Few hospitals are prepared to handle a mass casualty event that overwhelms available resources, even though most have a disaster response plan, according to a report from the Institute of Medicine.

The report provides a guide to help hospitals and acute care centers respond during and after a catastrophic disaster like a flu pandemic or tsunami, while making optimal use of limited resources.

"At the time the disaster strikes is the wrong time to start thinking about crisis standards of care," said Dr. Stephen V. Cantrill, director of emergency medicine at Denver Health Medical Center and a member of the IOM’s Committee for Establishing Standards of Care for Use in Disaster Situations. He added that statewide and regional coordination on disaster preparedness for hospitals is rare and often depends on funding, time, and the interest of legislators.

"If you have a statewide emergency preparedness group that is very gung ho in this area and has reached out to the medical community, then you’re better off" than if your institution tries to do it all alone, he said.

The report emphasizes the need for a coordinated response among emergency management, public health, and public safety departments; emergency medical services; and health care providers.

"Regional coordination allows the maximum use of available resources ... and provides a mechanism for policy development and situational awareness that is critical to avoid crisis situations and, when a crisis does occur, ensuring fair and consistent use of resources to provide a uniform level of care across the region," the report said.

A regional preparedness plan should specify where to focus the often-limited funding to meet the unique needs of the community, according to Margaret VanAmringe, vice president for public policy and government relations at the Joint Commission.

"You look at what you believe are your highest risks, and you prepare for those risks. There’s no preparing for a flood in the middle of the mountains of Utah," she said.

When creating a disaster response plan, the report recommended that hospitals address the following:

• Resource shortfalls. Make sure you anticipate shortfalls in resources and can implement adaptive strategies as needed. Identify which devices and medications are functionally equivalent. Conserve therapies for only those who really need it. For example, reserve your oxygen supply for patients with documented hypoxia. Know which devices can be reused with proper sterilization. Reallocate treatment time and supplies to the patients who are most likely to benefit.

• Communication. Maintain communication directly with the emergency medical services, public safety officers, hospital partners, the state’s Department of Public Health, the National Weather Service, community members who can offer clinical care, and technical experts in areas such as blood banking, burn surgery, and mental health. Make sure staff and administration know how to receive and share information with the state disaster medical advisory committee. Coordinate with other geographic areas to provide telemedicine or hotline specialist support. Offer regular updates through a hotline, Twitter, or Facebook. The public information officer should also coordinate with the media to inform the public about where to seek care.

• Triage. Develop criteria for triage into levels of care, including the chronically ill. Prioritize care based on societal need and achieving the greatest good for the most people. However, make sure it’s possible to also reverse triage decisions based on changes in conditions and resource availability. Decide what to do with patients expected to die imminently.

• Palliative care. Determine what resources are needed to provide palliative care. Long-term care providers should shelter the elderly and disabled who can’t stay in their homes. Determine what care can be delivered and who is responsible to deliver that care. Keep a stock of pain medications such as opioids, acetaminophen, and steroids.

• Space flexibility. To make optimal use of space, consider using operative space for inpatient care, placing patient cots in open areas such as lobbies, and sending patients to alternative care sites. Adjust admission criteria to accommodate as many people as possible.

• Staff flexibility. Extend operating hours, and adjust regular staffing hours and documentation requirements. Delegate nonclinical duties to volunteers or administrative staff. Perform clinical assessments like vital signs less frequently, based on clinical changes. Provide immediate training to staff so they can provide basic patient care.

The report also encourages hospitals and physicians to fully evaluate the existing legal protections and liabilities regarding emergency care.

The Joint Commission applauded the IOM report for its recommendations and has already begun reevaluating its own standards in response, Ms. VanAmringe said.

The IOM "tried to set these crisis standards of care [by] thinking about what happens when the infrastructure changes so dramatically that you have to move your focus from patients to populations," she said. "It’s going to take a lot more than just one report to get there, but this is a very nice step."

IOM: Hospitals Need Coordinated Disaster Response