The Role of Information and Information Needs in a Crisis Event

Accurate and timely information providing a detailed description of a disaster zone is a significant prerequisite to an efficient relief operation. A large-scale crisis situation following a natural or man-made disaster event immediately creates information demands by all those involved while concurrently disrupting the means that are usually available to obtain and distribute information. The decreased ability to provide and receive information following a crisis event is the combined result of several joint factors, including the disruption of telecommunication infrastructures, an overwhelming demand that remaining functional infrastructure is unable to sustain, as well as the effect on the human factor responsible for maintenance of vital infrastructure systems, and the provision of information. The discrepancy between the growing information needs and the ability to supply them creates a situation that can be termed an “information crisis,” which has to be quickly resolved to enable effective disaster response planning and relief efforts: activities that heavily rely on information.

This chapter focuses on the information needs and the means of information provisioning within a field- hospital operation, and so a broad coverage of the “information crisis” and its mitigation among all involved parties in a disaster event is beyond the scope of this chapter. However, following is a brief classification of information needs that immediately arise during a crisis event. At the time of writing, there is still a considerable way to go in terms of the abilities to effectively fulfill these information needs at the time of a mass disaster.

Different groups have divergent information needs during the acute phase of a crisis event.

Information as the Driving Force of Successful Field Hospital Operations

Acquiring and managing the information required for a successful field-hospital operation are the goals of deploying an information system within a field hospital. Information should be timely acquired, accurate, and comprehensive enough to serve the higher goal of contributing to the efficiency and effectiveness of the field hospital mission. It is important to remember there may be a multitude of means, systems, and technologies involved in the process of acquiring and managing information, but all these are meant to facilitate the achievement of the goal; they are not the goal itself. It is a fact that field hospitals have been deployed in the past without the use of electronic information systems, but information itself has always been an important asset. With an electronic system or without it, certain subgoals and principles in the acquisition and management of information and its flow within a field hospital should exist.

The Namespace: Putting a Stop to Outside Chaos

Disaster may cause levels of dysfunction and, depending on its severity, may be an inherently chaotic situation. This chaos is fed by the disruption of the normal fabric of life and an overwhelming number of individuals in need of acute care in the face of a struck infrastructure. Affected individuals, more often than not, will be separated from their families, their belongings, and their identifying documents. Victims in large numbers, hurt or not, may be roaming the streets after having lost their homes. Food and clean water may be in shortage. It is within this chaos that a field hospital is expected to function and provide high-quality medical care. One of the first objectives that need to be achieved is putting a barrier to the outside chaos and preventing its continuation within the field hospitals’ facilities. Good clinical practice cannot be provided in the face of chaos. An essential ability in the initial stages should be a basic internal and external communication means.

One of the first and most important anti-chaos measures a field hospital needs to apply is the creation of the namespace. The namespace is a predetermined system that should be strictly enforced to provide a unique and constant identity to each patient within the field hospital. An unidentified patient within the facility should not be allowed under any circumstance, including acute trauma care. Such a namespace can be based, for instance, on a unique alphanumeric identification in combination with a passport-style photograph. The primary namespace system of identification should be provided by the field hospital itself. Relying on local identification systems and numbers as the primary identification means is not recommended because, depending on the deployment area, such local systems may be partial (there may be individuals who do not possess a local identification at all) and identifying documents normally used to assert an individual’s identity may be lost or missing. Local identification numbers, if available, should be registered, but they should not be relied on as the main means of identification.

Patient Flow Management and Tracking

Allocating a unique identification to every patient is the first step and a prerequisite for a well-organized field medical caregiving system. Once patients are identified, their information may be gathered and kept under this identification tag in all stations of care. The required flow of patients within the facility may be guaranteed and whereabouts of patients may be tracked. Under such a system, it becomes possible to make sure that every patient is accounted for and that prescribed and planned treatments and procedures are actually being delivered and carried out. A large multidepartment field hospital might be difficult to navigate by patients, especially in the face of language discrepancies, and a personal escort for every patient is not always possible. It is not uncommon for patients to misunderstand their designated destination within the facility. For these reasons, it is advisable to register a designated destination (department or tent number) for every patient going through the triage area and track the whereabouts of patients by registering them on arrival to a certain department, including a timestamp. With such a system, the staff can be alerted in case patients do not make it to their designated department within a certain period of time. This also enables analysis of patient flow efficiency within the hospital and the identification of possible bottlenecks. If possible, the identification process should be implemented in the prehospital facilities.

Situational Awareness and Control

A disaster zone within which a field hospital is operating is a dynamic environment. A field hospital, as large as it might be, will typically have limited available resources in contrast to the needs, which may be overwhelming and changing with time. The allocation of those limited resources should be based on a clear and accurate picture of both the internal and the external situation at all times, which calls for a high situational awareness by hospital management and key personnel members. Such situational awareness is only possible if relevant accurate and timely information is available for decision-making. Departmental occupancy rates, next-day discharge predictions, numbers and percentages of inpatients versus outpatients, developing characteristics of the case mix, and the status of pharmaceutical and equipment stocks are some of the parameters that need to be evaluated timely by management for successful decision-making within a field hospital. For some departments within the hospital, daily aggregate reports may be enough. However, for some resources, a fine-grained situation analysis and awareness is required. An example of the latter is the management of intensive care beds.

Aggregative Data and its Role in Decision-Making within a Field Hospital

What exactly is situational awareness and how should it be defined in the context of a field-hospital operation? The extent of information that is required to achieve awareness depends on the level at which the term is applied. For example, the extent of information that is required by the hospital’s management team to be “situational aware” is quite different from that of a certain caregiver within the hospital or that of a logistics team member. So, perhaps it is best to define situational awareness as a state in which every official within the hospital has timely access to accurate and comprehensive information that is required for decision-making by that official. For example, personnel at the pretriage and triage areas need to be aware of departmental occupancies before making a decision to admit a new patient. A decision on admission of a patient that will require ventilation during the course of his or her treatment has to be made knowing whether and when a ventilator is made available. The hospital’s pharmacy personnel should keep track of critical pharmaceuticals inventories, laboratory staff need reports of the number and types of studies performed to predict reagent consumption rates, and so on. Therefore, it is quite clear that, to achieve the desired state of situational awareness by all hospital personnel, it is not enough to have information available at the level of a single patient, but rather information should be aggregated and presented as dashboards or reports to hospital officials on demand.

Aggregative information is also needed for reporting purposes and regulatory compliance. An EMT working within a disaster zone is usually required by local authorities to provide daily information summarizing the activity within the facility, as well as pointing out cases that may have a special significance for public health and safety such as certain communicable diseases.

The World Health Organization (WHO) EMT initiative has compiled a minimum data set (MDS) platform as a means of data collecting and reporting between the EMTs and the EMTCC (Figure 12.1). Due to the large variability in the size, staffing, and technical capabilities of the various teams, the MDS is based on symptoms rather than on diagnoses. It includes 50 reportable criteria regarding patient demographics, health events, procedures and outcomes, and context. These criteria are then aggerated into a tick box and tally sheet, and reported daily to the EMTCC. The system enables overall assessment of the situation and medical activity in the disaster zone, enhancing resource utilization, and alerting to significant events such as disease outbreaks and violent activity. The MDS forms will be available on the WHO EMT website[1].

Figure 12.1 The WHO EMT initiative MDS

Ethical, Legal, and Regulatory Considerations

A proper documentation of care is both an established ethical requirement of the modern medical practice and a legal requirement in many countries in the developed world, as well as elsewhere. Moreover, court rulings throughout the Western world emphasize the importance of medical recordkeeping and regard medical records as legal evidence-of-care documents and therefore often hold care providers responsible in case records are missing or incomplete. For instance, the American Medical Association Code of Medical Ethics state that “medical records serve important patient interests for present health care and future needs as well as insurance, employment and other needs[2].”

Although in most countries the physical record does not belong to the patient, the information contained in the record is usually considered as belonging to the patient, who has a right to obtain a copy of everything that is contained within the record.

The WHO publication Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters lists the keeping of a medical record as one of the “core standards” for all types of EMTs operating within a disaster zone, not just field hospitals[3]. WHO requires that medical teams “will undertake to keep confidential records of interventions, clinical monitoring, and possible complications.” Moreover, the WHO standard requires that EMTs “will undertake for the individual patient, to have record of treatment performed.”

Clinical Documentation as a Practical Necessity Within a Field Hospital

Legal and ethical considerations aside, keeping a comprehensive and updated “living” document of care is a necessity in any multipatient and multicaregiver environment and perhaps even more so in the extremely dynamic setting of a field hospital. With multiple patients pouring through the gates of a field hospital, many of them requiring care from multiple caregivers within the hospital, it is practically impossible to ensure the provision of adequate care, including the timely administration of medications at the appropriate dosages and the timely performance of procedures, as well as physician orders, in the absence of a well-kept medical record and chart.

Moreover, medical records are known to improve the quality of patient care by contributing to consistency and by providing a detailed description of a patient’s status and a logic for treatment decisions, which can be reviewed, analyzed, and acted on at any time. Moreover, electronic medical record (EMR) systems improve patient outcomes and safety through improved management, reduction in medication errors, reduction in unnecessary investigations, and improved communication and interactions among providers involved in care[4,5].

The returning patient is another challenge that cannot be dealt with without a proper medical record. During the time course of a field-hospital deployment, it is not unusual to encounter patients who are returning to the hospital for additional treatment or follow-up. Adequate care of these patients requires a correct identification and review of their prior encounter.

Ethical, legal, and international standards, and practical considerations should make the presence of a comprehensive and well-kept medical record a standard of care within a modern field hospital.

Enabling the Continuity of Care (Intra- and Inter-organizational)

Perhaps the most important role of a clinical medical record in a disaster zone setting is to enable the continuity of care, both within the field hospital itself and following discharge to the community or transfer to other medical facilities within the zone or elsewhere. Continuity of care may be defined as the ability of a caregiver to provide medical aid that takes into account care that has previously been administered, including performed procedures and prescribed medications, as well as the ability to rely on results of previously performed diagnostic tests in a way that minimizes resource usage and maximizes patient comfort and safety. A comprehensive medical record is the most important means of achieving continuity of care. For this means to be effective, medical records should be organized in a way that facilitates the creation of a structured medical care summary document, which can be provided to the patient and passed onto future medical facilities and caregivers. Imaging studies performed within a medical facility should also be made available to the patient and future caregivers on discharge or transfer, either in a hard copy or a digital format. There may be an advantage for hard copies over digital formats in a disaster zone due to the uncertainty regarding the availability of electronic equipment and electricity required for viewing imaging stored in digital formats.

As one may appreciate, when information is managed to the full extent (recorded, gathered, analyzed, collated, transmitted, and selectively made available to consumers), it becomes a driving force, which streamlines field hospital operations and facilitates mission accomplishment.

Lessons Learned from Past Experience

Medical literature that deals with medical record keeping in a setting of a disaster zone field hospital is scarce. However, existing publications demonstrate that medical record keeping has been an important issue since the early days of humanitarian medical aid. Jafar and colleagues[6] carried out an extensive literature review and analysis on the subject of medical record usage by foreign medical teams (FMTs) in sudden-onset disasters (SODs), and yielded just 15 publications in which a reasonably adequate description of the medical record keeping system that had been used was provided by authors. Publication years ranged from 1983 to 2011. The earliest paper from 1983 was about the 1979 Tumaco earthquake in Colombia[7]. The authors suggested that a quick “card” system for recording information will improve data collection.

The term “medical records” in those early days referred solely to paper charts, obviously. A paper-based medical record is still in use in many disaster-response medical teams. At the single patient level, an elaborate paper chart can be an acceptable solution even today. However, when all requirements are considered, including the need to produce aggregative data for management decision-making and reporting purposes on the fly, there is a clear advantage to the use of electronic (computerized) records.

One of the first descriptions of the feasibility of implementing a computerized medical-records system on a large scale within a field hospital is our own experience from the Israeli field hospital that had been deployed in Port-au-Prince, Haiti, following the 2010 earthquake[8]. In the course of this deployment, which lasted 10 days, the electronic medical system registered more than a thousand patients, and hundreds of procedures and surgeries were documented, as well as follow-up information, pharmaceutical therapy, imaging studies, laboratory results, and lists of diagnoses. The clinical record also included a patient digital media album in which passport-like images and photos of injuries were documented. This deployment served as proof that it is possible to use a computerized system as the main means of care documentation, while at the same time demonstrated some of the possible risks and difficulties including developing a dependency on technology in a harsh and demanding environment in which technology can sometimes fail; a fact that highlights the importance of built-in redundancies, routine backup procedures, and a detailed fallback plan.

Currier and colleagues (from the Haiti aid project, Medishare), in a paper describing aid following Hurricane Katrina[9], and Burnweit and Stylianos (from the American Red Cross), in a paper describing aid following the Haiti 2010 earthquake[10], state that they had no adequate record-keeping method in place and that such a method had to be devised during the relief efforts. Additionally, Burnweit and Stylianos emphasize that the medical record system should allow for modifications based on specific needs encountered during the mission. This is an important lesson, which should impact the way medical record systems for disaster response are developed.

Many publications describe the changing case mix of patients over time. It is a recognized pattern to encounter patients with afflictions directly related to the disaster early on in the course of the deployment, with the ratio of these patients diminishing over time, and the ratio of patients with general ailments unrelated to the disaster increasing[11,12]. Again, this is an important lesson mandating that field hospital medical record systems be tailored to suit the documentation of various types of diseases, including chronic conditions, not just trauma or disaster-related cases.

Callaway and colleagues described their experience with an off-the-shelf modified mobile health record iPhone application (iChart) at a field hospital in Fond-Parisien, Haiti, following the 2010 earthquake[13]. Their experience is important in several aspects. Firstly, the EMR app was put to use seven days following the hospital deployment so that patients initially admitted were being treated without a record-keeping system in place. Thus, the authors were able to appreciate the effects of the lack of such a system within a busy field hospital:

Following the introduction of the iChart app, the authors state the observed benefits: the triage process became more accurate. The majority of providers felt that a handheld, electronic patient tracking system and medical record could reduce workload, improve patient care, and prove valuable in the postdisaster care setting. The iChart app improved provider handoffs and continuity of care within the facility. Patient information was standardized. Patients could be tracked within the facility and those who needed special postsurgical care, such as amputees and patients with external fixation devices, were flagged and easily searched and located within the database and the facility. Information on amputation patients was made available to UN-sponsored registries to facilitate postoperative treatment, short-term wound care, rehabilitation, and prosthetic planning. Aggregative reports prepared following data export from the app assisted hospital administration in planning logistic support, operations, and staffing requirements. Another important aspect of their experience is the successful use of mobile handheld devices as the major means of interaction with the medical record; no doubt a marker for the future.

Deployment Plan

A successful deployment of an IT solution within a field hospital begins with an elaborate planning process, which should be undertaken prior to and without relation to any certain mission. An IT plan can be created only as a derivative of a more general hospital deployment plan. Only after key operational parameters are known can a suitable IT plan be produced. These parameters include the deployment scheme, types of departments, expected hourly and daily flow of patients, and possible characteristics of patients, numbers and types of personnel, housing types, and types and quantities of certain medical equipment such as laboratory devices and radiology machines, as a minimum. Prior to an actual deployment, additional mission specific planning should be carried out going all the way down to the most basic details.