1. 
   

   What leadership principles should be followed by hospitalists and key leaders of the organization during a disaster?

   
   
2. 
   

   How should an emergency command center be designed and operated while conveying an environment of safety for your staff and other essential personnel?

   
   
3. 
   

   What are some significant considerations for hospitalist and organizational staffing and planning models during a disaster?

Despite the best preparations and planning, many aspects of managing an organization and a hospitalist practice change rapidly, and many new, often unanticipated, problems arise during the peridisaster and recovery period. We present our management learnings as a large hospitalist program within a tertiary-care referral center during an unprecedented disaster in Hurricane Katrina and extend preparedness principles to other types of man-made, natural, planned, and unplanned emergencies.

Organizational

The ability to lead others through change and adversity and to sustain an effective team with a unified purpose is required during a disaster, not only within the hospitalist program level, but also at an organizational level.

All top leaders in an organization need to be present during and/or in the aftermath of a disaster. This includes not only the CEO and COO, but also the CFO, VP for human resources, and so on. In a severe disaster, issues like how to pay employees if major electronic systems are down, how to prepare an insurance claim for business interruption insurance (documentation needs to start during the actual disaster), access to significant cash reserves in order to function, and how to manage employees who have neglected their responsibilities will be among the multitude of issues for which leaders will be needed. A leadership structure with the appropriate scope of responsibilities and number of direct reports needs to be functional, and on-field promotions will likely be required. Assigning responsibility for conducting every detail of your plan is essential. It will be necessary to ask unofficial leaders to step up and help manage particular functions or groups of individuals and they must be given the authority to do so with appropriate levels of support. They need to have the traits of selfless dedication, courage, decisiveness, compassion, and optimism. The failure to quickly create new leadership structures to fill in for leaders who cannot be present will lead to an unmanageable situation.

A Few Key Leadership Principles

A strong sense of purpose with optimism: “We will make a difference in this disaster. We will care for our patients who depend on us to manage through this difficult time. Here are our challenges and we’ll face them together and get through this fine.” Employees (or at least all key managers) need to hear this and be updated with the status of the organization and challenges twice a day with the expectation that they drive it down into the institution. A sense of unaffordable failure can be a self-fulfilling prophecy.

Stopping rumors is one of leadership’s first priorities. Rumors can quickly supplant the appropriate focus of employees. Managers should immediately report rumors to the highest level of leadership and, to the extent possible, all activities in which executive leadership are involved at the time should stop so that the rumor can be addressed.

In a disaster situation, strict rules are important. In our situation, without water pressure, fire represented our most significant threat. Smoking anywhere around campus became an immediately terminable offense. Everyone must understand the rules in a disaster. Do not hesitate to be clear. In a disaster, rules that are explained will be followed.

In a disaster, everyone’s job becomes whatever they can do. If a physician is not busy, he or she can help in the cafeteria. Make this expectation clear: people will surprise you and the positive effects of acts such as this will last long past the disaster.

Emotional support in a disaster is critical for many employees. Usually, this is with a friend or colleague. It should be a stated understanding that anyone might and perhaps most people will have to step away for a moment and compose themselves in order to return to duty capable of performing their job. It is normal during a crisis. Formal counseling should also be available. Psychiatrists and/or psychologists should be essential personnel in a disaster in order to provide regular group and individual counseling as needed.

In planning for a disaster, there is no such thing as a “doomsday scenario.” There is no situation that should be described in planning as “if this should happen, it would be so bad that we really couldn’t plan for it.” This is a fallacy. A whole city flooding was a scenario that easily could have been seen to fit in this category. However, those organizations that planned as best as they could for such a severe event did far better than those that did not. Even for events with a high likelihood for significant mortality, such as a terrorist attack or severe flu pandemic, those organizations that plan will be far better off, and no matter how bad the disaster, there will be many survivors looking to those most prepared for needed help.

Hospitalist

As a key component of any hospital’s disaster response, it is important for the department chairperson or group leader of the hospitalist team to be involved in disaster planning. Strong leadership is crucial to maintaining a sense of confidence and an optimistic outlook in times of uncertainty.

Our past hurricane experience led us to develop a two-team system for all disasters. The number of hospitalists on Team A was determined by anticipating at least a 15–20 census per physician. These physicians are required to stay on campus. Team B is composed of individuals who have an expectation of being available within a week to relieve Team A. For predictable disasters, such as hurricanes, discharge and transfer protocols based on time until landfall can assist in volume and census management.

After Hurricane Katrina, it was uncertain how many patients would require medical care in the community. From the Hurricane Ivan experience in Pensacola, we were advised that in the 10 days after the disaster, one could anticipate a doubling of the highest emergency department volume for several weeks. The group leader must plan for surge capacity.

Included in the Hospital Medicine disaster plan would be the consideration of closure of other health care facilities and the absorption of those patients into the organization. To offer quality and safe clinical care and remain able to perform under such conditions, our hospitalists unanimously agreed to care for our patients 24/7 in weekly rotation. Our hospital census during this period was at 60% of usual, and our admission rate was running at 40% of normal. We decreased the residents staffing from three members per team to two in order to provide a five-day rotation of three teams. If possible, a staging center in a facility outside the disaster area to organize the faculty and resident staff and provide transportation is very helpful.

We experienced a sense of camaraderie after seeing all our colleagues participating in activities beyond the boundary of usual roles. For example, you should consider eliminating exclusive service functions. Our skilled nursing physician might care for the acute stroke victim, and so forth.

Emergency Command Center

Like governmental agencies, emergency command centers must be created and predesignated before a disaster. This might simply be a centralized location where administrative support and executive leadership would meet and plan. Ideally, it would be a location for the various communication devices and other equipment needed to communicate with external agencies—a central repository of key information available 24 hours a day.

Your command center should be located in a secure area of your safest building and ideally would have no external windows. The location of the command center (and other essential functions) would depend on the likelihood of different disasters. In our case, flooding is the major concern; hence all essential functions are moved to the second floor. It needs to be 100% self-sufficient with stand-alone emergency power, food, water, toilet facilities, heating, and air conditioning. This will be your communication hub with satellite TVs, satellite Internet stations, fixed antenna satellite phones, hospital emergency administrative radio (HEAR), emergency communication radios, and ham radios. Connection to all facility security cameras, including zoom cameras, covering all approaches to the facility is required. In the likely event communication networks fail, this will be your lifeline to the world (Figure 265-1)!

Communications

Organizational

Effective communications within the facility and with external agencies, vendors, and so on will be critical. Numerous emergency communication tools and redundancies should be built into the plan. Communication failures led to many of the untoward events following Katrina.

Satellite phones with fixed antennas mounted through an elevator shaft to the roof with a detachable antenna on the roof and ham radios (with operators) are important when regular service fails. Cell phones become useless (even if towers stay up) since the circuits are simply overloaded. Two things that did work better were cell phones with out-of-state area codes (we now keep some of these at all times) and text messaging. We were fortunate to have an internal phone system (Spectralink phones) that allowed for rapid communication internally. Given that most people will be on the run and not in their usual location, as many leaders as possible should have these phones (and regular meetings twice a day within each department or unit can provide updates for everyone else). It is virtually impossible to over-communicate.