What is the role of healthcare providers in managing patients with various demographics and pre-existing conditions, such as chronic diseases, disabilities, or mental health conditions, during a disaster scenario?

Role of Healthcare Providers in Disaster Management

Healthcare providers must function within a collaborative team model where critical care specialists supervise non-specialists in expanded roles, matching caregiver competencies to patient needs through deliberate delegation and cross-training, rather than attempting to maintain standard-of-care staffing ratios. 1

Core Staffing Principle

The fundamental approach to disaster healthcare delivery requires abandoning traditional one-to-one specialist-to-patient models. All healthcare workers are essential during disasters, but not all usual work is essential—the goal is to match caregiver competencies with patient needs through systematic delegation. 1

Physician Roles and Responsibilities

Intensivists must oversee 4-8 non-intensivist physicians, each caring for up to 6 critically ill patients (total 48 patients per intensivist), rather than providing direct bedside care themselves. 1

• Non-intensivist physicians (hospitalists, anesthesiologists, surgeons, emergency physicians, obstetricians, general internists, pediatricians) should be assigned to collaborative critical care teams based on their recent ICU experience 1
• The level of independence granted to non-intensivists must be commensurate with their recent critical care experience, with closer supervision initially until competence develops 1
• Intensivists should be immediately present at bedsides of only the most unstable patients, while providing oversight and rapid consultation for others 1

Nursing Structure and Delegation

The most experienced critical care charge nurse must immediately take command to assign patients and caregivers based on acuity and staff capabilities. 1, 2

Two viable models exist for nursing organization:

Pod-Based Model (Preferred): 1, 2

• Critical care nurses oversee a "pod" of patients and mentor non-critical care caregivers assigned to their pod
• Non-critical care nurses are assigned no more than 2 critically ill patients under supervision of one critical care nurse 2
• Critical care nurses care for the most challenging patients while remaining available to assist non-critical care nurses 1

Functional Model (Alternative): 1, 2

• Critical care nurses are assigned to all patients for assessment and complex decision-making
• Non-critical care nurses and pharmacists deliver medications
• Paramedics maintain airways
• Allied health professionals (physical therapists, occupational therapists, social workers) perform specific care functions like patient turning, bathing, vital sign monitoring 1

Essential Competencies for Non-Critical Care Staff

All caregivers assisting at the bedside must possess six core competencies before patient assignment: 1, 2

1. Infection control practices (first priority for staff and patient safety) 2
2. Physical care activities (patient turning, cleaning, positioning) 1, 2
3. Suctioning and artificial airway maintenance 1, 2
4. Vital signs and monitoring equipment operation 1, 2
5. Foley catheter care and management of bodily wastes 1, 2
6. Medication and nutrition delivery through enteral tubes and IV pumps 1, 2

Respiratory Therapist Allocation

Critical care respiratory therapists should supervise 1-3 non-critical care respiratory therapists, with each critical care RT managing 12-14 mechanically ventilated patients total (versus 4-6 under normal conditions). 1

• Non-critical care RTs perform simpler tasks: airway suctioning, aerosolized bronchodilator delivery, circuit maintenance 1
• If respiratory therapists remain insufficient, allied health professionals (occupational therapists, physical therapists) can perform airway suctioning, oxygen saturation checks, and metered-dose inhaler administration after just-in-time video training 1
• Critical care RTs must perform complex tasks and provide intensive supervision initially, decreasing oversight once competency is demonstrated 1

Patient Management Priorities

Hospitals must prioritize only interventions that improve survival, don't require extraordinarily expensive equipment, and can be implemented without consuming extensive resources. 2

Essential Interventions to Deliver

2

• Basic mechanical ventilation modes (not advanced modes)
• Hemodynamic support with IV fluid resuscitation and vasopressors
• Antibiotic or disease-specific countermeasure therapy
• Prophylactic interventions: head of bed at 45° for ventilated patients, thromboembolism prophylaxis

Resource Allocation and Triage

When hospital resources are limited and critically ill patients are numerous, triage decisions must be guided by the principle of helping the greatest number of people survive the crisis—including patients already receiving ICU care who are not casualties of the precipitating event. 2

Special Considerations for Vulnerable Populations

Patients with chronic diseases, disabilities, or mental health conditions require specific attention during disasters:

• Chronically ill patients displaced from usual care will seek medical attention for medication access and disease management, not just disaster-related injuries 3
• Healthcare facilities must plan for retrieving medical records and allocating new ones when infrastructure is damaged 3
• Mental health control must be established as a distinct management theme alongside physical care 4

Critical Operational Requirements

Staffing Assignment Principles

Patient care assignments must follow these four principles: 1

1. Assignments managed by the most experienced clinician available
2. Assignments based on staff abilities and experience
3. Delegation of duties outside usual scope of practice is necessary and appropriate under surge conditions
4. Systematic efforts to reduce care variability, procedure complications, and errors of omission must be implemented

Cross-Training Requirements

Non-critical care health professionals must receive cross-training in basic, core critical care medicine before disaster events, not just-in-time training alone. 1

Resource Stockpiling

Hospitals must stockpile sufficient equipment for IV fluid resuscitation, vasopressor administration, and personal protective equipment to manage mass casualties for at least 48 hours without external resources. 2

Common Pitfalls to Avoid

• Do not attempt to maintain standard intensivist-to-patient ratios—this is impractical and will result in inadequate coverage 1
• Do not assign non-critical care nurses more than 2 critically ill patients—this exceeds safe capacity even with supervision 2
• Do not rely solely on just-in-time training for respiratory procedures during respiratory pathogen outbreaks—pre-event cross-training is essential 1
• Do not lose visual contact with patients—physical environment must support constant observation through large windows or glass doors 2
• Do not delay implementing evidence-based protocols while awaiting specialist consultation—rapid decision-making by the supervising intensivist is mandatory 5

Coordination and Communication

Inter-agency coordination, information management, and communication systems are essential themes affecting healthcare management success in disasters. 4

• Effective healthcare in disasters requires close relationships and interaction between different sectors of disaster management, not just healthcare 4
• Providing continuing patient care when infrastructure is damaged requires careful advanced planning across all departments 3