Emergency preparedness for the emergency department- myth verses reality

Michael G. Guttenberg, DO FACEP FACOEP, Chair, Department of Emergency Medicine, St. Joseph’s Medical Center, Yonkers, NY; Chair, ALS Committee New York City REMAC

“Everyday after the last disaster brings us one day closer to the next.” These or similar words are frequently cited by emergency preparedness planners to justify funding, training, and the acquisition of appropriate equipment and infrastructure for disasters and mass casualty incidents. Disasters or mass casualty incidents include acts of terrorism, industrial accidents, motor vehicle collisions, hazardous materials incidents, fires, infectious disease epidemics, and highlighted most recently, weather related catastrophes. Emergency physicians and emergency department staff understand this better than most. In addition to our daily ED crowding, a day in the life may include a bus accident, a multiple shooting, a fire with burn and smoke inhalation victims, or multiple victims of carbon monoxide exposure. Several popular television series, the events of September 11, 2001, the ongoing terrorist threat, and fear of emerging infectious illnesses have not really redefined what emergency physicians and emergency departments have always done. Instead, the community at large now has a better understanding and a higher expectation of our role.

Despite the above, certain numbers and statistics are startling. The health care system in the United States is becoming increasingly strained. Access and funding for emergency care is declining while demand is increasing. The recently released national report card on Emergency Medicine by the American College of Emergency Physicians lists New York State as forty nine out of the fifty states for the availability of emergency departments per one million people (7.7 emergency departments per 1 million people). Nationwide, the number of emergency departments and hospital beds have declined over the last 30 years while demand has increased. The American Hospital Association estimates 70 million patients were seen in almost 5000 U.S. emergency departments in 1973. In 2000, almost 4100 emergency departments saw 103 million patients, and in 2003, 113 million patients were seen. Emergency physicians and departments are clearly doing more with less.

Emergency departments are overcrowded and under increasing stress to accomplish their mission to provide care. Disasters and mass casualty incidents make accomplishing this mission even more problematic. With this in mind, a careful review of past disaster and mass casualty incidents and their injury statistics may prove helpful for future planning and preparedness. Before continuing, it is appropriate to distinguish between a disaster and a mass casualty incident. Although different text sources provide different specific definitions, a disaster implies the destruction of property and infrastructure, such as electricity and public utilities. Although unplanned, a disaster is not necessarily unexpected. A disaster may be caused by natural events, such as the recent hurricanes, tornadoes, floods, and earthquakes, or man made events, such as terrorist bombings and chemical fires. Disasters typically overwhelm the ability of a community or region to meet its health care needs creating a public health or humanitarian emergency. With a disaster, there is no implication of casualties, which can be many or few.

Like disasters, a mass casualty incident is also unplanned but not necessarily unexpected. There is no implication of property damage, which may or may not exist. A mass casualty incident, such as a bus accident or train crash, may produce more patients than a disaster. The impact of a mass casualty incident differs by region and its available resources. Thirty stable patients from a bus accident in Midtown Manhattan is more likely to impact traffic than the health care and EMS system. While the same accident in Cooperstown, NY with one hospital and a small EMS system, may temporarily overwhelm the system. The Joint Commission on Accreditation of Hospital Organizations (JCAHO) uses the encompassing definition of an ‘Emergency’ to define both of these as events that ‘disrupt the environment of care or result in a significantly increased demand for services.’

Much of emergency preparedness is based upon lessons from the past as a means of preparing for the future. A review of several recent disasters and mass casualty incidents reveals some interesting statistics. The Centers for Disease Control (CDC) has looked at these numbers carefully and has drawn some conclusions, which may be helpful to your institutional planning. The closest three hospitals to an incident can anticipate the majority of patients (this will be altered in large urban environments with multiple hospitals in close proximity). Half of all patients will arrive in the first hour after an incident and the remainder will arrive over the next 23 hours. Staffing needs should be planned accordingly. Additionally, bombings and collapse scenes with a large number of casualties will likely yield the following injury severity prediction- one third will be dead or critical (ISS >8) with the remainder, treated and released. A review of Israeli literature yields a twenty percent dead and twenty percent hospital admission prediction following a bombing.

The World Trade Center terrorist events of 9/11/01 produced several thousand on site deaths from the plane crashes and subsequent building collapses. Over the next 24-36 hours, the Ground Zero Hospitals (six closest) saw 2128 WTC related patients with 243 (8.8%)
admitted. New York City hospitals treated approximately 5800 WTC patients with 454 (13%) admitted and 16 in hospital deaths reported. These deaths resulted mostly from burns. Most of the injuries were reported as inhalation of dust, eye foreign bodies/corneal abrasions, and assorted abrasions/lacerations.

Additional examples include the Oklahoma City Federal Building Bombing, which resulted in 361 total patients. Of these, 163 died and 198 survived with 50 (25.3%) hospitalized. 153 of the deaths were in the collapsed portions of the building. A December, 2003 train bombing in Moscow, Russia resulted in approximately 200 injuries. Of the 44 (22%) deaths reported, 31 were pronounced on site and never transported. 50 patients were reportedly treated and released on site. The multiple simultaneous March, 2004 Madrid train bombings resulted in 1430 injuries and 192 deaths (182 pronounced on site). 972 patients were treated in the hospitals with 10 (1%) deaths occurring. 392 patients were identified as dead or critical (27%). The London Train bombings in July, 2005 resulted in approximately 700 injured with approximately 20 deaths and 50 critically injured.

The above numbers are illustrations of high profile bombing disasters or mass casualty incidents that have taken place over the last several years. The numbers are intended to illustrate their impact on hospital and emergency department preparedness planning and the truly remarkable outcomes that occur if the patients survive long enough to reach the hospital. The numbers also illustrate the impact of pre-hospital triage. These numbers are not presented to minimize the senseless and tragic deaths that have occurred as a result of terrorism. Additionally, these numbers do not reflect how emergency departments have been impacted by the recent hurricanes and floods, such as Katrina, as these represent unique, not new, challenges to the health care system. Lastly, these numbers do not reflect the potential consequences of the predicted infectious illness epidemics and pandemics that will impact our emergency departments and hospitals in the years to come.

A common myth of emergency preparedness planning is the role of Emergency Medical Services (EMS) in a disaster or mass casualty incident. Overseas television images of people being put into cars and pick up trucks and then rushed to the hospital are realistic, even in this country. Hospitals and emergency departments should expect their first arriving patients to be self-referrals utilizing their feet or public transportation to get to the hospital. This can be problematic. These ambulatory patients, who usually constitute the ‘walking wounded or worried well,’ may overwhelm an emergency department prior to the arrival of the more seriously ill and injured, who will be triaged, decontaminated, and transported by the EMS system to the closest appropriate hospital. If a local trauma center is the closest hospital to an incident, they can anticipate a majority of the self-referral patients as well as the critically ill who are transported. A lengthy period of time may occur between these two groups. Additionally, these ambulatory patients are potentially contaminated and have not undergone any decontamination. This now becomes the responsibility of the receiving hospital, which will not have the support of the local hazardous materials team. Although counterintuitive to what we do in Emergency Medicine, the concept of ‘Locking the Doors’ is very appropriate. The majority of these patients are the ‘walking wounded and worried well.’ We triage our patients 24/7. Why should we do it differently now? Self-referral rates of up to eighty percent have been reported at several urban disaster or mass casualty injury sites. Data collected after 9/11/01 was able to account for just over 500 ambulance transports of the more than 5800 people treated at New York City hospitals. A review of the Oklahoma City statistics revealed a thirty two percent EMS utilization rate.

Discussed at length in Emergency Preparedness and Disaster literature is the role of sanctioned and unsanctioned volunteer resources. This is an emotionally charged debate although probably less evident at the hospital or emergency department than an incident location. Following the discussions of 9/11/01, the recent example of Hurricane Katrina shows that very little was accomplished nationally at creating a ‘sanctioned’ volunteer medical reserve corps. The uplifting note was people’s continued desire to help and serve despite the risks to personal safety and loss of income. Hopefully, the right pieces will be in place the next time such services are required. ‘Unsanctioned’ volunteers, although with the best of intentions, create several challenges to the system including a lack of accountability, lack of reliability, lack of quality control of credentials, lack of integration with organized efforts, lack of personal protective equipment, and a lack of infrastructure to sustain themselves.

While emergency preparedness is a multidisciplinary approach to a crisis, the Emergency Physician should play a key role in a hospital’s planning and response to a disaster or mass casualty incident. No other medical specialty is expected to coordinate and multitask on a daily basis like emergency medicine. No other medical specialty is expected to triage on a 24/7 basis like emergency medicine. When the disaster bell strikes, a few suggestions that may assist you in your endeavors to provide leadership during a time of crisis include: LOCKDOWN the Emergency Department after confirming the incident; Put on the appropriate Identification Vest as the physician in charge; Clear the Emergency Department of admitted patients and non essential personnel; Identify the need for decontamination- on the outside of the ED; Stay out of the Haz Mat Suit (impossible to provide care and you may become a patient as well); Triage outdoors if possible (this will extend the size of the Emergency Department and avoid the possibility of contaminating the ED); Don’t forget about the special needs of the elderly and pediatric patients; and Document your efforts and patient encounters. You do want to get paid for your services, don’t you??

Lastly, don’t rely on other agencies and services to help you for the first several hours to days. Federal and state resources and assets have to arrive and develop their own infrastructure. Local hazardous material units need to complete their task at the incident location. The local police, fire, and EMS have their own concerns. The surrounding hospitals have their own patients.

Emergency preparedness is an essential and evolving component of hospital and Emergency Department planning. Proper planning and practice prevents poor performance. Remembering the myths and realities above should prove helpful. Remember the big picture to protect yourself and your staff. Lastly, patients who arrive alive at the Emergency Department are likely to have a good outcome.

What are your hospitals best practices? How do you accommodate surge capacity in your emergency department? Your thoughts are welcome.

Resources and Links:
1.) Local and State Health Departments
2.) Joint Commission of Accreditation of Health Care Organizations- www.jcaho.org
3.) Occupational Safety and Health Organization- www.osha.gov
4.) Centers for Disease Control- www.cdc.gov
5.) Greater New York Hospital Association- www.gnyha.org