Days of Reckoning: The Maximum Effort

Many hospitals and emergency agencies (such as the police and fire departments) already have plans on hand to call up their off-duty staff in times of a natural or manmade disaster or other crisis in their home communities. It is intuitive to think of the term “maximum effort”’ when referring to all of the on-duty as well as off-duty staff that are called in during such situations. But there are a number of significant problems that must be dealt with when, and preferably before, a maximum effort is called for.

The first reason that maximum efforts are rarely practical is that, when all members of the hospital’s staff have been called in, there will be too few staff able to work the following day. In short, a truly maximum effort is not sustainable beyond the short term. Probably only sustainable for incidents that are shorter than the time it would take to call in the off-duty staff.

The second reason that maximum effort is seldom practical is that the hospital’s “routine” must still be done. Patients will continue to come in by ambulance, by private car, or as “walk-ins.” And all of them, particularly those coming to the emergency room (ER), will still require care.

There are several steps short of the maximum effort that can be taken to help a hospital care for the “routine” patients while dealing with the influx of incident-related patients in times of crisis. Many of those steps are designed to decrease the number of patients in the hospital who are not there because of the specific crisis. In these situations, the term maximum sustainable effort refers specifically to a staffing level and use of resources that do not strip the hospital’s ability to function the next day — or leave it unable to deal with the “usual” volume of non-crisis-related emergencies that it has to cope with in a theoretically “average” day.

A useful way to think of the problem, perhaps, is as an equation — with the resources (including staff) on one side and the patients that can and must be treated on the other. Planning for a maximum sustainable effort almost always involves adjusting both sides of the equation.

Patient Flow: Shifting the Equation

As with any emergency, there is usually some routine work that can safely be set aside — for example, a police officer might well decide to respond to a report of a violent crime in progress rather than to ticket an illegally parked car. Similarly, hospitals should have plans to shift from their normal workday status to a situation calling for a maximum sustainable effort. One way that a hospital can do this is to decrease its in-house patient population — e.g., by postponing elective procedures that can be rescheduled for another day. In addition, but only to the extent that it can be done safely, patients who are ready or almost ready for discharge can be “fast-tracked” and sent home or to a rehab facility.

Hospitals and EMS (emergency medical services) agencies already collaborate on a system involving so-called “diversions,” which frequently are used when a hospital is full to capacity for a particular type of patient (burn patients, for example, or patients who have been seriously injured in a train or car wreck). The hospital relays such information to the EMS system so that ambulances will transport new and/or additional patients to other hospitals or other medical facilities that are not as crowded.

In theory, patients receive better care this way, because they have a shorter wait for treatment at the hospital that is not overwhelmed and/or where there are more medical and personnel resources available. During any truly major crisis, any and all hospitals in the area should at least consider going “on diversion.” This would permit the hospital’s own staff — who would normally be caring for ambulance patients in the ER and/or after they have been admitted — to be shifted to care for emergency room patients from the scene of the crisis.

The EMS system can help significantly by, among other things, distributing the overall patient load between the hospitals both in and outside the affected area. This requires some very important decisions, of course — preferably by someone at a level where he or she “sees the whole board.” Such decisions cannot be made “on the fly,” but must be made based on the information available from the hospital and from the scene of the accident or incident. Under the incident command system (ICS), the transportation unit leader — who is usually the ideal individual to make such calls — decides which patient goes to what hospital, taking into account the needs of the patient and the capabilities and workloads of the available hospitals.

There are several ways that hospitals and/or EMS agencies can improve the staffing side of the equation. One way is to move from three 8-hour shifts to two 12-hour shifts. This would stretch the staff by a third, and decrease the number of tour changes a day — thereby cutting to some extent the productivity loss that usually occurs when the shift changes. In addition, staff members who usually do not take care of patients but are licensed or certified to do so can be pressed into service. Training, support, and administrative staff, for example, can be shifted temporarily into the patient care arena. The only caveat to diverting personnel this way is that their regular work, usually essential to the smooth functioning of the hospital, may still need to be done. If an administrator is responsible for making sure that supplies are available, he or she might be more valuable in doing that than in treating patients.

Answers: In Advance, and in Writing

It should be obvious that all hospitals should have one or more crisis plans, including at least one dealing with a local crisis (the loss of electric power, for example) and others for off-site disasters — a train wreck or plane crash — that would result in a major influx of patients. Such plans should at least consider the use of other medical facilities in the area.

When a comprehensive plan is in place, hospital workers not only know what to do in a crisis but also where to go to for answers in these times of crisis. To fully achieve these benefits, though, requires frequent and thorough training. When a crisis or disaster or other event occurs of such a magnitude that the entire emergency services resources of the community are needed to respond — or, worse that those resources are quickly overrun — hospitals and first-responder agencies are forced to activate their mutual-aid plans. Simply stated, a mutual-aid plan is a written agreement between emergency services agencies that they will come to help one another in times of crisis.

When an emergency agency cannot quickly respond, for example, to deal with a major disaster, a mutual-aid plan previously agreed to will specify what other agency or agencies in the area can be called in to help. This plan is used during a disaster and when normal call volume increases to a point where a routine request for help would have to wait for a unit to become available.

Typical mutual-aid plans provide such information as who and/or what agencies are covered by the agreement, how the request(s) for help should be communicated, who has the authority to make the request, and — perhaps the most difficult decision of all — who or what agency is responsible for a broad spectrum of financial liabilities and payments. (Generally, the agency “owning” the resource continues to pay for its own staff, and related maintenance costs, while the agency receiving or being helped by the resource is responsible for damage and loss. However, this varies from agreement to agreement and should be clearly stated to avoid problems.)

Many states now not only have in place a statewide mutual-aid plan but also require the development of local plans. However, most of these plans and requirements only pertain to EMS, fire, and police agencies and have no bearing on other resources. In addition, other government agencies are seldom covered by these requirements.

An example of how the mutual-aid concept could be applied to non-emergency-services agencies would be the typical sequence followed when there is a major incident involving a large number of fatalities. In such disasters, it frequently happens that the local public health agency or coroner’s office is responsible for processing the human remains but is not able to complete all of the post-mortem work needed in a time frame acceptable both to the victims’ families and to the local community. The instinctive answer, of course, is that neighboring communities will simply send their own coroners to help as needed.

But there are numerous legal, financial, and other issues involved: the identification of remains, for example, and the legal certification of death. There also may be jurisdictional issues that must be dealt with, and there are several cost issues that would not be easy to resolve — e.g., Who will pay the salaries of those who have “volunteered,” so to speak? In addition, who or what agency of government will indemnify the “on-loan” coroners if they are injured, or if they cause some kind of damage, or if there are legal issues over the identification of, release of, or treatment of remains? (Malpractice insurance, in other words.)

As with the pay issue, there are numerous points of view, and a very large number of economic, political, and other factors that must be taken into consideration. For planning purposes, though, what is important is not how these questions are answered, but that they are answered — in advance, in writing, in the mutual aid agreement documents.

By taking into consideration both sides of the staff-patient equation, a hospital crisis plan can maximize the effectiveness of the facility without surrendering jurisdictional control to an all-agency effort. Hospitals are major community resources and vital components of the local infrastructure. But most hospitals can and must be much more responsive and much more capable than they now are.

Joseph Cahill
Joseph Cahill

Joseph Cahill is the director of medicolegal investigations for the Massachusetts Office of the Chief Medical Examiner. He previously served as exercise and training coordinator for the Massachusetts Department of Public Health and as emergency planner in the Westchester County (N.Y.) Office of Emergency Management. He also served for five years as citywide advanced life support (ALS) coordinator for the FDNY – Bureau of EMS. Before that, he was the department’s Division 6 ALS coordinator, covering the South Bronx and Harlem. He also served on the faculty of the Westchester County Community College’s paramedic program and has been a frequent guest lecturer for the U.S. Secret Service, the FDNY EMS Academy, and Montefiore Hospital.



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