The Hurricane Katrina response represented a dramatic absence of professionally crafted and guided processes for disaster preparedness and management — processes that are comprehensive and customizable for the incident, transparent, tested and glued together at the seams with the major public and private healthcare organizations, public health and safety agencies and other critical infrastructure stakeholders. These processes needed to be well suited to optimizing responses around limited time, limited resources and limited fore-knowledge of the unfolding circumstances. Up until now there has been no simple way to build and imbed these processes in an environment of both diverse and dispersed responsibility and authority.

However, as difficult as it is, we know we cannot simply throw up our hands and seek no solution other than condemnation. 

System solutions
Fortunately, growing up like shoots of green in an early spring lawn are business tools that may benefit the way we manage highly complex tasks like disaster preparedness and response. These are rapidly maturing techniques and technologies that are wrapped into what are commonly called expert systems. In this context, expert systems mean software applications that provide the user with work process tools that incorporate the know-how of the best disaster management experts and emergency department doctors and nurses. A true expert will quickly assess the situation and apply their expertise through a general framework, if/then logic and rules of thumb to guide his or her response. Similarly, an expert system can guide a user to a recommended response based on a quick profiling of the situation. For example, a senior nurse working at 2 a.m. in an emergency department might be faced with a barrage of ambulances carrying victims of a chemical attack or spill. An expert system can quickly guide her to the optimal response: Set up a decontamination center and administer the proper antidote protocol for the specific chemical agent identified by the expert system based on the casualties’ symptoms.

Such systems can already be found to some degree in the world defense establishment but the culture of the Department of Defense often leads to over-engineered, ponderous and exceptionally expensive systems. Business enterprises operate with far more limited resources in competitive and quick-cycle environments. Commercial expert systems tend to be nimbler, faster to build and faster to modify. They are a means to capture and deploy both expert know-how and transparent, systematic work processes. Increasingly these commercial expert systems are Web-based and part of the world of "software on demand" that enables the consumer access to best practices and the most recent enhancements without investing in in-house software development, maintenance or management resources.

Puzzle pieces
While no comprehensive Web-based, open system for hospital disaster management is yet fully implemented, the pieces of the puzzle are now rapidly coming together. They are sufficiently matured to the point that no progressive hospital system can afford to ignore the role of expert systems in disaster management. This is especially true because software-on-demand expert systems are a shared resource. They can be "pulled" off the Web and easily configured to accommodate local details without any need for an upfront capital investment. If properly designed, Web-based expert systems can even cope with situations where the electric grid or Internet is down, by caching the latest version of the system output when a disaster occurs (with the specifics of the disaster inputted), printing it while your hospital generators are still functional and using it in hardcopy form until Web systems are back up.

For example, a close cousin of disaster management expert systems is one that Olympus America makes available to its hospital and ambulatory surgical center customers called EndoPlanner. Olympus is a leading global provider of medical equipment based on optical/digital technology, typically providing the key endoscopy equipment in a surgical center. Olympus’ EndoPlanner is a comprehensive tool for determining the financial feasibility of a surgical center, building a detailed development plan, tracking the project’s implementation (more than 400 specific steps), then helping monitor and manage its operating performance, and finally identifying opportunities for remediation where shortfalls are detected. The EndoPlanner is a shared resource and is offered to Olympus customers at a very small fraction of what it would cost to build and maintain independently.

Successful steps
How can similar expert systems help hospitals prepare for the next Katrina? A hospital disaster management expert system would provide a common tool for preparing for and managing disasters, used by disaster management personnel, emergency department staff, environmental and safety and security personnel and hospital administrators. The expert system would achieve the following six tasks.

First, create a structured but flexible common operating picture around all the central components of hospital disaster management: (1) before an incident, completing a hazard vulnerability assessment, preparing or updating your disaster management plan, training and drilling key personnel in disaster management and, importantly, satisfying JCAHO accreditation standards, (2) during an incident setting up the command center, issuing relevant HEICS-based job action sheets, mustering necessary resources (pharmaceuticals, surge materials, transport, back-up utilities and supplies), managing patient surge, crisis communications with the public and media, and recording expenses incurred, and (3) after an incident managing the recovery, capturing lessons learned, identifying remediation opportunities and obtaining reimbursement of expenses.

Second, train and drill around a transparent disaster management program where all hospital constituencies can see their roles; see the inter- and co-dependencies; anticipate shortfalls in skills, materials and other resources; test triaging techniques and, yes, satisfy JCAHO.

Third, include supply chain management – working with your group purchasing organizations to plan, marshal and deliver required supplies in advance of, during and after a disaster event (from food, water, clothes, ice and basic medical supplies to oxygen cylinders, IV antibiotics and pumps, feeding pumps, diabetes pills, cardiac drugs, vaccines and crutches). Supply chain management represents a significant part of preparations for, during and after a disaster, which will be addressed in a subsequent article.

Fourth, connect the dots to non-hospital inter- and co-dependencies, helping foresee the linkages among your hospitals, public health and safety agencies, the first responder community, city, county and state political authorities, the federal agencies (HHS, CDC, FEMA) and NGOs (Red Cross, Salvation Army).

Fifth, provide confidence to your stakeholders that you have anticipated and prepared for a sensible array of disaster scenarios in light of your circumstances and environment:  owners, boards of trustees, financial management, regulatory, compliance and audit personnel, your staff, the media and the public. This confidence will be an asset when coping with a live crisis and when the support of these stakeholders is needed.

Sixth, better assure that the safety and security of your own hospitals, especially that your clinical staff are as safe as is feasible during the incident, so that they can continue to perform their vital roles. For example, in addition to the availability of things like appropriate antiviral drugs, this means good two-way communications with the families of hospital personnel during a crisis.

Each of these six components of a holistic disaster preparedness and management system can be planned and managed with the support of expert systems. Expert systems have proven themselves in other, similar applications. They will now prove themselves in disaster management.

A properly designed expert system should provide a comprehensive system for preparing for and managing incidents in hospitals, from mass casualty events to the temporary patient surges that most hospitals encounter on a weekly basis. The system should address all three stages of an incident:

• Before, with the preparation of a Hazard Vulnerability Assessment and Disaster Management (DM) Plan, establishment of DM committees and responsibilities, and training and drilling.

• During, with setting up the incident command center, distribution of customized job action sheets, crisis communications and bed management and patient flow.

• After, with recovery activities, capturing lessons learned and remediation.