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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Ongoing Disaster Response Preparedness Concerns Post-Katrina
Lessons from the JPS model
The power of primary care
Exposing vulnerabilities: Primary health care and surge capacity
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Thomas F Gavagan, Houston, TX Department of Family & Community Medicine, Baylor College of Medicine
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The report from Fort Worth describing their experience caring for Hurricane Katrina evacuees is quite useful and parallels our experience caring for 13,000 patients at the Houston Astrodome super-shelter with a predominance of primary care problems including chronic disease care, gastroenteritis and acute respiratory infection. Due to the scale of the response in Houston with 25,000 evacuees arriving from the New Orleans Superdome, the Baylor College of Medicine Family Practice group was quickly overwhelmed and response at the medical center level activated with separate areas constructed for pediatrics, mental health, women’s health and other specialties, social services, as well as adult primary care and an area for isolation and rehydration. The level of acuity was also high with over 50 patients transferred daily for several days with many children and elderly patients arriving severely dehydrated. Our experience was that we were only able to organize this large disaster response because many factors were in our favor. First, we had the resources of the large Texas Medical Center available with over 800 physicians and 1000 nurses volunteering during the two weeks. Critical transportation, supply and communication systems were all intact since Houston sustained no damage from the storm. The large Astrodome facility was empty and available for use with good prior planning with sufficient cots and meals which were immediately made available. The numbers of arriving injuries and critically ill patients did not exceed the capacity of local emergency centers and hospitals. Evacuees arrived in good spirits and became assimilated into the local community. As in New Orleans itself, our result could easily not have been so rosy. We had no mechanism of registering and tracking thousands of arriving evacuees which is necessary for family re-unification and epidemic contact tracing. We were fortunately able to contain a large gastroenteritis outbreak which occurred at the super-shelter; quarantine proved unworkable and sanitation facilities at the sports complex were overwhelmed. As in most communities, there is no organized plan for incorporation of medical services into the emergency operations command structure as there is for public health, security, etc. Pre-existing relationships between county government, hospital district, and the medical schools allowed an organizational structure to be created on the fly to facilitate the large response that was necessary with daily adaptation to changing conditions. We should not allow ourselves to become complacent following one successful disaster response considering unknown future conditions and events such as epidemic flu. Considering the possible increase in disasters and epidemics globally related to climate change and population vulnerability globally, we have considerably more work to do prior to the next disaster. References: Gavagan TF, Smart K, Palacio H, et.al. Hurricane Katrina: medical response at the Houston Astrodome/Reliant Center Complex. South Med J 2006;99:1321. Sirbaugh PE, Gurwitch KD, Macias CG, et.al. Caring for evacuated children housed in the Astrodome; creation and implementation of a mobile pediatric emergency response team; regionalized caring for displaced children after a disaster. Pediatrics 2006;117: S428-38. Yee EL, Palacio H, Atmar RL, et.al. Widespread outbreak of norovirus gastroenteritis among evacuees of Hufficane Katrina residing in a large “megashelter” in Houston, Texas: lessons learned for prevention. Clin Infect Dis 2007;44:1032-9. Competing interests: None declared |
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Wayne Higgins, Bowling Green, KY, USA Professor of Health Service Administration, Western Kentucky University
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Hurricane Katrina forced thousands to evacuate the Gulf Coast and devastated health systems in its path, reducing hospital capacity in New Orleans by 80%. Many residents were forced to evacuate without their medication. Cities hundreds of miles away, including Houston, Dallas, and Ft. Worth in Texas, welcomed thousands of evacuees placing increased demands on their health care systems. The paper by Edwards, Young and Lowe describes how JPS Health Network (JPS), a large tax-supported integrated health system in Tarrant County (FT. Worth) responded to the needs of 3,700 Katrina evacuees. Drawing upon the resources of a large family medicine residency program, JPS established a triage center several miles from the hospital and referred almost all of the 1,600 evacuees seeking medical care to a primary care clinic, thus preventing a large increase in demand for emergency department and hospital services. The JPS model may have wide applicability in similar circumstances and offers at least three important lessons for emergency planners: First, large regional disasters may require massive evacuations and thus impact health systems in distant cities.Some evacuees will travel in their own vehicles and may present at emergency departments for routine care. However, many may be transported by air or bus and for these groups the triage and primary care clinic model is well suited. Regional disaster plans should account for the possibility of an influx of large numbers of evacuees as well as local disaster victims. Second, it is widely recognized that hospitals and emergency departments are likely to be overwhelmed in a mass-casualty incident and that many of the patients who present at these facilities may not require emergency care. Off-site triage and primary care sites can address non-urgent needs while preserving scarce hospital and emergency department capacity for the most serious cases. The JPS model provides an excellent example of this process under favorable circumstances (large numbers of transported evacuees and time to prepare). Planners should consider a similar approach where conditions and resources allow. Finally, the family medicine residency program provided JPS with the in- house physician surge capacity to respond to the needs of evacuees with minimal disruption of routine operations. Many hospitals and health systems do not have similar resources available, but where they exist, family medicine residency programs can be valuable partners in health system preparedness. The broad medical education of family physicians make them ideally suited to provide triage, as well as primary care, to evacuees and local disaster victims. When this can be accomplished away from hospital campuses it can relieve the burden on vital emergency departments. Emergency planners should work closely with these programs to ensure they are incorporated in regional disaster response planning. Wayne Higgins, PH.D Professor of Health Service Administration Western Kentucky University Competing interests: None declared |
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John L. Hick, Minneapolis, MN Assistant Professor of Emergency Medicine, University of Minnesota, Hennepin County Medical Center
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Edwards et.al. (1) offer a valuable contribution to the disaster literature with their discussion of a healthcare system's response to arriving evacuees from Hurricane Katrina. A few points are worth emphasis: 1. Outstanding partnership was exhibited between county emergency management and the JPS healthcare system. Estabilishing these relationships in advance of any incident is important to timely and appropriate use of primary care resources. 2. The JPS system was able to access and deploy a wide range of resources to both traditional and non-traditional locations to support the response effort. This institutional commitment and the flexibility and scalability of the response are admirable. 3. Primary care skills are far more important in disasters than is commonly appreciated. This is of particular importance when the disaster results in loss of healthcare infrastructure in the affected area and/or is an infectious disease event affecting the community. Planning to incorporate primary care outpatient practices and staff into community plans can literally make or break a disaster response. 4. Though healthcare disaster planning efforts to date often focus on inpatient surge capacity (2) there is no true community surge capacity for disasters without the involvement of primary care (and other outpatient clinics) and their staff. 5. Supply planning for disasters often concentrates on medications and supplies to be administered in hosptial environments. Greater emphasis is needed on stocking adequate outpatient medications including analgesics, anti-hypertensives, antibiotics, insulin and oral diabetes control agents, bronchodilators, and other commonly used medications. This article should stimulate needed discussions and planning with practice colleagues, local emergency management, hospitals, and parent healthcare corporations to determine the roles and responsibilites of primary care practictioners in local disaster response to assure their optimal utiliztion for the community's benefit. 1. Edwards TD, Young RA, Lowe AF. Caring for a surge of Hurricane Katrina evacuees in Primary Care Clinics, Annals of Family Medicine, March/April 2007;5(2):170-4. 2. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253–261 Competing interests: None declared |
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Frederick M. Burkle, Jr., MD, MPH, DTM, Cambridge, MA, USA Senior Fellow & Scientist, Harvard Humanitarian Initiative, Harvard School of Public Health
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Edwards, Young, and Lowe write that they hope their study will provide valuable lessons learned for future disaster planning.[1] This may be one of the greatest understatements coming out of the Katrina experience. Those of us who have spent careers in managing prototypical international public health emergencies resulting from war, conflict, and epidemics in the developing world, have painfully learned, often too late, the dominant and critical role that primary health care plays in managing these catastrophes.[2] Prior to Katrina, the US had not witnessed a large -scale public health disaster in almost 100 years. Our neighbors in Toronto faced the only SARS epidemic in North America and quickly recognized the need to rapidly switch from a conventional hospital -oriented mindset to that of population-based community primary health care clinics. Whereas hospital cases in every country drew the attention of the media and the bulk of the scientific literature, the stark reality is that the enhanced and sustained surge capacity of primary healthcare clinics proved to be the focus for successful management. Unfortunately, as the authors clearly recognized in this study, lessons learned for the crucial role of primary healthcare clinics did not find their way into after-action reports, evidenced-based literature, and worse, in revised community level disaster plans. Major disasters keep us honest in defining the public health and exposing its vulnerabilities.[3] All public health emergencies that compromise the protective functions of the public health infrastructure, which includes availability and access to health care, must have immediate surge capacity and capability as the first phase response to prevent an escalating deterioration of the health of the population, especially the most vulnerable. This pragmatic study needs to be read by every community-based Department of Health and disaster planner. References: Competing interests: None declared |
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