Large-scale catastrophic events and infectious disease outbreaks, including the terrorist attacks of September 11, 2001, the outbreak of severe acute respiratory syndrome first identified in 2003, Hurricane Katrina, the 2009 H1N1 influenza pandemic, and Hurricane Sandy, have highlighted the need for disaster planning at all community levels. Because of the unpredictable and variable nature of these occurrences, attention has been focused on measures that can minimize the effects and effectively prepare citizens, businesses, locales, health care facilities, and nations to manage disasters. Given the central role that health care institutions have in responding to disasters, the discipline of hospital preparedness now occupies a central role in effective disaster mitigation planning (1, 2). Many of the existing guidance documents that address hospital preparedness are relevant to most medical facilities. Much of the focus on this topic has been discussed in relation to pandemic influenza preparedness before the 2009 H1N1 influenza pandemic (1, 3). However, many of the same principles apply regardless of the specific disaster. Box 1 lists suggested steps for all health care facilities to consider during preparedness planning. Providers of obstetric care and facilities that provide maternity services offer services to a population that has many unique features warranting additional consideration. Additional obstetric-specific considerations and recommendations are listed in Box 2 and are addressed more extensively in the subsequent paragraphs. The goal of these efforts is to minimize maternal and neonatal morbidity and mortality before, during, and after a disaster.
Box 1. General Considerations and Recommendations for Hospital Preparedness
- Appoint a full-time disaster coordinator for each hospital
- Participate in regional hospital disaster planning
- Create surge capacity planning for up to 30% more patients
- Augment hospital infection control practices to permit application of different measures to minimize in-hospital spread of disease depending on the nature of each disaster. Examples of such measures include, but are not limited to the following:
- Group patients with similar disease characteristics
- Have available for employee use all appropriate Personal Protective Equipment
- Limit numbers of staff exposed to potentially infectious individuals
- Have in place and enforce employment guidelines addressing employees not coming to work when sick
- Prioritize clinical services and develop contingency plans for canceling or minimizing elective procedures, or office visits, or both during high volume times.
- Consider alternate care facilities to provide services during high volume times
- Develop ethical algorithms for rationing limited health care resources in the event of demand for services exceeding supply
- Establish templates for altered standards of care during high volume periods
- Consider mechanisms for rapid clinical credentialing of health care providers not currently practicing to enable augmentation of work force
Data from Toner E, Waldhorn R. What hospitals should do to prepare for an influenza pandemic. Biosecurity and Bioterrorism 2006;4:397–402.
Every state has a disaster preparedness team directed by the Federal Emergency Management Agency and the Department of Homeland Security. It is essential that there is a plan within each state team specific to the health of women and infants and that hospitals that provide obstetric and gynecologic services coordinate such care. In some instances of disaster, the National Guard and the Department of Homeland Security may take over the administration of an existing hospital or set up satellite medical facilities. Facilities should recognize this potential and be involved in those plans.
Most health care facilities have standing emergency planning committees. Given the potential effect on patient volume surge and resource use, emergency planning forums should take into consideration the specific vulnerabilities and needs of obstetric patients. Pregnancy increases the risks of untoward outcomes from various infectious diseases, such as influenza (3–7). Trauma during pregnancy presents anatomic and physiologic considerations that often can require increased resource needs, including high rates of cesarean delivery (8). Recent evidence suggests that floods and man-made disasters increase the risks of spontaneous miscarriages, preterm births, and low birth weight infants among pregnant women (9). Often, these data are unknown by other health care providers and may not be routinely considered. Given these unique vulnerabilities, it is recommended that representatives from both obstetric and maternity nursing leadership be members of each hospital’s emergency planning committee. In addition, pediatric medical and nursing representation is also critically important for effective preparation.
Regardless of whether a hospital has an active maternity service, all facilities need to prepare to offer basic obstetric services and potentially stabilize pregnant women because these patients may be brought to the nearest hospital after a disaster occurs. Regional patterns of maternity care services (provided by facilities) often are evolving and also require advance consideration. These trends of care have implications in terms of the potential for patient volume expansion, for smaller local facilities as well as the larger regional tertiary care hospitals. Issues that are specific to individual locales highlight the importance of coordination between regional medical facilities. Consideration also should be given to shared needs during disaster management.
Health care facilities need to consider both mother and fetus or neonate in terms of resource allocation and surge capacity. This requires that facilities plan for additional increases in necessary resources when supporting a surge of pregnant patients above and beyond what would be required for patients in the general population. This may be especially true when focusing specifically on influenza pandemics. Data from influenza pandemics demonstrate the heightened rates of hospitalization and preterm birth noted with maternal influenza infection (3–7). The increased number of preterm newborns has clear implications for neonatal intensive care capacity and resource allocation that parallels the increased maternal resource needs.
Box 2. Additional Obstetric-Specific Considerations and Recommendations
- Appoint an obstetrician to direct disaster planning for maternity services
- Pediatrician involvement (or co-director) recommended
- Maternity and pediatric nursing also recommended
- Consider regional patterns of obstetric care provision and disaster scenarios
- Consider both obstetric and neonatal needs with high obstetric patient surge
- Establish policies for visitation and lactation that balance infection control concerns with patient and familial desires for involvement in the birthing process
- Foster functional working relationships with local and regional critical care clinicians
- Have a working algorithm for ethical resource allocation when demand exceeds supply that considers obstetric and pediatric specifics
- Develop a surge capacity plan with the realization that control of patient volume is challenging during pregnancy
- Consider the option of temporary alterations to usual standards of obstetric care and mechanisms to optimize obstetric services with less resource use. Examples include, but are not limited to the following:
- Early discharge after delivery
- Enhanced telephone triage with attention to documentation requirements
- Rapid credentialing of health care providers to enable delivery of obstetric care when there are work force limitations
Two special considerations presented by the obstetric population related to infection control practices are 1) the desire for familial involvement in the birthing process, and 2) the importance of lactation and early parental bonding with the neonate. Infectious disease outbreaks often require tight restrictions on visitation procedures while the nature of the epidemic is being investigated. This is often a difficult hospital practice to undertake, and is especially challenging to enforce in the obstetric population given the frequent need for support during labor, delivery, and the postpartum period. Likewise, the importance of lactation and early parental–neonatal bonding introduces unique infection control questions that are not relevant to other patient populations and, therefore, warrant additional advance consideration.
Few obstetricians are trained in critical care, yet obstetric patients are often more severely affected by infectious disease outbreaks and require disproportionate critical care resource allocation (3–7). In many facilities, adult intensive care units are distant from labor and delivery units. Physical separation may pose logistical barriers to the delivery of optimal critical care for critically ill pregnant women. These barriers may be exacerbated during times of overwhelming patient volume. These trends warrant thoughtful consideration and extra coordination with critical care clinicians before and during disaster mitigation.
The important and challenging issue of ethical resource allocation when demand exceeds supply has been addressed in the general medical literature (10, 11). Much of the focus on this topic addresses distribution of limited numbers of ventilators among large surges of critically ill patients who require respiratory support. Although the focus has been primarily on ventilators, these principles also apply to other potentially limited resources as well (eg, cardiovascular support medications, antimicrobials, and intravenous supplies). Many of the proposed algorithms lack direct relevance to the obstetric population and may require a compromised approach. Although some general principles are relevant, a maternity-specific approach for triaging limited medical resources, such as ventilators, may provide obstetric-specific guidance in this rare, yet potentially challenging circumstance (12). To optimize outcomes, it is recommended that hospital committees charged with disaster planning review these important resources and familiarize themselves with the suggested approaches before real-time disaster management.
In addition to the aforementioned unique challenges, much of the planning for general hospital preparedness centers on the ability to have at least partial control over elective procedures and visits and thereby reduce patient volume. This concept has obvious importance in temporarily decreasing nonurgent procedures, which allows for more intensive focus on those affected by the outbreak and an opportunity to manage the increased surge of resource-intensive patients. There is little control over the timing of labor and delivery, which makes patient volume control in obstetrics more challenging and further complicates facility planning and management.
An additional consideration is the potential need for temporary alterations to the usual standards of care. Effective medical care during large-scale disasters temporarily alters the usual focus from individual patient well-being to one that strives to maximize benefits for the greatest number of patients. Such alterations are often necessary and beneficial when the volume of patients in a health care facility is unusually high. This is a recognized concept that has received considerable legal and medical attention (13–15). The goal of these efforts is to give facilities and health care providers guidance on temporary flexibility in care standards as well as who is permitted to provide care. Equally important is planning by the hospital leadership for the potential need to rapidly credential temporary obstetric providers in the face of a health care provider shortage that can occur with different disaster scenarios. Facility preparedness committees are encouraged to consult with their local legal colleagues to assist in interpreting state and federal guidance on this issue.
One specific example of a temporary alteration to the usual standards of care in obstetrics may be a shorter than usual postpartum length of stay after uncomplicated vaginal delivery (changing from 24–48 hours to 12–24 hours) among women who are clinically stable. Moving stable women in the postpartum period out of the hospital early and arranging for greater postpartum home-health visits (if possible given work-force limitations) to accommodate a temporary surge in pregnant patients could improve overall provision of maternity care services.
In the case of an environmental disaster, it is possible that pregnant women and women in the postpartum period in need of care may be cut off from the hospital facility, medical records, and health care providers. Flexible infrastructure that permits for an expanded role of temporary “distance prenatal care,” or telephone triage, or both also may be of great value during times of overwhelming volume. Given its importance, this topic has been recently considered by the Institute of Medicine, and one such example of successful use in obstetrics has been reported (16, 17).
If feasible, creative use of evolving telemedicine capabilities could enable maintenance of care in the face of increased local resource demands and provide a mechanism for consultation between smaller regional facilities and larger tertiary care facilities. It should be recognized that while using these temporary care methods, documentation in the prenatal record of all patient–health care provider interactions remains paramount, and that the ability to access prenatal records is also very important. Advance consideration of existing patient documentation mechanisms and emerging electronic medical record capabilities to accommodate input in prenatal records, as well as mechanisms for providing patients with their medical records, is recommended.
Advance consideration should be given to the disaster recovery phase and establishing local mechanisms, or triggers, or both for transitioning back to the usual standards of care. The goal is to enable a smooth recovery once the acute phase has resolved that optimizes care and resource use that parallels the rate of return to baseline facility function.
The discipline of hospital disaster preparedness has developed in recent years in the wake of past disasters. Many of the suggested approaches should be considered by all obstetric providers and by facilities providing maternity services.
- Toner E, Waldhorn R. What hospitals should do to prepare for an influenza pandemic. Biosecur Bioterror 2006;4:397–402. [PubMed] ⇦
- Center for Biosecurity of UPMC. A crossroads in biosecurity: steps to strengthen U.S. preparedness. Baltimore (MD): University of Pittsburgh Medical Center; 2011. Available at: http://www.upmc-biosecurity.org/website/resources/publications/2011/pdf/2011-09-08-crossroads-in-biosecurity.html. Retrieved November 7, 2012. ⇦
- Beigi RH. Pandemic influenza and pregnancy: a call for preparedness planning. Obstet Gynecol 2007;109:1193–6. [PubMed] [Obstetrics & Gynecology] ⇦
- Harris JW. Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases. J Am Med Assoc 1919;72:978–80. ⇦
- Siston AM, Rasmussen SA, Honein MA, Fry AM, Seib K, Callaghan WM, et al. Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States. Pandemic H1N1 Influenza in Pregnancy Working Group. JAMA 2010;303:1517–25. [PubMed] [Full Text] ⇦
- Hewagama S, Walker SP, Stuart RL, Gordon C, Johnson PD, Friedman ND, et al. 2009 H1N1 influenza A and pregnancy outcomes in Victoria, Australia. Clin Infect Dis 2010;50:686–90. [PubMed] [Full Text] ⇦
- Goodnight WH, Soper DE. Pneumonia in pregnancy. Crit Care Med 2005;33:S390–7. [PubMed] ⇦
- Oxford CM, Ludmir J. Trauma in pregnancy. Clin Obstet Gynecol 2009;52:611–29. [PubMed] ⇦
- Eskenazi B, Marks AR, Catalano R, Bruckner T, Toniolo PG. Low birthweight in New York City and upstate New York following the events of September 11th. Hum Reprod 2007;22:3013–20. [PubMed] [Full Text] ⇦
- Hick JL, Rubinson L, O’Laughlin DT, Farmer JC. Clinical review: allocating ventilators during large-scale disasters—problems, planning, and process. Crit Care 2007;11:217. [PubMed] [Full Text] ⇦
- Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006;175:1377–81. [PubMed] [Full Text] ⇦
- Beigi RH, Hodges J, Baldisseri M, English D. Clinical review: Considerations for the triage of maternity care during an influenza pandemic—one institution’s approach. Magee-Womens Hospital Ethics Committee. Crit Care 2010;14:225. [PubMed] [Full Text] ⇦
- Institute of Medicine. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington, DC: National Academies Press; 2009. ⇦
- Agency for Healthcare Research and Quality. Bioterrorism and other public health emergencies: altered standards of care in mass casualty events. AHRQ Publication No. 05-0043. Rockville (MD): AHRQ; 2005. Available at: http://archive.ahrq.gov/research/altstand/altstand.pdf. Retrieved November 7, 2012. ⇦
- Annas GJ. Standard of care--in sickness and in health and in emergencies. N Engl J Med 2010;362:2126–31. [PubMed] [Full Text] ⇦
- Institute of Medicine. Public engagement on facilitating access to antiviral medications and information in an influenza pandemic: workshop series summary. Washington, DC: National Academies Press; 2012. ⇦
- Eppes CS, Garcia PM, Grobman WA. Telephone triage of influenza-like illness during pandemic 2009 H1N1 in an obstetric population. Am J Obstet Gynecol 2012;207:3–8. [PubMed] [Full Text] ⇦