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Institute of Medicine (US) Forum on Medical and Public Health Preparedness for Catastrophic Events. Medical Surge Capacity: Workshop Summary. Washington (DC): National Academies Press (US); 2010.

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Medical Surge Capacity: Workshop Summary.

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At-Risk Populations: Behavioral Health Effects and Medical Needs

Public health emergencies and pandemics are not equal opportunity offenders. The very young, the very old, the chronically ill, and the mentally ill all are more vulnerable. Special planning considerations need to be made for how to treat these patients in any emergency. Pre-existing vulnerability puts tremendous additional pressure not only on the medical system, but also on those already charged with caregiving before an incident occurs. Substantial time was dedicated at the workshop for discussion of various vulnerable populations, what makes them special, and what issues need to be addressed.


Children and youth make up approximately a quarter of the U.S. population. They are in daycare facilities and schools for much of their waking life, which increases their risk of contracting an infectious disease. As summarized by Arthur Cooper, director of Pediatric Surgical Services and the Regional Trauma Center at the Harlem Hospital Center, in the medical view, children are not small adults. They are more vulnerable to toxic exposures because of their metabolism and developing bodies. They require more food and water per pound than adults, which comes into play when planning for sheltering. And perhaps obviously, they are children. This means they need more supervision, reassurance, and help than adults, and are unable to care for either themselves or others. They may not be able to report symptoms or exposure reliably, may not be able to self-identify, and cannot legally consent to care.

Workshop participants stressed that all of these factors complicate the caring for children and need to be planned for specifically in any emergency preparedness plan. This extra planning is made more important when we consider that, paradoxically, children are both vulnerable and healthier, as a population, than other groups in the nation. A smaller slice of the healthcare pie goes to children than other segments of the population. This leads to fewer resources, and less ability to surge.

Children have many unique needs in a disaster—from reunification with families to special decontamination facilities that can handle family groups and non-walkers. But considerations also need to be made for the people who take care of the children. Parents’ concerns for their children and the stress of taking care of severely ill or injured children weigh heavily on caretakers. “Post-traumatic stress disorder [PTSD] … is not limited to families, but also to the caretakers,” asserted Joseph Wright, director of Pediatric Medicine and vice president for Patient Care Services at Children’s National Medical Center. “It is an important issue to keep in mind when taking care of children and families.”

Workshop participants expressed a general concern that some elements of disaster preparedness have not been adequately tested and evaluated for children. Wright suggested that the Pediatric Emergency Care Applied Research Network (PECARN), a federally funded research network, is a resource where these issues can be addressed. PECARN is working on a new set of performance measures for the Emergency Medical Services for Children Program. “We are proposing that there be a new performance measure on state preparedness for children and disasters, and this might be an opportunity to really get engagement of multidisciplinary folks,” said Wright. “This is a working document right now and I think an opportunity to engage.”

H1N1 and Children

To provide a concrete example during the workshop, Richard Hatchett, director of medical preparedness policy for the National Security Staff at the White House, presented an update on the H1N1 influenza and its incidence in children. The CDC numbers as of early June 2009 showed H1N1 to predominately affect younger age groups, with about two-thirds of infected people being under age 24. Of the 27 deaths that had been reported in the United States as of June 5, six occurred in the 5-to 24-year age group.

Hatchett noted that school closures across the nation peaked around May 5, with 700 schools closed, affecting 450,000 students.2 New York City was hit especially hard, with seven deaths occurring in the city and a number of schools closing for up to a week, as of the beginning of June.

There were lessons to be learned from New York City’s H1N1 outbreak. First, schools will be highly affected during pandemics, and not just because of the possible increase in risk of passing contagions. During the H1N1 outbreak, there were high rates of absenteeism in many schools, with about a third of NYC schools experiencing 20 percent higher absenteeism than usual for that time of year.

Not all students who stayed home were sick, leading workshop participants to ask: What do we do about the “worried well”? The NYC Department of Health and Mental Hygiene estimated that two-thirds of the absenteeism was due to parents keeping their children home as a result of parental anxiety. Unless we can develop ways to ensure that our schools are safe environments for our children, Hatchett suggested, this is probably going to be a significant factor going forward.

Hatchett noted that the response to the H1N1 virus changed as information was gathered. The CDC “did strike a cautious pose initially in terms of their recommendations relating to non-pharmaceutical interventions and the initial recommendations about school closure,” said Hatchett. “And they changed course very quickly. I think that they are to be credited for taking a look at the situation and, as they got a better handle on it, shifting gears toward a more calibrated approach to the virus that you were actually facing.”

The challenge, of course, is keeping children in school while preventing the spread of disease.

The New York Approach

New York City has taken the approach of looking at the pediatric chain of survival for evaluating care options: prevention, access to care, life support, and specialized care. As Cooper, who is also a professor of surgery at Columbia University, stated, “If any of these links in the chain is broken, children cannot be expected to receive the care that is necessary.”

In New York City, prevention is supported through risk communication. Access to care is supported by the creation of a triage plan. As far as the links of life support and specialized care, New York City has established which hospitals have pediatric facilities, either as tier-1 facilities (children’s hospitals with a pediatric intensive care unit [PICU]) or as tier-2 facilities (general hospitals that have pediatric inpatient units, but no PICUs). For medical surge, NYC is focused on increasing the human capabilities of hospitals without PICUs to be able to care for children who are sicker than usual, but with an emphasis on transferring children to specialized children’s hospitals as quickly as possible. Although this plan is sound in principle, it makes many assumptions—especially that interfacility transportation will be available in the midst of a crisis.

Older Adults

Although there is little disagreement that older adults are at risk, there is not a broad consensus about the definition of “older adults.” Older adults can be defined as over 80, over 65, or even over 50. Each group has different specific characteristics and needs, and needs increase as the population ages. Charlotte Yeh, chief medical officer of AARP Services Incorporated, shared some characteristics of the over-65 Medicare population with the workshop:

  • More than 80 percent of all Medicare beneficiaries have at least one chronic illness, with 20 percent of them having four or more;
  • 42 percent of women 65 and older have arthritis;
  • Roughly 50 percent of men and 33 percent of women have hearing difficulties;
  • 20 percent of all men and women have visual impairment or visual difficulty;
  • 42 percent of the 65-and-older population is compromised in activities of daily living (trouble with handling the telephone, shopping, managing money, cleaning the house, etc.);
  • 20 percent of men 65 and older and 40 percent of women 65 and older live alone; and
  • The population is growing older. Estimates show that by 2030, the United States may have nearly 20 million people aged 80 and older—and the over-100 population is also growing. In 2008, nearly 100,000 people turned 100. By 2050, that number may reach 1 million.

Complicating these factors, many older adults are reluctant to request public assistance because they are afraid of being institutionalized or put into facilities. Because they value their independence even more than their health in some cases, Yeh said, “They are often invisible to relief workers.”

The consequences of these characteristics were seen in the aftermath of Hurricane Katrina. Of the approximately 1,300 people who died in New Orleans, 71 percent were 60 or older. Forty-seven percent were older than 75. Most people who died did so in their own homes and communities. Even those who did survive had long-term health effects. “There are tremendous ramifications for displacement and deterioration in their health and their vulnerability because of the change in environment,” Yeh commented.

Unique Challenges

For many older adults, chronic illnesses mean a reliance on multiple medications. About half of people aged 65 and older take three or more prescription medications a month. This has huge ramifications when thinking about care after a mass-casualty event. Not only will medications be needed to treat whatever illnesses and injuries arise from the event itself, but the prescription and medication system needs to be in place so that patients can continue to get their routine medications as well. Additionally, people with chronic illnesses have a higher risk of developing pneumonia even before the effects of a pandemic or toxic exposure have occurred.

Chronic illnesses also frequently require medical appliances that need electricity and supplies, from oxygen pumps to home dialysis machines. An electrical outage due to an emergency can mean these patients may need medical sheltering before the general public. Raymond Swienton, codirector of the Section of Emergency Medical Services, Homeland Security and Disaster Medicine at University of Texas Southwestern Medical Center, explained, “The reality of most special needs patients are they are simply at home, living day to day in a very fragile, self-designed medical community.” That self-designed medical community—their home—can become nonfunctional in an instant with the simple removal of electricity or a failure in the supply chain.

The older population faces challenges simply in moving physically through the system. The higher incidence of arthritis in the population causes complication boarding public transportation to get to alternate care facilities, and those sites need to be accessible to those who use a wheelchair, walker, or cane.

Even communication can be a challenge. Hearing difficulties complicate verbal announcements and information. Visual impairment complicates written communications, and a lower level of “health literacy” in some older populations can make communicating written health information and even collecting accurate patient data more difficult. Yeh cited a recent example in which a third of the 75-and-older population could not circle and identify when their next appointment was on a hospital appointment form. “In fact only about 4 or 5 percent of those 75 and older are even thought to have any proficiency in healthcare literacy,” Yeh explained.

There is one encouraging statistic in communicating with older adults—they’re relatively easy to target as a population. People over 65 spend, on average, 50 percent of their leisure time watching television. They are also among the fastest growing populations on the Internet—in fact, women age 55 and older are the most rapidly growing segment on Facebook and other social networking sites.

Some states are making it easier to locate vulnerable groups of older adults. Florida is required to have a special needs registry that lists every resident who needs assistance with activities of daily living. This enables the state to find people who will need extra help in the event of a hurricane or other emergency.

Treatment needs of the older population may overlap with those of the pediatric population. Some older people may be disoriented and unable to remember all of their medical needs, and they may need more help with self-care because they are confused. However, how the system deals with these issues can be problematic. “Under CMS, if we want to pay you for nursing home services, you have to meet certain levels of criteria,” Yeh noted. “Well, what if it is a pandemic? You do not have those kinds of facilities in your ordinary shelters. You might want to put them in facilities like nursing homes. How do the nursing homes actually get paid when essentially these individuals do not quite need that skilled level of nursing care, but they need it during a disaster or a surge response?”

Many workshop participants emphasized that tackling the issue of Medicare funding in mass-casualty events is an important area for future work to improve emergency preparedness and response.

The Chronically Ill

The chronically ill have many of the same needs as older adults. They can have multiple medications, require oxygen or other medical support systems, and have complex care plans. The chronically ill can be too fragile to move safely without significant planning and specialized transportation. During an emergency evacuation, this can be impossible.

Workshop participants shared numerous anecdotes from Hurricane Katrina about nursing homes that were not evacuated in time. The natural reaction is always “Why? Why didn’t they evacuate, why didn’t they leave sooner?”

Swienton related a conversation with one administrator who explained that he had been told that between 1 and 10 percent of the patients he needed to evacuate would not survive emergency evacuation. He had to weigh that with the risk of riding out a storm. While perhaps a shocking illustration, the question remains valid. “What is the answer?” asked Swienton. “What can a healthcare community do to move these people effectively?” There are no metrics available to make this kind of a decision, and the evaluations are necessarily situational.

Psychological Impact

When talking about behavioral health, there are a number of things to consider that impact medical surge. Behavioral science suggests that people respond in counterproductive and counterintuitive ways when confronted with an emergency: sheltering in place when they should evacuate, and evacuating or migrating when they should shelter in place. People tend to go where they feel safe. “You may not have people come to the emergency room. You may have them plant tents around the hospital,” said Robert Ursano, chair of the Department of Psychiatry at the Uniformed Services University and director of the Center for the Study of Traumatic Stress.

Alternatively, people may migrate out of the area, as seen after Hurricane Katrina. “New Orleans was not the disaster zone,” Ursano said. The disaster zone “was, in fact, the entire nation.” When people migrate in response to a disaster such as an epidemic, they carry the disease with them, spreading the event and the breadth of the required medical surge.

The injured or ill are not the only ones who seek care in a mass-casualty event; those who believe they are ill, injured, or exposed may also seek care. The 1995 sarin-gas attack in Tokyo’s subway system killed 11 people, but more than 5,000 sought care. In 1987 in Brazil, a radiological hazard contaminated 249 people and caused 4 deaths, but caused approximately 110,000 to seek screening (International Atomic Energy Agency, 1998). “You must deal with the question of those who are distressed, and not only those who are actually exposed,” cautioned Ursano.

Behavioral responses also can contribute to casualties. During the SCUD missile attacks in Israel in 1991, 1,059 people went to emergency rooms. Twenty-two percent were direct casualties of the attacks, and the remaining 78 percent were behavioral stress casualties: About half were suffering from anxiety, some had auto-injected themselves with countermeasures without being exposed to a biological agent, and seven people died due to incorrect use of gas masks.

A disaster has very real psychological effects on victims, survivors, and relief workers, including healthcare providers. “The mental health burden of illness doubles in the face of disasters,” said Ursano, citing research done after Hurricane Katrina. A wide range of behavioral responses occur after disasters, including PTSD, increased use of alcohol and cigarettes, delirium/organic brain syndrome/psychosis, mourning/traumatic complex grief, depression, sleep disturbances, increased family violence and conflict, overdedication to the group, helplessness and guilt, identification with the victim, and unexplained somatic symptoms.

Because responses to mass-casualty events can be long lasting, special needs must be met to sustain alternative care facilities and home care. Support needs to be available to caregivers and first responders. “Even those that take care of others need sleep, rest, connectedness, and hope,” said Ursano. “The question is how to address our first responders’ needs … in times of medical surge.”



These statistics were up to date at the time of the workshop, but are not current to the publication date.

Copyright © 2010, National Academy of Sciences.
Bookshelf ID: NBK32846
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