical care would do the most good. One example: If an avian flu victim believed to have only a 10-percent hope of survival and a myocardial infarction (MI) patient with a 50 percent likelihood of survival both need a single available critical-care space the medical marginal-utility argument would direct care to the MI patient who is “less sick” than the avian flu patient. 

Although establishing guidelines to Delay, Degrade, and Deny care may be difficult to consider, not to do so, in advance, would mean that these decisions will have to be made later – in a haphazard manner, in all probability, by medical staff operating under stress.  Without effective, and early, guidance, mistakes will be made and lives may be unnecessarily lost. To accommodate ethical, legal, and regulatory issues, a rational discussion on a “normal day” is the best way to consider these principles.  

The Solution: A Viable Paradigm

The laws that govern the usual practice of medicine are not written with disaster responses in mind.  In the place of statutory guidance, public health executives in most states are considered to possess the authority to make the decisions needed. But public-health officials in most cities, counties, and states of the nation are not acute-care practitioners. Moreover, as a practical matter, public health authorities certainly cannot be in all hospitals at all times to make the decisions needed.

One solution to this almost universal problem may be to establish, ahead of time, certain pre-set numerical thresholds for facilities of different sizes to operate in a delay, degrade, or deny mode (always, of course, in coordination with local public-health officials).

The specific powers of the medical facility and its practitioners in each mode of operation can then also be defined. An expanded scope of care and alternative use of the facility can be triggered by these thresholds, which should automatically be included in a disaster plan. By creating a common understanding with numerical thresholds and the authority to empower efficiency strategies within the medical system, the normal-day overloads that occur may be more efficiently managed and the disaster care provided will conform to common-sense ethical and logistical understandings. The all-hazards plan thus would evolve into a more effective modular disaster plan in which different strategies would be prescribed to meet different scales of events. 

Michael Allswede

Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.

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