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Gilmore Commission - Minutes

The Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction

Arlington, VA Friday 30 March 2001

Present: James Clapper, Vice Chairman L. Paul Bremer Ray Downey George Foresman William Garrison Ellen Gordon James Greenleaf William Jenaway Dallas Jones Kathleen O’Brien Jack Marsh M. Patricia Quinlisk Patrick Ralston Kenneth Shine Also present: Ellen Embrey, Department of Defense Representative Michael Wermuth, RAND project director Members Absent: The Honorable James Gilmore, Chairman Paul Maniscalco William Reno Joseph Samuels Hubert Williams

I. Critical Infrastructure Protection Presentations (Lunch)

II. Dr. Scott Deitchman, AMA Council for Scientific Affairs Deitchman: Summary of Presentation – AMA is the focal point of medical "societies." 99% of U.S physicians belong to medical societies. Because the consequence of terrorism will involve physicians both in their professions and as community leaders, physicians need to be involved in the plans. In MedicWMD2000, the AMA brought together stakeholders and our recent report discusses the needs, challenges, and issues presented to the medical community by terrorism. Physicians need to understand decontamination and uncommon medications or uncommon uses. Education is specialty-specific. Specialty medical societies should help define these education needs and state societies should liaison between the States and county-societies for planning and exercising.

Recommendations: 1) Public-private entity; 2) Roles for societies; 3) evaluate hospital plans and link them to accreditation processes.

Vice Chairman: Thank you. This is an outstanding presentation and I believe that you cast it right as this level.

Shine: My first question has to do with this public-private entity. What you are saying is that there are a variety of resources and players and you want a standing activity to make the use of these materials. Who should be around that table, what would it cost?

Deitchman: I have no idea how much it would cost. That depends on the process that this entity decides to take on itself. Who should sit around the table? Those with technical and treatment expertise: military, CDC, HHS OEP. These plans show who has been assigned to "participate." The medical specialty societies need to be there because they have special interest groups in (e.g.) disaster medicine and they will help you define what there members need to know and help you realize the role they will probably play.

Quinlisk: From what I think it comes down to three pieces: 1) individual physician level; 2) hospital level; 3) public health. One of the things I see is that each group has individual recommendations. I don’t see these three groups coming together and a guideline of how they should be working together. Do you agree that there is a need for this? I don’t think it would be very difficult.

Deitchman: I agree that was our perspective as well. Some communities do this better than others, and it is not being done at a national level.

Shine: We have lots of joint kinds of activities. What we are hearing is the notion that something should have the representation at the national level. But also something that is like the accreditation process that similar activities would occur at the state and local level. This is a useful model and we can bring it about.

Deitchman: We do need all the medical societies involved in discussing curriculum. We did not think that our group should devise model community emergency plans, but the medical aspect needs to be brought into the overall plan.

Quinlisk: We need to get the medical community’s act together, but this also needs to be fully integrated into the emergency communities as well.

Deitchman: We have heard testimony of doctors, where there is an emergency and the fire chiefs pick everybody up but the health department does not hear about it until the next day. This is a do-able challenge.

Quinlisk: With plane accidents, you know that the threat is obviously over. But what scares people the most is the "not sures" that is the thing that scares people to death. In the middle of an outbreak when I can’t tell you when it’s going to be over.

Shine: what I am hearing, that if we created the concept of a Council on Health and Public Health, that it had representatives of key sectors with associated conduit groups and it identified a number of priority approaches transmitted down the pipeline down to the local community level, but I think this concept is exciting because it is a vehicle that uses these organizations – nurses, CDC, specialties – to create a vertical network.

Embrey: It seems to me that with everything I’ve heard that improvements to the structure itself is a much better solution than focusing on terrorism per se. What does that mean in terms of your entity that you are recommending?

Deitchman: If you ask a physician to say what will strengthen health care delivery, it goes beyond what we are talking about today. This system is broken with regards to infectious and chronic diseases as well. As long as this can be used as a model to promote interaction, it should contribute to fixing the problem, though it won’t fix the problem entirely. We have to agree that this is a problem that can’t be fixed without a number a resources being directed at it.

A lot of the disaster planning has largely been law enforcement and health departments, but when the real emergency occurs you turn to the real physicians and nurses. AMA wants to help you address this issue and we can add that to the mix. We would certainly welcome discussions on how that can be integrated.

Jones: Also medical facilities are targets.

Deitchman: Tokyo is a good example because they didn’t have access control and hospitals need disaster plans if the hospital is the site of the incident.

Quinlisk: Could we start by having this committee sit down and look at the various plans that have been written to see what all three components need to be involved and then have that be commented on by the Emergency Management System. We have all of these great guidelines, but I haven’t seen each piece sit down and agree, "okay this needs to be done" and send that checklist down to the locals and give it to the emergency management people.

Deitchman: Model checklists should include evaluation material for a drill. You should tell them how to evaluate if the plans are working or not.

Shine: Okay, CA is an anomaly to an extent because it’s a little country. In most states it will require the authority of these medical societies. When the secretary of HHS wants to get information to the medical community they call the AMS and the societies.

Foresman: One of the challenges is defining the stakeholder groups. What do we call them? What happens when we run a hospital that will not participate because there is not a financial incentive nor liability? Where is there carrot and stick?

Deitchman: We have thought about that one as well. We think that the answer depends on which physicians you talk about. For example, the emergency physicians have the incentive. In terms of what you want your primary care doc to know and the time commitment, we may have to reframe the expectations.

USAMRID sponsored course was great on bio/chem. It was 24 hours, and those who couldn’t watch the whole thing, taped it. Basically what you want to do is scratch the surface and then give them a reference that they can get to when they have time. The truth is that you don’t need to be an expert, just aware.

Quinlisk: Don’t just present it as terrorism. They perceive influenza and infectious diseases and outbreaks - large number of peoples getting ill. If you do it right, they will participate.

Jones: Would you include coroners’ offices at this level?

Deitchman: I would indeed. The OEP (HHS) has Mort-Teams and has brought them together to discuss issues to help with care in biological incidences and a similar need is in chemical. There is a tension in competing needs with forensic efforts; these groups need to be engaged to retrieve evidence and find solutions. III. Presentation by Scott Lillibridge, CDC Bioterrorism Prevention and Response Lillibridge: Summary of Presentation – Over the last year we’ve had 200 items that have come to our labs. We need rapid detection technologies to confirm findings and enhance communication. We have drilled the movement between emergency managers and law enforcement that send items to our Rapid Response Labs and Specialty Labs.

In an epidemic emergency, your currency is the laboratories. So if you are not training with these labs, you are not collaborating. We also are working to standardize laboratory protocols. Again, standardization is much more than getting a group together, it is about work and drills and negotiating and rolling up your sleeves. Our Hazmat Teams are not widely publicized, but we are about to get more active because they can accelerate the process of identifying samples.

Bremer: My question is about surveillance, how good is your surveillance for picking up biological events within and outside the United States?

Lillibridge: Our activities are as good as our State and locals provide to us. We have 120 voluntary surveillance activities. We are looking at it, is it well tuned? No.

Bremer: What has to happen?

Lillibridge: There needs to be better awareness at the State and local levels. Once those two things happen, we can provide funds, resources, and direction. We have not been prepared to deal with this, because we were thinking "one location." Now we are moving to regional emergencies and national emergencies.

Quinlisk: In the last 10 years communication has improved, but we still need to get reporting into the healthcare system electronically. We also need to move from reporting a real incident to "suspect diagnosis." The CDC has been getting preliminary information to the State through the Epi-X system. I have been very impressed with this system. Prior to a year ago that was not happening.

Bremer: How does the international surveillance really work?

Lillibridge: Federal health officials have asked this question. I would say that as we think through it, one of the good models has been the USDA. It has regional officers that work in 2- 3 countries and they develop relationships with those countries and then investigate and help them. These people generally do not have problems getting in, because there is an incentive for the countries to let them in. On the human health side, it would be great to do this without the verticality of the WHO. This USDA method allows you to quickly look at things and jump to a country.

There are number of things that may address this in the national electronic diseases surveillance system, for example. There are others in their infancy just beginning to address some of these issues.

Wermuth: Could you provide us some information on that?

Lillibridge: We could have easily given you a "surveillance" presentation.

Wermuth: If you can, provide us background information on other things that are intended to lead to standardization.

Lillibridge: One of the things on labs and surveillance is to make it more operational and focused on preparedness with dual-use capacity. It’s essential that emergency management and public health get really latched up. Then we can ask the question on how we can get a certain type of information? Are the hospitals filled up?

Vice Chairman: Does CDC have interaction with the Armed Forces Medical Intelligence Centers?

Lillibridge: Indeed we do. But I will tell you that we really have a world where we can go anywhere as health officers to look at health emergencies. Because of our working relationship with the UNHRC, we are invited in to participate internationally. On any given day we have 45 CDC officials around the world. We are trying to figure out how to harness that.

Jones: How do you work with Guard Civil Support teams?

Lillibridge: We think that they should be hooked up to a local public health lab; some states have been trying to push the envelope on that.

Quinlisk: I would like to see further support and prioritization the electronic transport of information from the clinical setting to the public health setting. Right now it is still very paper-driven. I think one of the things is to get an electronic reporting from ERs and laboratories on a standardized basis.

Margaret Van Ameringe, Joint Commission on Accreditation of Healthcare Organizations

Van Ameringe: Presentation Summary - 85% of U.S hospitals are accredited nation-wide. This accreditation now has standards focused on natural disasters; we call them "emergency management standards." But this has been a concept shift. We are now asking hospitals to develop a chain of command and to drill once a year with the wider community of responders and other hospitals. In some areas we have run into challenges. For example, what happens once supplies are depleted? How can hospitals develop security for crowd control? How to develop protocols? How should hospitals handle public relations and understand their authorities? How to work within communication networks?

Right now we need the tools to help these organizations do things. Funding is especially important, but we also need criteria so that our surveyors can evaluate hospital plans in the accreditation process.

Foresman: You have a standard for hospitals to maintain a disaster plan, but where does the teeth come from? And shouldn’t the drills be a requirement without being reimbursed?

Van Ameringe: If we are going to have a drill that responds to the proportion of a biological or severe chemical attack would occur, then all organizations need to work together with police and other first responders. That kind-of drill costs a lot of money. We are going to be asking organizations to do something on a larger scale than ever before.

The teeth come in a couple of ways. If we take away accreditation, then they cannot get Medicare reimbursement, unless Medicare goes in and does their own assessment. Right now, Medicare does not have a disaster-planning requirement. .

Bremer: You used a term…

Van Ameringe: EMTALLA is a social security statue.

Bremer: I can imagine a community where hospitals divide responsibilities, if I understood you, now they are "required" to take every patient?

Van Ameringe: Under current law, you will be fined. You have to at least stabilize them.

Bremer: Does an MOU overcome the law? Van Ameringe: No, an MOU does not let you overcome the law. We need some harbor within the law so that hospitals can form agreements.

Bremer: To the extent that you can remove doubt about what there authority is…

Shine: So long that you do not avoid their responsibility.

Wermuth: You ticked off a pretty substantial list of recommendations. Do you have these documented these? Have you taken a public position?

Van Ameringe: Yes, I can provide these as positions of JACHO as an organization.

Shine: Until recently – 10 years – JACHO did not do performance measurements and if we could focus on performance measurements, you have a real opportunity. They are going to need help in terms of doing this. I think it is important that JCHO get involved significantly. Hospitals don’t like "you didn’t perform well" measures so they are good incentives.

Shine: You heard the public-private entity recommendation, what do you think?

Van Ameringe: Absolutely, this entity would be ideal and I think the time has really come.

Jenaway: Have you looked at the National Fire Association for preparedness planning?

Van Ameringe: No, and I will do that.

Jones: What we do in large-scale disaster planning, there seems to be a hesitancy to report bed availability, could this be an accreditation issue for daily reporting?

Van Ameringe: Clearly it is our intent that hospitals can work vertically and horizontally in the system, and if bed availability is crucial, we are open to considering that especially as we look at disaster issues next year. We would love to have somebody talk to us about that.

IV. Consensus on Approving the Minutes Vice Chairman: Of the 5 issues that we have focused on, in three of the five we have information gathered and I would hope that each subpanel meet and come to: 1) observations; 2) findings; 3) recommendations and commit that to a formal drafting process.

Adjourn