Principles of Hospital

Disaster Planning
• The purpose of this lecture is to outline the
basic principles of hospital disaster planning.
• It differs from those in other textbooks on
disaster and emergency medicine, as the
emphasis is not so much on the clinical aspects
of preparedness but rather on the
organizational, social, and political aspects.
• This material also focuses not just on what
ought to happen but rather on what actually
happens in disasters and why it happens.
• Disaster planning is only as good as the
assumptions on which it is based.
Unfortunately, many of these assumptions
have been shown to be inaccurate or false
when they have been subjected to
empirical assessment.
• A great deal of planning is based on what
is to be logically expected, but what is
logical is not always what happens. To
avoid this problem to the extent that one
can, the information found in this chapter
has been culled from field research
studies of hundreds of domestic disasters
over the last few decades.
• This material will address primarily domestic,
peacetime disasters. It points out more problems
than solutions, which might prove somewhat
frustrating to the disaster medical planner. Today
there are not definitive answers presented, an
accurate perception of the problems will bring
the solutions closer. In the meantime, some of
the proposed solutions must be treated like
hypotheses that still require testing.
 Why is it Necessary for Hospitals to
Plan Specifically for Disasters?

• Hospitals take care of emergencies every day,

so why is additional planning specifically for
disasters necessary?
• Some have argued that disasters are just like
daily emergencies, only larger. Therefore, they
conclude that the best disaster response is
merely an expansion of the routine emergency
response, supplemented by the mobilization of
extra personnel, supplies, bed space, and
equipment.
• It’s shown that this strategy is not successful
because disasters are not simply large
emergencies. Instead, disasters pose unique
problems that require different strategies.
• Disasters are not only quantitatively different, but
they are also qualitatively different. For example,
disasters tend to disrupt normal communications
systems (e.g., telephones and cellular
telephones), damage transportation routes, and
disable normal response facilities. It’s well-
known: disaster response involves working with
different people, solving different problems, and
using different resources than those for routine
emergencies.
One should recognize that planning
and response are different
• Planning is an organized effort to anticipate
what is likely to occur and to develop
reasonable and cost-effective
countermeasures. Response is the process
of dealing with what actually happens,
regardless of whether it was anticipated.
• When planning is effective, ad hoc, fly-by-
the-seat-of-your-pants responses are
reduced. However, the benefits of planning
are relative, not absolute.
• Utopian planning efforts that seek to
address every possible disaster
contingency are simply not realistic. Even
if these types of efforts were possible, the
planners would never have the funding to
implement them.
• It’s importantly to identify for planners the
most common problems and tasks they
will face in virtually any disaster.
Some believe that every disaster is
unique, meaning that effective
planning is not even possible
• However, empirical disaster research studies
have identified a number of problems and tasks
that appear to occur with predictable regularity,
regardless of the disaster. These problems and
tasks are the most amenable to planning. For
example, almost every major disaster requires
collecting information about the disaster and
sharing it with the multiple agencies and
institutions that become involved in the
response.
• Other tasks include warning and
evacuation, resource sharing, widespread
search and rescue, triage, patient
transport that efficiently utilizes area
hospital assets, dealing with the press,
and overall coordination of the response.
• Effective planning involves identifying and
planning for what is likely to happen in
disasters.
• It also requires procedures for planned,
coordinated improvisation to deal with
those contingencies that have not been
anticipated in the plan.
 Erik Auf Der Heide proposed the term:
Paper Plan Syndrome
• Just because a hospital has completed a
written plan does not mean the hospital is
prepared for a disaster. Although a written
plan is important, it is but one requirement
for preparedness. In fact, a written plan
can be an illusion of preparedness if other
requirements are neglected. This illusion
has been called
the paper plan syndrome
To avoid the creation of impotent paper plans,
the following must be true of the planning:
• Based on valid assumptions about what happens in
disasters
• Based on interorganizational perspective (Often,
hospitals, as well as other emergency and disaster
response organizations, plan in isolation, rather than
collaborating with other agencies likely to become
involved in the response [e.g., ambulance services,
emergency management agencies, blood banks,
dispatchers, law enforcement agencies, fire
departments, health departments, Red Cross and moon
personnel, news media, and other hospitals].)
• Accompanied by the provision of resources
(time, funding, supplies, space, equipment, and
personnel) to carry out the plans.
• Associated with an effective training program so
that users are familiar with the plan.
• Acceptable to the end users (If the plan users
are involved in the planning process, they are
more likely to be familiar with the final product; to
consider it practical, realistic, and legitimate;
and, most importantly, to use it.)
• Failure to comply with these prerequisites
may contribute to the development of
disaster plans that are unworkable in
practice, and it may explain why so often
the disaster response differs from what
was prescribed in the plan.
 Importance of the Planning
Process
• A frequently overlooked but important factor in
disaster planning is the planning process. Often,
the process of planning is more important than
the written document that results from it. This is
not only because those who participate in the
planning process are more likely to accept the
final product as legitimate and practical but also
because of the personal contacts that result. A
number of researchers have observed that
predisaster contacts among members of
emergency response organizations result in
smoother operations when disaster strikes.
• Organizations and their personnel are more
likely to interface successfully if they do not have
to do so with total strangers. Furthermore, in the
process of planning, the participants develop a
trust in one another, and they also become more
familiar with the roles of other individuals and
organizations in the response. Finally, during the
planning process, one learns how one's actions
in a disaster might enhance or detract from the
ability of others to carry out crucial activities.
Importance of Administrative Commitment
and the Provision of the Resources
Necessary to Carry out the Plan

• Success in any organizational endeavor

hinges on the extent to which the chief
executive officer is committed to that
success; disaster preparedness is no
exception. To gain the attention, respect,
and cooperation of organization members,
disaster planning needs to be given the
necessary status, authority, and support.
• Unfortunately, the disaster planning task is
often relegated to a position of low status
within the administrative hierarchy and is
isolated from any existing sources of
political power and from priority-setting,
budgeting, and decision-making
processes.
• One of the reasons things so often do not go
according to plan when disasters strike is the
failure to provide the resources (e.g., personnel,
time, money, equipment, supplies, and facilities)
necessary to make the plan work. Plans might
be developed without funding for equipment and
supplies. Time and money might not be
budgeted for the development of disaster
training programs or for the overtime needed for
training or drills.
• Persons assigned disaster planning tasks
might still be expected to carry out all of
their regularly assigned duties, and they
may receive little remuneration or
recognition for their extra efforts. One
should not be surprised that organizations
that allow planning to occur in this context
get what they pay for.
• If preparedness efforts are to result in
more than paper plans, the planning
process must be tied to the resources
necessary to carry out the mandate.
 Complacency toward Planning

• Hospital disaster planners must face the reality

that disaster planning is not always met with
enthusiasm.
• Often, getting chief executive officers and
organizational members to support disaster
preparedness is more difficult than developing
the disaster countermeasures themselves.
• A number of reasons can be found for this lack
of support for disaster preparedness activities.
First, some of those involved in routine
emergency responses believe that they already
know what to do because they see disaster
response as merely an expansion of daily
emergency response.
 Planning Assumptions

• The value of planning is in its ability to

anticipate the problems that are likely to
be faced in a disaster and to develop
realistic, cost-effective, and practical
countermeasures. It should not be
surprising to find that, if likely problems are
not anticipated, the plans will not be very
useful. Furthermore, if planning is based
on invalid assumptions, it may not
succeed in guiding an effective response.
Planners might, for example, assume the
following:

• A shortage of supplies and medical personnel will

exist.
• Hospitals will receive prompt notification after
disaster occurs.
• Responding emergency medical service units will
triage the victims, provide stabilizing first aid or
medical care, and then distribute casualties in such
a manner that no one hospital is inordinately
overloaded.
• Patients needing specialized care (e.g., hazardous
materials decontamination or burn care) will be sent
to hospitals that have the capacity to deal with
patients' conditions.
Hospitals might reasonably assume that
these activities will occur because they
are written in the disaster plan

• However, numerous field disaster studies

and after-action critiques have
demonstrated that these and other
planning assumptions, on which hospital
disaster planning is based, are often
inaccurate or untrue.
• Another common planning assumption
is that disasters are similar to daily
emergencies, except for the extreme
shortages of response resources. In
fact, disasters are often defined as
emergencies that exceed the available
resources to deal with them.
• Although this definition might hold true for
disasters in underdeveloped countries or
in military conflicts, this is uncommon in
domestic peacetime disasters. Numerous
events in the United States e.g.,that have
been called disasters have not been
characterized by severe shortages of
community medical resources.
• In a study of 29 mass casualty disasters in
the United States and its territories, the
Disaster Research Center found that only
6% of the hospitals had supply shortages
and that 2% had shortages of personnel.
Many hospitals reported that they had
more regular staff and medical volunteers
than they could effectively use.
 Private meaning:

• Resource shortages can occur at any given time or place

in a disaster. However, in the United States, more often
than not, overall community medical resources are
sufficient; but they must be used in different ways than
during routine, daily emergencies. One of the reasons
that disaster medical resources are not strained as much
as one would expect is because disasters in the United
States have been relatively small in comparison to those
in other parts of the world. In addition, the United States
is also comparatively well endowed with medical
infrastructure.
 Private meaning:

• One factor enhancing available medical

resources in disasters is that most hospitals
operate on a 24-hour basis. In a crisis, therefore,
many hospitals can rapidly double or triple their
available staff by calling in off-duty personnel. In
fact, most off-duty staff do not have to be
formally called back to duty; they will report to
their hospitals on their own without being asked.
In addition, physicians, nurses, and other
medical professionals not on the hospital staff
will show up to volunteer their services.
• The assumption that emergency response
personnel will abandon their professional
responsibilities to attend to their families in
disasters contributes to the belief that disasters
are resource-deficiency phenomenon.
• However, field studies have not borne out that
such professional role abandonment is common.
The few who must choose family over
professional emergency responsibilities are
more than made up for by the large numbers of
volunteers and off-duty staff who spontaneously
show up and offer help.
 Lack of Hospital Notification and
Information on Casualties

• Most community hospital and emergency

medical disaster plans assume that timely
and appropriate information will be
received from the disaster site. Information
on the nature and scope of the disaster
will allow responders to prioritize the use
of available resources and to mobilize the
appropriate numbers and types of
resources when and where they are
needed.
For the medical response, essential
information includes

• a) estimates of the numbers, types, and

severities of illnesses or injuries;
• b) the current abilities of medical facilities
(e.g., hospitals) to accept and treat
casualties.
• This information can be used to
facilitate the distribution of casualties
so as to spread the patient load among
area hospitals so that no single facility
is overwhelmed
• Although most casualties will bring
themselves to the closest or most familiar
hospitals by nonambulance transport, the
availability of the information in the
preceding text can still guide the destination
of patients transported by ambulances over
which local authorities may still have control.
For example, if hospitals closest to the scene
are being overloaded with patients
transported by private vehicles, ambulances
can be instructed to avoid those hospitals.
 In fact, many hospitals learn about the
disaster from the mass media, the first
arriving casualties, or ambulances rather
than from official sources.

• An overall needs assessment is unlikely to

occur when coordination and control at the
scene have not been accomplished, and
for coordination and control to occur early
in a disaster response is rare.
• Compared with the situation in daily emergency
responses, overall scene assessment is often
complicated in disasters when the scene is very
large, when multiple disaster sites exist, when
streets are strewn with debris that inhibits
access, and when emergency medical agencies
have not been integrated into the response.
• The process is further complicated when, as so
often happens, multiple agencies with
overlapping jurisdictional authority from different
levels of government and the private sector
respond.
 Lack of Interagency Radio
Communications Networks

• Lack of adequate information flow to

hospitals might occur because existing
radio equipment has been damaged or
even because the harried emergency
department staff has turned down the
volume so as not to be bothered by its
incessant noise.
 Unfortunately, even if telephone lines are left
intact by the disaster, the circuits will almost
certainly be overloaded and unusable
• Although emergency response organizations such as hospitals
can arrange to receive priority with the telephone company
when the telephone lines are jammed, little evidence shows
that most hospitals take advantage of this option.
• In recent years, as the use of cellular telephones has greatly
increased, cellular telephone connections have become the
victim of the same types of communications overload that wire-
based telephones encounter in disasters.
• Because wire-based and cellular telephones are unreliable in
disasters, interorganizational information flow requires that
emergency response organizations have common, mutual aid
radio frequencies on which to carry out two-way
communications.
Time Course of Casualty Arrival at Hospitals

• Casualties usually start arriving at

hospitals within 30 minutes of the
disaster impact, and the majority
arrive within 60 to 90 minutes.
Early casualty flow is made up
mostly of those with minor injuries,
probably because they are less
likely to be trapped in the rubble or
because they can more easily
escape or be rescued by
bystanders.
• Earthquakes (and other disasters) also
interrupt utility services, such as electricity,
sewer, water, and telephone lines, to the
hospital. However, the 2001 California
study could document fewer than 1% of
the state's hospital buildings whose
contents were adequately anchored or
braced and that had sufficient backup
power, water, and waste-water systems to
operate for 72 hours.
• Because of the lack of timely casualty
information from the scene, hospitals
might be unaware of the fact that more
serious victims are yet to arrive. When
these victims do arrive, all the
emergency department beds might
already be occupied.
 Survival versus Time until Rescued

• Although a few trapped disaster victims

have been rescued alive at 5, 10, and
even 14 days after impact, this occurs only
in exceptional cases. In the 1980
earthquake in southern Italy, for example,
94% of the trapped people who survived
were rescued during the first 24 hours. No
victims were rescued alive after the third
day.
• The 1990 earthquake in the Philippines yielded similar
findings -88% survival was seen for those rescued on
day 1, 35% on day 2, 9% on day 3, and 0% from day 4
onward.
• In the 1976 earthquake in Tangshan, China, those
rescued in the first half-hour had a 99% survival rate,
followed by 81% on day 1, 34% on day 2, 38% on day 3,
19% on day 4, and 7.4% on day 5.
• In the 1995 bombing of the Murrah Federal Building in
Oklahoma City, all but three of the survivors were
rescued alive within 5 hours of the explosion.
• Therefore, one can expect that
rescue teams responding to
large-scale disasters involving
trapped victims will have little
impact on survival unless they
arrive within 1 or 2 days.
• In other words, the local
emergency response is the
critical variable in the survival
of trapped casualties.
 Adapting Plans to Deal with Typical
Patterns of Disaster Behavior
• Disaster planners and responders can do
little to control the efforts of bystanders in
disaster situations. Disaster plans are
more effective if they are designed around
how people tend to behave in disasters.
This approach is likely to be more
successful than expecting persons to
conform to the plan.
• Planners and responders can influence the
outcome by anticipating the likely course of
bystander actions. For example, ambulances
should anticipate that the closest hospitals will
get the most patients and should therefore avoid
transporting additional patients to these
hospitals if possible.
• Hospitals should not expect that patients will be
triaged or decontaminated at the disaster site
but should instead make provisions to carry out
these tasks at the hospital.
Focus on Multiple Trauma Preparedness

• The common assumption in medical disaster

planning is that the primary medical need will be
to deal with large numbers of victims suffering
from multiple trauma.
• Approximately half the number of the casualties
were admitted more because they had been in
the disaster than because of the seriousness of
their conditions, and they were discharged the
next day. Therefore, only 10% of disaster
casualties really required even the most basic
inpatient care.
 Nontrauma Casualties and Loss of
Access to Routine Sources of Medical
Care
• In many disasters, most
patients need care for
conditions other than trauma
is not always appreciated.
• This set of patients might
include those who have lost
access to their routine
sources of custodial care,
medical care, mental health
care, or prescription
medications.
• Although disaster medical planning tends
to focus on hospital and EMS readiness,
most patients could be cared for in
nonhospital settings, such as physicians'
offices, clinics, and freestanding urgent
care or ambulatory care centers.
Unfortunately, these valuable medical
assets are often not included in community
disaster plans.
 Blood Donors
• Hospitals and blood banks are
often caught off-guard and are
unprepared for the quantities of blood
donors that show up during disaster.
These situation is aggravated when local elected
officials or mass media representatives issue
mass appeals for blood donors, often without
consulting the recipient organizations regarding
the actual need for blood.
 Example:
• Dallas, Texas DC-10 Crash, 1985. After a DC-10
crashed during a thunderstorm at Dallas-Fort Worth
International Airport in 1985, radio stations
announced the disaster before adequate medical
information was available. These stations suggested
that blood would be needed. Four hundred ninety-
one blood donors responded to the media's call for
blood. This inundated the local hospital's blood bank,
causing a problem with crowd control. Personnel had
to be diverted from the emergency department to the
blood bank to manage the people trying to donate
blood. Some donors were actually turned away from
the blood bank because personnel were unable to
process them at the time.
Example:
• Sioux City United Airlines Crash, 1989. At the
time of the Sioux City air crash, the blood
supplies at the local hospitals and at the
Siouxland Community Blood Bank were
adequate to meet all the demands. Although
officials made no public appeal for blood donors,
more than 400 persons turned out to donate
blood. Offers of additional blood from blood
centers in Des Moines, Omaha, and other areas
much further away were declined.
 Hospitals as Disaster Victims

• Although hospital plans often focus on

disasters that may affect the community,
insufficient attention is given to the
possibility that the hospital itself might
become a victim.
• Nonstructural damage can cause injury to
hospital occupants, and it can interfere with the
ability of the facility to care for patients.
Nonstructural damage includes those affecting
the nonload-bearing components of the building,
such as the windows, ceilings, light fixtures,
electrical circuits, water storage tanks, and
sewer and water pipes. It also includes the
material in the hospital, such as shelves,
cabinets and their contents, refrigerators,
laboratory supplies and equipment, cardiac
monitors, imaging equipment, computers,
communications equipment, and cafeteria
appliances.
• Numerous case reports illustrate the lack of
attention to basic measures to assure hospital
survival and function after disasters. Generator
failure is frequently mentioned.
• Hospital function has also been compromised by
inadequately anchored generators, unanchored
generator batteries, damage to the lines carrying
natural gas to power the emergency generators,
and the loss of water supply to cool emergency
generators.
• Generators and generator-switching equipment
have failed because they were located in
basements subject to flooding. Failures have also
resulted from inadequate electrical surge
protection, dead batteries, and an inadequate fuel
supply for the generators.
• Although the need for backup water provisions is
frequently mentioned as a necessity for
preparedness, hospitals continue to suffer when
water supplies are interrupted.
• Hospital functions that have been interrupted
because of their dependence on water include
operating room temperature and humidity
systems, sterilization equipment, water-cooled
refrigerators and freezers, hydrotherapy, x-ray
film developers, telephone switchboard and
computer mainframe cooling systems, air-
conditioning systems, fire sprinkler systems,
medical suction, cooling systems for lasers, and
emergency generators
• Other factors that have impaired hospital ability
to function after disasters, particularly
earthquakes, have included unanchored
pharmaceutical storage shelves; severed
oxygen lines; leaking natural gas lines; boilers
with no backup fuel source; broken windows and
glass; elevator malfunctions; and thelack of
battery backup lighting to stairwells, elevators,
operating room corridors, radiology, laboratory,
outpatient units, and areas of the emergency
department.
Improving Hospital Preparedness

The Joint Commission

on Accreditation of
Healthcare
Organizations
promulgates standards
for hospital
preparedness
 These standards require that hospital
disaster plans include provisions for the
following:
• Carrying out a hazard vulnerability assessment
• Activating the plan
• Integrating the hospital plan with the community disaster
plan
• Notifying external authorities that a disaster has occurred
• Alerting hospital personnel that the plan has been
activated
• Identifying hospital personnel
• Housing and transporting staff
• Providing for staff family support
• Maintaining supply management (e.g.,
pharmaceutical agents, medical supplies, food,
water, and linen)
• Controlling access, crowds, and traffic
• Maintaining media relations
• Evacuating and establishing alternative sites for
patient care when necessary
• Tracking patients and managing patient
medications and medical records during
evacuation
• Establishing and maintaining backup
communications and utilities
• Setting up facilities to deal with and isolate
patients contaminated by hazardous materials
• Assigning staff responsibilities during disasters
• Using a command structure consistent with that
used by the local community in disasters
• Training
• Evaluating the plan annually
 Mitigation
• The first duty of the hospital in a disaster is to avoid
becoming a disaster victim. One of the best ways for the
hospital not to become a disaster victim is for it not to be in
locations where disasters tend to occur.
• Hospitals should not be constructed in areas where
recurrent flooding occurs, near earthquake faults, on sandy
river bottom soil that amplifies seismic shaking, near coastal
areas subject to hurricane winds or storm surge, near
chemical plants or storage areas, or in forested areas
subject to recurrent wildland fires. When considering the
construction of new hospital facilities, the local disaster
office can be contacted for information on areas vulnerable
to disasters that should be avoided.
• Attention also should be paid to the
contents of the hospital building that might
be vulnerable to damage in a disaster. For
example, hospitals commonly locate
heating systems, backup generators, and
electrical switching equipment in the
basement, the most vulnerable area in the
event of flooding or water system leakage.
 Do Not Plan in Isolation

• One lesson that is clear from the disaster

research literature is that most response
problems are due to the lack of
interorganizational coordination and
communication. However, most hospitals and
other emergency response organizations plan
as if they existed in isolation. Hospital planners
should contact their local municipal or county
disaster or emergency management office to
find out if a community disaster planning
committee exists.
• Such a planning committee can be an
effective means of addressing a number of
issues related to disaster preparedness.
The committee can be the stage for
developing not only regional plans for
mitigation, response, and recovery but
also for the establishment of a joint
training program.
 Health and medical care responsibilities
that should be addressed by the
committee include the following:
• Warning and evacuation
• Mitigation activities for health care facilities
• Establishment of training programs for health care
providers
• Overall coordination of the health sector response
• On-scene medical assessment
• Overall coordination of site search and rescue
• Triage
• Hospital notification (including information on numbers,
types, and severities of casualties)
 Health and medical care responsibilities
that should be addressed by the
committee include the following:
(continuation)
• Inventory of current hospital patient loads and capacity
to receive additional patients
• Transport and distribution of casualties
• Use of nonhospital facilities for patient care
• Health facility recovery activities
• Public health and environmental health activities (e.g.,
management of infectious disease outbreaks and
chemical spills) and development of messages on
disaster-related health issues for the media and the
public (e.g., food safety when the power is lost, the
effects of hazardous chemicals, and the prevention of
chain saw injuries and carbon monoxide poisoning
during cleanup and recovery).
• Plan for Communications
• Management of Donations and
Volunteers
• Working with the News Media
• Postimpact Hospital Safety
Assessment
• Hospital Evacuation
• Hazardous Materials Problems
• Triage
• Security and Staff Identification
• Planned Improvisation
• Training, Drills, and Critiques
• The implementation of these plans is unlikely in the
absence of an effective training program. Several
advantages exist for establishing a joint training
program.
• First, disaster responses are more effective when formal
and even informal relationships have been previously
established among the various responders. Joint training
is one strategy for encouraging such relationships.
• Secondly, joint training fosters an understanding not only
of what activities and responsibilities need to be carried
out but also of how those activities facilitate or inhibit the
abilities of others to carry out their responsibilities.
• Finally, a community-wide or statewide
training program can reduce the costs of
training and can make carrying out training
at multiple times and locations
economically feasible, so that the training
is more available to the potential users.
 Conclusion
• Disaster planning is only as effective as the assumptions upon
which it is based. The effectiveness of planning is enhanced
when it is based on information that has been empirically
verified by systematic field disaster research studies.
• Most disasters cannot be adequately managed merely by
mobilizing more supplies, equipment, and personnel. Disaster-
related problems have been identified by disaster researchers,
and they can be anticipated and planned for.
• Plans must be practical for and familiar to the users. Plans
must also be interorganizational, and they must be based on
valid information about what happens in disasters. Finally,
resources (e.g., time, personnel, funding, facilities, and
equipment) must be made available to carry out the plan.
• The process of planning is more important than the written plan
because those who participate in the planning process are
more likely to accept the end product.
• In disasters, emergency response units will often come from
many miles away. For this reason, the establishment of
regionwide, or even better, statewide disaster plans, is helpful
in promoting a coordinated response.
• The effectiveness of the local response is a key determinant in
preventing death and disability. National rescue and medical
teams that come from across the country will have little overall
impact on casualty survival.
• Disaster planning should include provisions to assure the
survival and function of these routine sources of care (e.g.,
pharmacies, dialysis clinics, home health care agencies,
nursing homes, assisted living facilities, and psychiatric
facilities.
• When large numbers of casualties are seen and the cause of their
symptoms cannot be immediately identified, the best strategy may
be to provide a large-scale medical observation capacity until a
serious exposure can be ruled out (e.g., observation in an
auditorium or gymnasium where a few medical personnel can watch
a large number of people with access to rapid medical care if any
patient's condition deteriorates).
The End