Concepts
The Importance of Evidence-Based Disaster Planning

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Disaster planning is only as good as the assumptions on which it is based. However, some of these assumptions are derived from a conventional wisdom that is at variance with empirical field disaster research studies. Knowledge of disaster research findings might help planners avoid common disaster management pitfalls, thereby improving disaster response planning. To illustrate the point, this article examines several common assumptions about disasters, compares them with research findings, and discusses the implications for planning. These assumptions are that:

  • 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 severities of casualties to be transported to them.

  • 7.

    The most serious casualties will be the first to be transported to hospitals.

The current status and limitations of disaster research are discussed, and potential interventions to response problems are offered that may be of help to planners and practitioners and that may serve as hypotheses for future research.

Introduction

Numerous responders and planners who have been involved in disaster events have written articles reporting lessons learned in these events. 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. Although the reasons for this are complex, a significant contributing factor is that disaster planning is only as good as the assumptions on which it is based. Knowledge based on systematically collected data from field disaster research studies might help planners avoid common disaster management pitfalls, thereby improving disaster response planning. The focus of this article is on research dealing with operational and organizational emergency medical response issues in domestic, peacetime disasters.

Although there are many limitations on current research about disaster medical planning, many data have been gathered that can be used to improve emergency planning. The status and limitations of current research include the following:

  • Most operational research on disaster medical planning has been conducted on sudden, single-impact disasters such as tornadoes, flash floods, or explosions.1 In these sudden-onset events, the researcher usually cannot select the location where the data collection will occur.2

  • The selection of variables that can be controlled is often limited.2 The unexpected nature of disasters also means that data collection on emergency medical responses generally has to be retrospective.2 This, in turn, creates difficulties with before-and-after comparisons of the event. For example, persons in the locality before the disaster may have relocated because of destruction of their homes and workplaces. Others will have been in the area only temporarily because of the disaster (eg, assigned or volunteer responders).2 This makes probability sampling challenging.1

  • Data are often evanescent, which is the case for a number of reasons; for example, individuals and officials are often more willing to share information in the immediate aftermath of a disaster than later.3 Many of those affected will be in the area only temporarily because of the disaster and may be difficult to identify and locate subsequently.2 Over time, memories fade, and recall bias may become a problem.1, 4 For example, later interviews often tend to depict the response as less ad hoc than it actually was.5

  • Recordkeeping may be abandoned in favor of patient care under the pressure to provide lifesaving care to a large number of victims.1, 6, 7, 8, 9 Because of these limitations, research on disasters is not likely to meet with the expectations of those who think of research in terms of randomized, double-blind, clinical studies, or even the less rigorous observational case-control or cohort studies.

  • Research on disaster medical responses has, for the most part, used qualitative methods and case or case series design. Typically, researchers have analyzed descriptive data and have derived empirical generalizations based on that material. Generally, this material came from interviews, sometimes supplemented by government documents, emergency department (ED) logs, after-action critiques, media accounts, and other sources of information.10, 11 This information may be coded for quantification and analysis. Examples of categories of information that might be coded are existence of a disaster plan, numbers or proportion of casualties transported by ambulance, hospital notification, number of casualties received or admitted, injury or illness severity, and damage to hospital systems.12 Many of these studies are descriptive, rather than tests of hypotheses.1

  • Some reports provide quantitative estimates but often without documentation of methodology. These statistics include such things as numbers of casualties, numbers of patients rescued by other survivors, and numbers transported by ambulance. Furthermore, although mean values are reported, measures of variation (eg, SD or 95% confidence intervals) are often lacking. Notably lacking are studies that examine mitigation, preparedness, response, and recovery variables with respect to their outcome in terms of morbidity and mortality. Another limitation of the existing literature is that many of the research reports are not published in peer-reviewed journals but rather appear in reports published by government agencies or academic institutions.

  • Finally, some of the more useful case series are dated, and there have been significant changes in public health and emergency medical systems since their publication. Although these studies need to be validated with more recent data, some case studies and anecdotal reports suggest that problems identified by these earlier systematic studies may still be major obstacles to effective response.

Despite its methodologic limitations, empirical observation of disaster responses identifies a number of problems that appear to compromise effective provision of health and medical services in disasters. Many of these data have been collected systematically and objectively. In a number of studies, data have been collected from a broad range of individuals and organizations (eg, hospital administrators, physicians, nurses, dispatchers, emergency medical services [EMS] providers, police departments, fire departments involved in or affected by the disaster), thus allowing an analysis of how the various emergency response organizations interacted and giving a picture of the overall communitywide response.11, 12 This helps not only to assess the consistency of observations from multiple sources but also to develop a picture of the event from a “systems perspective,” that is, to identify the interaction of various responders at a community level. This is important because what happens in one organization or locality can often influence what happens in another. For example, the actions or inactions of those in the field (eg, whether or not authorities in the field or their dispatchers promptly notify area hospitals of the event and the types, numbers, and severities of casualties they are likely to receive) will often affect subsequent operations at hospitals. The observations from these research studies reveal that what happens in disasters often differs from what the conventional wisdom would suggest. In at least 2 studies, observations have been carried out across multiple disasters in an effort to identify commonalities and patterns that may be difficult to discern in a collection of individual case studies. The first such study was the Disaster Research Center study, carried out in the late 1970s, during which data were systematically collected from 29 mass casualty events in the United States and its territories.9, 11, 12, 13, 14, 15, 16, 17 Tierney used this same approach to assess 8 US disasters in a 1993 unpublished report.17

The goals of this article are to:

  • raise awareness of some key disaster preparedness planning and response problems identified in field research studies;

  • propose and stimulate the development of some potential interventions for these problems;

  • generate interest in learning more about disaster research findings; and

  • make suggestions for future research.

Additional sources of information are provided at the end of the article. In the following section, a number of common planning assumptions18, 19, 20, 21 are listed and then contrasted with findings from field studies of disasters (see the Table). Implications of these findings are discussed, and some potential interventions are presented. These potential interventions may serve as hypotheses to be tested in future research studies.

Section snippets

Assumption 1: Dispatchers will Hear of the Disaster and Send Emergency Response Units to the Scene. Research Observation: Emergency Response Units, Both Local and Distant, will Often Self-Dispatch

Early in a disaster, it is not always clear who at the scene is in charge and can be contacted about the need for assistance.6, 9, 13, 15, 22, 23, 24, 25, 26, 27, 28, 29 Emergency responders may first hear of a disaster from police scanners or the news media before they are informed by official sources. Frequently, initial reports are greatly dramatized and exaggerated.9, 30, 31 For emergency responders, getting accurate, official information on the extent of the disaster and the need for help

Assumption 2: Trained Emergency Personnel will Carry Out Field Triage. Research Observation: The Survivors Themselves Carry Out Most of the Initial Search and Rescue

Studies of search and rescue in disasters have shown that a substantial proportion of, if not most, search and rescue is carried out by untrained survivors.8, 10, 17, 24, 26, 27, 37, 39, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83

  • Example: Earthquake, San Francisco Bay Area, 1989. A random household survey of residents in 2 of the 6 counties impacted by the earthquake showed that 3% of the residents of San Francisco County and 5% of the residents of Santa Cruz County became involved in

Assumption 3: Trained EMS Personnel will Carry Out Triage, Provide First Aid or Stabilizing Medical Care, and—If Necessary—Decontaminate Casualties Before Patient Transport. Research Observation: Casualties are Likely to Bypass On-Site Triage, First Aid, and Decontamination Stations and Go Directly to Hospitals

Although disaster plans may call for casualties to be triaged and given lifesaving first aid in the field, survivors often bypass field first aid and triage efforts9, 80, 93, 94 because they may not know that field first aid or triage stations exist, much less where they are.9, 95 In addition, survivors may consider these stations as a lower level of care than that available at hospitals.9

Although there are limited data on hazardous materials disasters, it is possible that decontamination

Assumption 4: Casualties will be Transported to Hospitals by Ambulance. Research Observation: Most Casualties are not Transported by Ambulance; Rather, they Arrive at Hospitals by a Variety of Nonambulance Vehicles (eg, Private Cars, Police Vehicles, Buses, Taxis, or Even on Foot)

For many untrained persons who become involved in search and rescue at a disaster site, the “best emergency care” is seen as transport to the closest hospital as quickly as possible. If ambulances are not promptly available, survivors do not tend to wait for their arrival but will use the most expedient means to transport the casualties.11, 13 The Disaster Research Center study ascertained that the initial means of casualty arrival at 75 hospitals for which data were available was as follows:

Assumption 5: Casualties will be Transported to Hospitals Appropriate for their Needs and in Such a Manner that no Hospitals Receive a Disproportionate Number. Research Observation: Most Casualties are Transported to the Closest or Most Familiar Hospitals

The ideals for civilian disaster medical care are based on the military precepts of triage, that is, doing the greatest good for the greatest number of casualties, which implies making the best use of available medical resources. For example, casualties with sprained ankles and minor lacerations should not be sent to trauma centers or burn centers. Also, casualties should be distributed among the hospitals available so that no one hospital is disproportionately overloaded and so that patient

Assumption 6: Authorities at the Field will ensure that Area Hospitals are Promptly Notified of the Disaster and the Numbers, Types, and Severities of Casualties to be Transported to them. Research Observation: Hospital Notification of a Disaster may be from the First Arriving Victims or the News Media, Rather than from Authorities in the Field. Often, Information and Updates about Incoming Casualties are Insufficient or Lacking

To the extent that hospitals can be forewarned before casualty arrival, they can better organize the resources necessary to treat the casualties. The types of information needed by hospitals include the nature and scope of the disaster; the numbers, types, and severities of injuries or illnesses; and the estimated time of victim arrival. However, the Disaster Research Center Study showed that most often the first notification of hospitals was not from authorities at the scene but rather from

Assumption 7: The Most Serious Casualties will be the First to be transported to Hospitals. Research Observation: The Least Serious Casualties Often Arrive First

The Disaster Research Center Study observed what one might call “reverse-triage,” with the least serious casualties tending to arrive first.9, 11, 12, 14, 113 Similar observations were reported in the 1989 San Francisco earthquake130 and the 1985 Mexico City earthquake.131 This could be because the more serious casualties were more likely to be trapped in the rubble, requiring more sophisticated search and rescue efforts to extricate them. Also, the least serious casualties are often more able

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    The findings and conclusions in this report are those of the author and do not necessarily represent the views of the Agency for Toxic Substances and Disease Registry.

    Supervising editor: Jonathan L. Burstein, MD

    Funding and support: The author reports this study did not receive any outside funding or support.

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