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The Importance of Evidence-Based Disaster Planning

April 27, 2010

Recently, I came across this great article on how disaster planners build their plans. The author argued that disaster planning started off behind the eight ball due to lousy assumptions that planners make. Our plans are only as good as what we assume others will do while the plans are being executed, so this makes some kind of sense.

The article is, “The Importance of Evidence-Based Disaster Planning,” (pdf) and the author is Erik Auf der Heide from the Agency for Toxic Substances and Disease Registry (ATSDR).

The article has a list of seven assumptions that the evidence does NOT support, yet the author feels that they are “common” assumptions used in disaster planning. They are:

  1. Dispatchers will hear of the disaster and send emergency response units to the scene
  2. Trained emergency personnel will carry out field search and rescue
  3. Trained emergency medical services personnel will carry out triage, provide first aid or stabilizing medical care, and — if necessary — decontaminate casualties before patient transport
  4. Casualties will be transported to hospitals by ambulance
  5. Casualties will be transported to hospitals appropriate for their needs and in such a manner that no hospitals receive a disproportionate number
  6. Authorities at the scene will ensure that area hospitals are promptly notified of the disaster and the numbers, types and severties of casualties to be transported to them
  7. The most serious casualties will be the first to be transported to hospitals

Anyone with experience in disaster situations care to share stories of times these things didn’t happen? But if the plan was written thinking that they would happen, then those hospitals would be in for an unpleasant awakening.

Reading through the article there are a number of very interesting passages and ideas. I wholeheartedly recommend folks download the article (while it’s 15 pages long, four of those pages are references and the rest goes down very easily) to get the full flavor as I’ll be focusing on those key passages I mention above.

First off the bat, in fact, the second sentence is something that I see as a tremendous failure in our field:

A review of this literature, however, shows that many of the problems experienced in planning and responding to disasters seem to be “learned” over and over again in disaster after disaster.

When you or your agency writes a plan, how much research do you do? Literature searches? Checking LLIS? Asking regional/state/federal partners what they think? Probably not as much as is ideal (though surely as much as we have time for).

The authors notes, in a section on the limitations of depending on disaster research, two things I found interesting. The first was a passage about how most disaster research utilizes qualitative data or quantitative data where the collection documentation is seemingly less than rigorous. While it’s true that this is a problem, I feel that it’s more a symptom of the field the literature is based upon and what wildly different circumstances must be dealt with to gather data. The second, however, is a passage that I agree with very much. The author says that much of the disaster research is simply old. Either response protocols have changed, research methodologies have changed or our understanding of disasters and how people react to disasters have changed. This is worrisome because it has the potential to lead disaster planners to plan using outdated assumptions, much like those listed above, which is less than useless, it’s actually harmful. It’s a shame that the state of the literature is like this; though it argues that there is fertile ground for research-minded students to make a name for themselves.

Assumption #2 talks about how trained personnel will conduct search and rescue operations, though we’ve seen and heard accounts (through folks like Amanda Ripley) that the real first responders are the survivors. The author’s recommendations include teaching first responders how to integrate those survivors into their larger, more coordinated efforts. I, instead, argue that we should teach folks how to do search and rescue and stabilization and triage (which, to be fair, he recommends in his recommendations for Assumption #3). Instead of having these people be counter-productive (in the eyes of the emergency manager) for a half-hour while waiting for USAR to show up, take advantage of that time. Groups like CERT, MRC and the American Red Cross should be training everyone. For more examples of how this should work, see John Solomon’s In Case of Emergency blog.

Assumption #4 talks about how folks get to the hospital after a disaster, by ambulance or other way. The research shows that a sizable percentage of people show up on foot, by car, by police car, by taxi, any way except by ambulance. This poses problems for decontamination protocols, victim tracking protocols and patient load preferences amongst area hospitals. While I agree that the assumption that ambulances will transport all victims leads to poor planning, is it advisable to try to fix the problem, or should we just update our planning assumptions? Should folks be told to stay at the scene and wait for crews to get to them, or is immediate transport — even if it messes up protocols — the better option? I honestly don’t know. Any EMS or ED docs care to comment?

Assumption #5 is about loading in hospitals. The closest hospitals get slammed, while more distant hospitals see little or nothing at all. MOUs should help balance these loads over time, but the initial crush of patients is problematic. I also see it as problematic in that, the first thing hospitals do after a disaster is clear bed space by releasing folks who don’t really need to be there. I’m not saying that I know it’s been a problem, or heard of situations that it could be a problem, or even rumors that it was ever a problem, but wouldn’t it be better to allow Mr. Jones to get that one last checkup before being released in preparation for receiving disaster victims? Especially if that hospital doesn’t see any victims for six to eight more hours? Especially  if something happens to Mr. Jones after he gets home?

In summation, the author makes a recommendation that I think is a GREAT idea. LLIS strives, I think, to be this, but I find it difficult to use and less than useful for real data comparison, besides being very homeland security focused. Here’s the passage:

A national clearinghouse for disaster health and medical research is needed that can collect, collate, analyze, and disseminate research findings. Making these findings available in digital format at no cost to planners an practitioners would help to ensure that they are more often integrated into practice.

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