HealthHealth CareCare atat thethe CrossroadsCrossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Joint Commission on Accreditation of Healthcare Organizations © Copyright 2003 by the Joint Commission on Accreditation of Healthcare Organizations. All rights reserved. No part of this book may be reproduced in any form or by any means without written permission from the publisher. Request for permission to reprint: 630-792-5631. Health Care at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Joint Commission on Accreditation of Healthcare Organizations Joint Commission Public Policy Initiative
This white paper is the second work product of the Joint Commission’s new Public Policy Initiative. Launched in 2001, this initiative seeks to address broad issues that have the potential to seriously undermine the provision of safe, high-quality health care and, indeed, the health of the American people. These are issues which demand the attention and engagement of multiple publics if successful resolution is to be achieved.
For each of the identified public policy issues, the Joint Commission already has state-of-the-art standards in place. However, simple application of these standards, and other unidi- mensional efforts,will leave this country far short of its health care goals and objectives. Thus, this paper does not describe new Joint Commission requirements for health care organizations, nor even suggest that new requirements will be forthcoming in the future.
Rather, the Joint Commission has devised a public policy action plan that involves the gathering of information and multiple perspectives on the issue;formulation of comprehensive solutions; and assignment of accountabilities for these solutions. The execution of this plan includes the convening of roundtable discussions and national symposia, the issuance of this white paper, and active pursuit of the suggested recommendations.
This paper is a call to action for those who influence, develop or carry out policies that will lead the way to resolution of the issue. This is specifically in furtherance of the Joint Commission’s stated mission to improve the safety and quality of health care provided to the public. Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Table of Contents
Preamble ...... 4 Introduction ...... 5 Part I. Enlist the Community in Preparing the Local Response ...... 10 Enlisting the Community ...... 11 Forging New Partnerships ...... 12 An Exemplary Effort ...... 13 Lessons Learned ...... 14 Getting There ...... 16 Recommendations ...... 18 Part II. Focus on the Key Aspects of the Preparedness System that Will Preserve the Ability of Community Health Care Organizations to Care for Patients, Protect Staff and Serve the Public ...... 19 Define Surge Capacity ...... 19 Preserve the Organization – Protect the Staff ...... 23 Ensure Care for the “Other”Patients ...... 25 Manage the Incident ...... 27 Consider the Threat to Mind, as well as Body ...... 28 Enlist the Public ...... 29 Identify Communication and Information Needs and Meet Them ...... 31 Test, Learn, Improve and Be Ready ...... 33 Recommendations ...... 34 Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems ...... 37 A Question of Accountability ...... 37 Sustainable Funding ...... 39 Guiding the Effort ...... 11 Knowing What Works ...... 40 Recommendations ...... 41 Conclusion ...... 43 Acknowledgements ...... 44 End Notes ...... 46
3 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Preamble
It does not take long for complacency to set- But now, in the face of an atrophied public tle in. Eighteen months after the September health infrastructure and lack of leadership 11, 2001 attacks and the subsequent, insidi- and coordination among other emergency ous, selected and deliberate dispersion of preparedness constituencies, hospitals and anthrax spores, there are clear signs that the other health care organizations are being focus of American attention has long since asked to step up their level of emergency moved on. The sense of urgency to prepare preparedness involvement. This unfortunate- has now become a wait-and-see sense. ly is occurring at a time when many of those Vigilance eventually gives way to ambiguity. entities face severe resource constraints and Indeed, the two occasions during the past may not always be able to manage current six months in which the national terrorism day-to-day patient care demands. level has been raised to Orange (high threat) have generally provoked public mysticism as At a recent national symposium on to what individuals should do to prepare. emergency preparedness, Jerome Hauer, This confused state of non-readiness is what acting assistant secretary of the Office of terrorists lay in wait for. And, the world in Public Health Emergency Preparedness of which we carry out our daily lives can the Department of Health and Human change in an instant. Services (DHHS), remarking on the strong likelihood of another terrorist attack in the This is not our world as we once knew it. It near future, said,“At the end of the day, it is is no longer sufficient to develop disaster medical care that will be needed.” But if plans and dust them off if a threat appears medical care capacity is already in variable imminent. Rather, a system of preparedness and sometimes scarce supply, planning for across communities must be in place every- unexpected surges in demand becomes all day. Such systems make effective responses the more critical. So, too, does funding and to emergencies possible, and they also serve federal leadership for these efforts. as deterrents to actual attacks. And, they are needed – whatever the level of our sense of The purpose of this report is to frame the security – to facilitate the management of issues that must be addressed in developing crises that seem to be becoming everyday community-wide preparedness and to delin- occurrences. eate federal and state responsibilities for eliminating barriers, and for facilitating and The concept of community-wide prepared- sustaining — through leadership, funding ness systems is new to most health care and other resource deployment – organizations. While most have long pre- community-based emergency preparedness pared and tested disaster plans, health care across the United States. organizations have operated in isolation, and their disaster plans reflect this mindset.
4 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Introduction
On the day that America experienced its apparent, priority brought into sharp relief worst violation at the hands of terrorists, the fundamental new needs for emergency pre- many “first responders” involved in rescuing, paredness that would call for leadership and treating and protecting the thousands of coordination at the community level, which people who were victimized, or had the did not then, and largely does not now, exist. potential to be, valiantly performed their jobs. But for many, their efforts were futile in This does not gainsay the continuing the face of such enormous destruction. extraordinary efforts of the three public Emergency medical personnel and health safety agencies that this country has long care workers from nearby and far away were relied on – law enforcement, fire and rescue, drawn to these scenes of destruction to lend and emergency medical services. Nor does it their support and expertise. Hospitals in the ignore the sometimes heroic efforts of vicinity of the World Trade Center, despite underfunded public health agencies and being overwhelmed by power outages, health care provider organizations in disabled telecommunications, and the rush of managing extremely challenging situations. the injured and those fleeing the But in most communities there is no team, smoke-choked streets for shelter, were nor teamwork, among all of these players nevertheless able to summon a response. and other municipal and county leaders. And, there is no community emergency pre- And then, while the country was still reeling paredness plan, nor program, nor system. from the September 11 attack, a different kind of attack, this time with a biological While the cast of emergency preparedness agent, anthrax, unfolded in Florida, New York, players in a given community can lengthen New Jersey,Washington D.C. and rapidly, there is no denying the central role Connecticut.These disasters, wrought by that hospitals can and must play in these terrorism, rapidly focused the nation’s efforts. However, these are difficult and attention on national security – the need to occasionally overwhelming times for protect American ideals and resources, and hospitals, even without this expanded most fundamentally, the very safety and responsibility. In fact, many hospitals are health of the American people. Both for struggling to meet the daily demands for America’s leaders and for this nation’s their health care services. communities, this compelling new, or newly
It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday.
5 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
As a matter of public policy, this country has Add to this brewing cataclysm the need for purposefully shrunk the installed capacity of “surge capacity” – the ability to care for per- its health care delivery system over the past haps hundreds to thousands more patients at two decades. This has translated into the a given time – in hospitals already full, closure of many hospitals and even more already stressed, and already searching for emergency departments, despite the more resources to provide care, and the escalating demands for services. In addition, challenge of preparedness becomes even many hospitals now are experiencing severe more daunting. shortages of nurses and other essential health care personnel. This is further reduc- Since the Fall 2001 terrorism attacks, there ing the capacity of these hospitals to deliver has been a flurry of activity focused on the care, including emergency care. Today’s hard preparation of emergency preparedness reality is that hospital emergency depart- plans.The emphasis on plans substantially ments across the country are overcrowded understates what are really needed – and, even absent any external disaster, likely emergency preparedness programs. to be diverting patients on any given day. According to a recent report,“Preparedness at home plays a critical role in combating Adding to these problems are sky-high terrorism by reducing its appeal as an liability insurance premiums for physicians effective means of warfare.”4 However, this that are limiting the availability of critical level of preparedness implies a tightly knit specialists in certain jurisdictions. Further, system among the key emergency most states in the country, with strapped preparedness participants that simply does budgets, are reducing the numbers of people not exist in most communities today. “All on their Medicaid rolls.1 Medicare too is emergencies are local” is a truism that threatening more cuts in hospital reimburse- conveys the responsibility of the community ment2 and the numbers of uninsured are on to plan, prepare and respond to an the rise.3 All of these factors promise to fur- emergency. But as this paper points out, that ther undermine the ability of hospitals to truism is today far more a call to action than meet the routine, let alone the extraordinary, a reality. This paper is a call to action for needs of their communities. federal and state governments as well, for weaving the tightly knit system of preparedness also takes resources, leadership and guidance.
6 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Since the events of September 11 and the none yet that present evidence-based models subsequent anthrax attacks, the federal which are likely to be adaptable to the government has stepped forward to fund varied urban, suburban and sparsely the rehabilitation of the public health populated communities that make up system, and to a significantly lesser extent, the United States. the preparedness efforts of the nation’s hospitals. However, although the federal Given the urgency for community-based plan enlisted state governments to allocate emergency preparedness and the obvious federal funds to their hospitals well over a barriers to achieving this goal across the year ago, the money has not yet reached hos- country, the Joint Commission convened an pitals and some local public health agencies. expert Public Policy Roundtable to discuss There unfortunately is an oft-repeated refrain emergency preparedness issues and to frame of money not making it from Washington to specific recommendations, fulfillment of the trenches where it is needed.5 The which would permit achievement of a level money may eventually make it, but the funds of preparedness that could truly offer are a small sum in comparison to what is protection and assurances to the American actually needed.6 public. Among the specific issues addressed by the Roundtable were the resources and In addition to the disputes and confusion requirements for community-based response over meeting what remains today for many systems; the need for collaboration between hospitals, an unfunded mandate, hospitals the medical care and public health and their communities are struggling to establishments, as well as other new know how to get started. There is a funda- partnerships that must be forged; issues of mental need for templates or scalable models accountability and mechanisms for validating of community-wide preparedness to guide readiness; and the appropriate roles of planning before, and actions taken during federal and state governments. and after, an emergency. Several nascent templates are emerging; however, there are
In addition to the disputes and confusion over meeting what remains today for many hospitals, an unfunded mandate, hospitals and their communities are struggling to know how to get started. 7 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Based on those discussions, the following II. Focus on the key aspects of the recommendations are proposed: preparedness system that will preserve the ability of community health I. Enlist the community in preparing the care resources to care for patients, local response protect staff and serve the public. • Initiate and facilitate the development of •Prospectively define point-in-time and community-based emergency preparedness longitudinal surge capacity at the programs across the country. community level. • Constitute community organizations that • Establish mutual aid agreements among comprise all of the key participants – as community hospitals and other health care appropriate to the community – to develop organizations. the community-wide emergency prepared- • Ensure a 48-72 hour stand-alone capability ness program. through the appropriate stockpiling of • Encourage the transition of necessary medications and supplies. community health care resources from an • Fund and facilitate the creation of a organization-focused approach to credentialing database to support a national emergency preparedness to one that emergency volunteer system for health care encompasses the community. professionals. •Provide the community organization with • Make direct caregivers the highest priority necessary funding and other resources and for training and for receipt of hold it accountable for overseeing the plan- protective equipment, vaccinations, ning, assessment and maintenance of the prophylactic antibiotics, chemical preparedness program. antidotes, and other protective measures. • Encourage the pursuit of substantive • Support the provision of decontamination collaborative activities that will also serve to capabilities in each hospital. bridge the gap between the medical care • Maintain the ability to provide routine care. and public health systems. • Make provision for the graceful degradation •Develop and distribute emergency planning of care. and preparedness templates for • Provide for waiver of regulatory potential adaptation by various types of requirements under conditions of extreme communities. emergency.
8 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
• Adopt incident management approaches III.Establish accountabilities, that provide for simultaneous management oversight, leadership and involvement by multiple authorities and sustainment of community fluidity of authority. preparedness systems • Make provisions for accommodating and •Develop and implement objective managing the substantial acute mental evaluation methods for assessing the health needs of the community. substance and effectiveness of local • Directly address the fear created by terrorist emergency preparedness plans. acts through targeted education, application •Provide funding at the local level for of risk reduction strategies and the teaching emergency preparedness planning. of coping skills. • Explore alternative options for providing •Provide public education about emergency sustained funding for hospital emergency preparedness. preparedness activities. • Actively engage the public in emergency • Initiate and fund public-private sector preparedness planning. partnerships that are charged to conduct • Anticipate the information needs of the research on and develop relevant, scalable community. templates for emergency preparedness plans •Create redundant, interoperable that will meet local community needs. communications capabilities. • Disseminate information about existing best •Develop a centralized community-wide practices and lessons learned respecting patient locator system. existing emergency preparedness initiatives. • Engage the mass media in the emergency • Clarify the applications of EMTALA, HIPAA, preparedness planning process. EPA and other regulatory requirements in • Regularly test, at least yearly, community emergency situations. emergency preparedness plans through • Coordinate domestic and international reality-based drills. emergency preparedness efforts. • Assure the inclusion of all community emergency preparedness program participants in the plan tests.
This paper provides supporting documentation for its conclusions, describes specific recommendations, and assigns accountabilities for carrying out these recommendations.
9 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
I. Enlist the Community in Preparing the Local Response
A New Context for Disaster Planning preparedness to one that encompasses the The Joint Commission has long required entire community and its resources. The accredited organizations to create disaster planning process is expected to systematical- plans and to test them at least twice a year. ly address the full range of potential disasters For many organizations, these requirements – including terrorism -- identified through a have often seemed like “make-work.” Only in “hazard vulnerability assessment,”that is those communities where actual disasters conducted in collaboration with the have struck has all of the actual preparation organization’s community. The standards appeared to have been worth it. But the also require that organizations define an events of September 11, 2001 have created a internal command structure that links with new world for America’s communities and a the community command structure. A new context for disaster preparedness for final new requirement, stemming from the health care organizations. 2001 Houston flood experience and the September 11 experience, requires the Almost propitiously, the Joint Commission health care organizations in the community had -- during 2000 -- been working to to work cooperatively to create a mutual aid upgrade and reframe its traditional disaster context for planning and response efforts. preparedness standards into an expanded community-based emergency management Underlying the new Joint Commission framework. These new requirements were standards is the fact that, in an emergency introduced in January 2001. The urgency to situation, health care provider organizations move these new requirements forward had must work with each other and with other resulted from a series of conversations with public safety and support entities to manage senior military and health care officials. the casualties that have occurred and to minimize the risk of additional casualties. The expanded framework of expectations Managing a mass casualty or bioterrorism now in place seeks to transition hospitals situation is no job for a single provider and other health care organizations from an organization. organization-focused mindset of disaster
Managing a mass casualty or bioterrorism situation is no job for a single provider organization. This is, in fact, the responsibility of “the community” – an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations.
10 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
This is, in fact, the responsibility of “the disease prevention activities, management community” – an as yet ill-defined composite of disease outbreaks, and intervention in that, at a minimum, includes emergency community-wide emergency department medical services, fire, police, the public overcrowding situations. health system, local municipalities and government authorities, and local hospitals Community-wide emergency preparedness and other health care organizations. programs do exist, and some are quite Emergency planning must be local – that is, elaborate. However, they are few in number, based in the community – because almost all and almost all exist is large metropolitan disasters and mass casualty situations are areas. By contrast, most of America’s local. The sobering reality is that many communities are “waiting for someone to communities will be on their own for the call the meeting.” first 24-72 hours after such an event. Creating a detailed emergency preparedness Enlisting the Community plan, or program, particularly in the face of There thus exists a fundamental need to uncertain resource support is – to be sure – formalize an organization of community a daunting challenge. Indeed, planning resources. That organization should templates that might serve as reference comprise those authorities, agencies, points for inexperienced project leaders are providers, industries and other vital commu- virtually non-existent. And the challenge is nity elements that are critical to mounting an heightened still further by the fact that the effective emergency response and protecting core participants are in many ways strangers the community. This new “community to each other, and each, by virtue of their organization” must then have the authority, unique responsibilities, is used to being “in and with this, both the necessary funding control.” and accountability for planning, assessing and maintaining community-wide emergency Yet, the planning process – the building of preparedness -- in effect, making the plan a the relationships that will become the program. Further, the program that is program – is a fundamental exercise in brought to life must have an ongoing reality, give-and-take. This is indeed a process in one in which the participants become which primacy and control are relinquished familiar with their respective roles and a to create a greater good.The new give-and- capabilities because they are working and take relationships also set the stage for the interacting with each other on a regular management of actual disasters. Such basis. Such operational preparedness management is almost always situational. programs need not be theoretical. Among That is, the nature of the situation dictates the obvious opportunities for ongoing the command structure and who will be collaborative efforts are community-wide “in control.” health promotion and
11 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Community-wide preparedness also has its One focuses on the care of the individual, pragmatic virtues, particularly in optimizing the other on the health of the population. the deployment of available resources. For Their funding sources reflect these differing example, communication and collaboration orientations – medical care is dependent on among local hospitals make it much less private funding; public health on public likely that multiple hospitals will be funding. But these old divisions must be depending on the same community bridged in order to ensure an integrated resources for their own emergency planning emergency response – in order to create a purposes. tightly woven preparedness system. Some of the ways in which the medical care and The potential response capability may public health sectors can and should begin in fact be called upon to expand in relation to collaborate are in developing health to the reach of the devastation brought by a surveillance systems, in facilitating inter-orga- catastrophic event. Such an event may cross nizational communication systems, and in multiple jurisdictions, necessitating a broader the training of care providers to recognize coordinated response among community- signs and symptoms of exposure to based emergency preparedness programs. chemical, biological or radiological agents. However, the effectiveness of a broad response cannot be fully realized unless the There have also been frictions, of varying basic community programs are first put degree, between fire and police, between in place. emergency management agencies and public health agencies, between emergency medical Forging New Partnerships services and hospitals, and between city and Some of the partnerships that must be county government authorities, among forged face long-standing historical obstacles. others. But these frictions can and must be There, for example, exists a long-standing overtaken by a new partnership mentality, gulf between medical care and public health. and additional partners need to become These two health care sectors have never engaged. had an effective working relationship.7
Tactics Accountability
• Initiate and facilitate the development of municipalities community-based emergency prepared- emergency management agencies ness programs across the country. hospitals public health agencies
12 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
There are now encouraging indications that across responding organizations and this is beginning to happen. For example, agencies. The Council has also facilitated the since September 11, the military have been implementation of syndromic surveillance involved in training civilian health care systems at both the state and local levels. In personnel and in participating in hospital addition, the Council has aided the New York emergency drills.8 And, in New York City, State Department of Health in the city and state public health agencies, development of a Web-based capacity-moni- hospitals, emergency medical services, city toring system to gauge bed and supply emergency management officials, and others availability, and staffing levels at area have established new working relationships hospitals. The Web-based system also that undergird a state-of-the-art collects patient information to serve as a preparedness system. patient locator system in the event of a mass casualty event. An Exemplary Effort In the aftermath of the terrorism attacks in Taking the lessons learned from the World New York City, the Greater New York Trade Center disaster and the subsequent Hospital Association (GNYHA) has taken a anthrax attacks, the GNYHA and its leadership role in forging a cross-disciplinary, Emergency Preparedness Coordinating cross-jurisdictional partnership among Council have focused on helping local health responding authorities, agencies and care organizations and public safety agencies providers. In creating the Emergency to improve upon those response elements Preparedness Coordinating Council, the that went wrong. For instance, telecommuni- GNYHA has helped its member organizations cations capabilities in the vicinity of Ground -- and local, state and federal public health Zero were lost. To ensure effective and emergency management agencies -- to communications in the event of another become better prepared, and able to offer an disaster, the Council has worked with the integrated response to a disaster.9 Office of Emergency Management (OEM) to According to the GNYHA, many of the purchase and distribute 800 Megahertz initiatives that the Emergency Preparedness radios, and has established a dedicated Coordinating Council has spearheaded have channel for health care organizations to focused on the collection of data -- before, communicate with one another and with during and after an emergency – that are OEM. The Council has also taken a critical to waging an effective response and prominent role in informing and educating recovery. Among these initiatives, the health care personnel in the detection of and Council has developed an emergency response to biological, chemical and contacts directory to improve nuclear events. communications among key personnel
13 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Lessons Learned Letters mailed in October of 2001 that The events of September 11 were instantly contained highly virulent, weaponized recognizable as disasters, and each prompted anthrax constituted the first bioterrorism immediate action by all first-responders. In attack in this country to which the Centers New York, calls went out across the city, the for Disease Control and Prevention (CDC) state, and surrounding states for hospitals to had to respond.10 A total of 22 confirmed or ready for victims. But some emergencies are suspected cases of anthrax infection --11 not readily apparent. Rather, they unfold inhalational, which led to five deaths, and 11 over days or weeks. The anthrax attack in cutaneous cases – resulted from the anthrax the fall of 2001 was just such an emergency, attack.11 While the investigation into the and it raised important issues of cross-disci- perpetrator of the “anthrax letters” remains plinary and cross-jurisdictional coordination open, the public health response and and authority as the impact of the attack medical care for those affected are now a unfolded. case history of lessons learned.
Tactics Accountability
• Constitute a community organization that community organization participants comprises local government officials, emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medi- cal services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program.
• Encourage the transition of community community organization health care institutions from an organization-focused approach to emergency preparedness to one that encompasses the community.
• Provide the community organization with federal and state government agencies necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program.
14 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
The first challenge in responding to the both postal workers from the Brentwood anthrax attack was in making the initial postal facility in Washington, D.C., who diagnosis. Few clinicians have presence-of- sought medical attention for their severe mind awareness of the signs and symptoms flu-like symptoms.15 of bioterrorism agents, such as anthrax, smallpox, and plague. In fact, in a recent In addition to the fatal delays in diagnosis, study of preparedness among family there were significant breakdowns in com- physicians for bioterrorism, only one-quarter munications across health care disciplines of those surveyed felt prepared, and still and public health authorities in the anthrax fewer, 17 percent, reported that their local attack response. In particular, the ability or medical communities could respond willingness of the public health system to effectively.12 However, prior training in communicate and work with the medical bioterrorism was a significant positive factor care system arose as an issue.When the first in the responses of physicians who case of inhalational anthrax in a Brentwood perceived themselves to be ready to postal worker was preliminarily diagnosed at respond to an attack.13 a D.C.-area hospital and reported to public health officials, these officials, doubting the The first diagnosis of anthrax in the 2001 diagnosis16, did not immediately act to notify attack was made by an astute physician who other area hospitals. At an early evening suspected the disease; the confirmation was news conference the following day, officials subsequently made by a laboratory worker “played down” the patient’s condition, saying who had undergone bioterrorism prepared- it was “unconfirmed.”17 Potentially important ness training. But the general unfamiliarity opportunities for screening emergency of medical professionals with bio-agents department visitors were lost across the contributed to the misdiagnosis and delayed D.C. area. treatment for two other infected patients,
Emergency preparedness is already a way of life in some countries; it needs to be woven into the fabric of American life to a much greater extent than it is today.
15 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Aside from local grass roots efforts, there was The Hart Senate Office Building was closed, no infrastructure in affected areas that would as were other Senate office buildings, and, have made it possible for vital clinical even briefly, the House of Representatives, information to be shared in an emergency until the risk of anthrax exposure had been situation across the medical care community, clarified. or between public health authorities and practicing clinicians. Stories were told about Until credible, standardized bioterrorism physicians, even in prominent teaching response protocols are established and hospitals, having to get their medical widely disseminated, the risk of information from CNN during the height promulgation of conflicting information and of the crisis.18 diversity in responses will continue to exist. This fundamental missing link could The communications failure between and eventually undermine the public trust in the among public health officials and the limited infrastructure now in place. medical community, and the limited base of expert information among those providing Getting There critical advice, had a tragic impact on postal Americans, their families, and their workers in Washington D.C.’s Brentwood community institutions increasingly tend to postal facility who were repeatedly reassured lead insular existences, but insularity is the that no risk of anthrax contamination was antithesis of what will be needed to create posed to them.19 Two eventually died from emergency preparedness programs across inhalational anthrax. America’s communities. Emergency preparedness is already a way of life in some In New Jersey, the health commissioner countries; it needs to be woven into the decided to ignore CDC recommendations fabric of American life to a much greater and administer prophylaxis to all postal extent than it is today. workers at two Trenton-area postal facilities.20
Tactics Accountability
• Encourage the pursuit of substantive health care and public health collaborative activities that will also serve membership organizations to bridge the gap between the medical federal government agencies care and public health systems.
• Develop and distribute emergency federal and state government agencies planning and preparedness templates for potential adaptation by various types of communities.
16 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
What needs to be done? few of these dollars are making their way down to the local community level. The First, someone does need to call the first funding allocated to public health is highly meeting, to bring the parties together. The appropriate, but at the planned funding participants will vary by community, but the levels will only restore most public health logical conveners are relatively few: the departments to a baseline functional state. local emergency management agency, the Meanwhile, most hospitals, which are local public health agency, and/or the local required by the Joint Commission to be hospital(s). In small, sparsely populated engaged in emergency planning and pre- communities, the hospital may be the only paredness activities, have yet to see their first logical convener. nickel of federal terrorism preparedness funds. Over time, the emergency prepared- Second, community planning templates need ness engine simply cannot run without fuel. to be developed and disseminated. The disaster-based experience that is needed to One might well ask whether such an develop meaningful templates is, fortunately, extensive community-preparedness effort, limited in this country, but available and the funding and other resources knowledge from experiences in the United required to support such an effort, are really States and elsewhere needs to be harvested necessary or justified. Today, the perceived and translated into scalable models that lend terrorism vulnerabilities are clearly focused themselves to ready adaptation by on the country’s major metropolitan areas. communities of various types. Emergency Nevertheless, it is well to remember that the preparedness plans that are created out of primary objective of terrorism is to create whole cloth are unlikely to offer fear. Little imagination is required to comprehensive protection for a community. understand the potential psychological impacts on the populace of even a few Third, emergency preparedness at the com- selected terrorism attacks on typical small munity level takes resources, especially towns across America. money. Despite the ballyhooed billions of federal dollars being poured into terrorism prevention and preparedness efforts, very
17 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Recommendations
Tactics Accountability
• Initiate and facilitate the development of municipalities community-based emergency emergency management agencies preparedness programs across the hospitals country. public health agencies
• Constitute a community organization that comprises local government officials, community organization participants emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medi- cal services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program.
• Encourage the transition of community health care institutions from an community organization organization-focused approach to emergency preparedness to one that encompasses the community.
• Provide the community organization with necessary funding and other resources federal and state government agencies and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program.
• Encourage the pursuit of substantive health care and public health membership collaborative activities that will also serve organizations to bridge the gap between the medical federal government agencies care and public health systems.
• Develop and distribute emergency federal and state government agencies planning and preparedness templates for potential adaptation by various types of communities.
18 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
II. Focus on the key aspects of the preparedness system that will preserve the ability of community health care organizations to care for patients, protect staff and serve the public.
Preparedness Priorities time-limited period to accommodate the Developing a community-based preparedness needs emanating from an acute disaster will program requires forethought of a wide eventually be needed by patients having variety of issues that could determine the more “routine” care requirements such as outcome of a response. These include surgical procedures, cancer chemotherapy, or education of first responders, provider the delivery of a child. Thus, the capacity organization staff, and the public; creation of needed to manage longer-term disasters, e.g., redundant, reliable communication systems; a biological attack, may eventually be in definition of roles and responsibilities among direct competition with the ongoing care responders; definition of available human, needed by the people in the community. equipment and supply resources; and incident management and coordination, It is important that surge capacity – both in among others. Among these are a series of its point-in-time and longitudinal dimensions truly critical elements of the preparedness – be prospectively determined as part of the system that are integral to the ability of a emergency planning process. There is also a community to successfully mount an basic need to define an agreed-upon set of effective response. These are elaborated units, or measures, of surge capacity at the upon below. federal level or, at the very least, at the state level. Such definition is essential to the 1. Define Surge Capacity communication of needs within and across Surge capacity – the ability to expand care communities. capabilities in response to sudden or more prolonged demand – is perhaps the most Current Capacity fundamental component of an emergency The American Hospital Association (AHA) preparedness program. Surge capacity reports that there are 900 fewer hospitals encompasses potential patient beds; available today than there were in 1980.21 Through space in which patients may be triaged, the 1980s and 1990s, the expansion of managed, vaccinated, decontaminated, or managed care and increasingly stringent simply located; available personnel of all federal reimbursement policies progressively types; necessary medications, supplies and leveraged hospitals to close and consolidate, equipment; and even the legal capacity to and to reduce overall capacity in an effort to deliver health care under situations which create greater efficiencies in the delivery exceed authorized capacity. Surge capacity system. Today, with the aging of society and has both point-in-time and longitudinal the corresponding increase in patient acuity, dimensions, and these differ from each other. many hospitals are now challenged to meet a That is, capacity that can be mobilized for a typical day’s demand for their services.
19 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
As a reflection of this challenge, hospital surge capacity exists in these communities. emergency departments in many cities are The underlying causes of this problem are frequently overcrowded and likely to be well known -- inadequate numbers of diverting ambulances on any given day. hospital beds, limited access to primary care, According to a recent AHA survey, 62 unavailability of physician specialists, and percent of all hospitals and 79 percent of major shortages of other key clinical urban hospitals are at or over emergency personnel, especially nurses. department (ED) capacity.22 More than half of urban hospitals report that they have In many communities, accurate, standardized been on “diversion” – diverting ambulances – measurement of bed capacity has become an for a portion of time.23 immediate need. Available hospital bed capacity is typically determined through a Overcrowded emergency departments are a daily midnight census of occupied inpatient clear and visible symptom of a destabilized beds. Measuring bed capacity in this way fails health care environment, and raise clear and to account for the inflow and outflow compelling questions as to whether any real
Tactics Accountability
Surge Capacity
• Determine standardized, universal federal and state government agencies measures of surge capacity. community organization
• Prospectively define point-in-time and community organization longitudinal surge capacity at the community level.
• Identify latent space and human resources community organization capacities.
• Establish mutual aid agreements among health care organizations community hospitals and other health community organization care organizations.
• Ensure a 48-72 hour stand-alone capability health care organizations through the appropriate stockpiling of community organization necessary medications and supplies.
• Standardize equipment, supplies and health care organizations medication doses to facilitate the pharmaceutical companies provision of safe, efficient care. community organization
• Fund and facilitate the creation of a federal government credentialing database to support a national emergency volunteer system for health care professionals.
20 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems occurring throughout the hospital all day also the Nursing Reserve Corps. – long and almost certainly overestimates a roster of volunteer nurses who may be available capacity. The Agency for Healthcare deployed to a disaster site or mass Research and Quality has embarked on a vaccination clinic if and when such needs study to determine useful, relevant measures arise. However, the actual availability of that can predict the imminent onset of these nurses during a disaster remains emergency department overcrowding. uncertain. Depending on the extent of the Overcrowding in most or all of a communi- disaster or the occurrence of concurrent ty’s emergency departments which results in disasters, many of these nurses may be widespread ambulance diversions is, one needed in their own communities. Even could argue, itself a community disaster absent a local disaster, provider organizations which should cause activation of the in a given community may not be able to community’s emergency preparedness plan. release volunteer nurses from their staffs without compromising their own care Too Few Caregivers capabilities. A severe shortage of nurses is already compromising access to health care services In addition to the shortage of nurses, there today,24 and a potential shortage of more are acute shortages of pharmacists, than 400,000 nurses is projected by 2020.25 laboratory technicians, respiratory therapists, Given this reality, it is unclear how additional and, increasingly, physicians. nursing services can be made available in the face of a natural or terrorist disaster. A planned source of surge capacity in the event of a disaster is the National Disaster Several major initiatives are underway to Medical System (NDMS). NDMS is attract potential nurses into health care. administered by the Office of Emergency Most notable among these is the recently Response (OER), which will transition from enacted, but only modestly funded thus far, DHHS to the Department of Homeland Nursing Reinvestment Act. This Act contem- Security in March 2003. NDMS teams plates support both for nursing school facul- include nearly 8,000 volunteer health care ty and for aspiring students, and provides for professionals from around the country who nurse recruitment campaigns. However, the have been organized into general and long-term impacts of these initiatives are specialty teams to help local communities difficult to gauge. DHHS Secretary Tommy respond to a disaster. Thompson recently called for more robust funding for the Nurse Reinvestment Act, and
In many communities, accurate, standardized measurement of bed capacity has become an immediate need.
21 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
There are currently 27 primary care teams was no existing mechanism to document who can, under ideal circumstances, respond their knowledge, skills, and experience – i.e., to an emergency call within 12 to 24 hours. their credentials. Nor was there any way to Four teams specialize in responding to an objectively catalogue the special competen- incident caused by a chemical or bioterror- cies that were then on-site and those that ism attack. There are also burn teams, mental were still needed. health teams and disaster mortuary teams that can assist in a mass casualty event. But The subsequently enacted Public Health for the same reasons that a threshold Security Act includes a provision for the cre- number of nurses may not be available to ation of a national emergency volunteer sys- travel to a disaster, neither may the health tem for health care professionals. However, care workers who comprise the NDMS DHHS has not yet funded this initiative. The teams. events of September 11 dramatize the urgen- cy for moving this project forward. A nation- Truly adding to the capacity of available al credentialing system built upon a common personnel in a disaster or emergency technology platform and using consensus response may necessitate drawing upon credentialing standards would also provide medical, nursing and allied health students. rapid access to information on volunteer DHHS is also encouraging health care clinicians – both in the planning process and organizations to consider retired physicians during an actual event. and nurses in their personnel surge capacity planning.26 Finally, there is also a clear role Space and Supplies for the lay public in caring for themselves or Space is a further critical consideration in family members in the face of a disaster. defining and developing surge capacity. Even today, 70-90 percent of routine care is Space needs are defined in large measure by being provided by family members or other the uses for which the space might be non-professional caregivers.27 While the lay deployed. Such uses include a wide range of caregiver role certainly has its limitations, an potential activities which should be educated public is an important potential catalogued and addressed in the emergency resource. preparedness plan. Among the diverse potential needs for space are triage, At the same time, a disaster must not become decontamination, mass vaccination, a disorganized free-for-all for well-intended, temporary mortuary, counseling, and patient would-be caregivers. In the immediate after- care. In some instances, temporary math of the September 11 events, physicians expansion of hospital capacity will be most and nurses came to the disaster sites and appropriate, e.g., through converting single nearby hospitals from near and far to offer patient rooms to doubles, and use of their services. But nobody knew who they cafeteria, meeting room and office space. were. Had their services been needed, there In other cases, nursing homes, clinics,
22 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
rehabilitation centers, and surgery centers patients for the first 48 hours of an will be appropriate to the needs. And in still emergency. Distribution of the SNS supplies other instances, hotels, closed hospitals, also requires that there be local capacity to armories, auditoriums and similar facilities quickly unload, transport and administer the can be utilized. Finally, caring for people in drugs across the affected region. their own homes is an important source of surge capacity, and may be a particularly There is finally an important need to attractive alternative in the event of a standardize equipment and supplies to the biological attack with an infectious agent. extent possible. With the potential for Fully cataloging space options is also enlisting volunteer medical personnel or particularly important in light of the distinct borrowing staff from other hospitals in the possibility that hospitals and other organized region, such standardization will reduce the settings of care may themselves become likelihood of errors and untoward events and disaster casualties. facilitate the provision of care. Examples include standardizing switches, dials and As important as the need for identifying gauges on oxygen equipment, and space options, is the need to assure the standardizing packaged doses of availability of adequate reserves of pharmaceuticals. medications, equipment and other supplies. While immediate outside support may be 2. Preserve the Organization -- Protect forthcoming, a given community may be on the Staff its own for hours to days following a “When I had a chance to look outside the disaster. command center, I saw all the doctors and nurses watching and waiting,”said Mary By way of example, although a “push pack” is Thompson, the incident commander and promised within 12 hours of request, chief operating officer at Bellevue Hospital pharmaceutical supplies from the Strategic in Manhattan, following the September 11 National Stockpile (SNS) may take up to 48 attack on the World Trade Center.28 “I real- hours to reach the locations in which they ized if there was a biological component to are needed. DHHS suggests that hospitals this attack, they would all be contaminated. maintain enough antibiotics on hand to If that had been the case, I would have had supply hospital staff, first responders and to call all new surgeons.”29
Despite their eagerness to respond, health care workers face real risks in doing so. Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response – to themselves and to the organization.
23 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
There are important lessons to be gained 500,000 first responders and health care from this potential scenario. Sadly, one of workers. A growing number of hospitals those lessons is that there is no “face value” have abstained from the pre-event to terrorism. Every event must be regarded vaccination program, citing the unnecessary with great caution and suspicion – a bomb risk to health care workers and others from may be a “dirty bomb,”an explosion could be the vaccine in absence of a clear smallpox accompanied by a release of a biological threat.30 agent. The responsibilities of hospitals and other Despite their eagerness to respond, health health care organizations to their employees care workers face real risks in doing so. extend beyond physical protection. An Staff members need to be trained and be emergency response can be as emotionally provided proper equipment to reduce anguishing as it is physically punishing. The the risk of an unsafe response – to care and support for organization staff must themselves and to the organization. These encompass their mental health needs as staff must also have the highest priority for well. Hence, there is a particular need for prophylactic antibiotics, chemical antidotes, sensitivity to personal concerns and obliga- and other practical therapeutic measures. tions when workers, for instance, may be separated from their families and loved ones Each hospital should have a decontamination for long hours and even days. capability in place to manage workers and Communications support, attention to patients and to preserve the ability of the child-care needs, provision of transportation organization to provide care. Although there alternatives, and even direct on-site personal has been some debate as to the need for support can all help to alleviate worker such a broad-based capability, the practical stress. In fact, health care organizations may reality is that the determination of be well served by gathering information contamination will often not occur until the about staff concerns and obligations before patient has undergone a screening an event occurs. For example, sixty-two examination and initial stabilization. percent of St.Vincent’s Catholic Medical Center’s emergency department nurses are Reducing the risk to caregivers and preserv- spouses or partners of first responders in the ing the capability of the organization to treat New York City region.31 On September 11, patients also underlies current planning they were asked to perform their duties on a regarding smallpox vaccinations.The day that must have been both professionally President has authorized a pre-event and personally anguishing. vaccination program beginning with the voluntary vaccination of approximately
24 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
In addition to receiving communications “federal zone,”prohibiting entry by support in reaching family and loved ones, unauthorized individuals and vehicles. frontline workers need real-time, current New York University Downtown Hospital information about an event that is in became the home care provider of only progress. Keeping staff apprised of “what’s choice for the residents of an apartment going on” within the organization and across building across the street when home care responding organizations helps them antici- agency nurses could not breach the federal pate downstream needs and gain a sense of zone.32 Fortunately for these home care control over their own environment. In patients, a hospital was located across the addition, maintaining contact with the street. “outside world” through the Internet and broadcast media can help staff avoid feelings In order to gain capacity to care for more of detachment. victims in the wake of an emergency, hospi- tals may cancel scheduled surgeries and 3. Ensure Care for the “Other” Patients defer other planned diagnostic, therapeutic In a massive disaster, there is the potential and rehabilitative activities. This may buy that many chronically and acutely ill patients time, but it will not buy long-term capacity. could lose access to their physicians or Scheduled surgeries have been scheduled for settings where they usually receive care or sound reasons and cannot be delayed obtain medications. This happened in New indefinitely. York City on September 11 when the affected portion of the city was declared a
Tactics Accountability
Direct Caregiver Protection
• Make direct caregivers the highest priority health care organizations for training and for receipt of protective community organization equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures.
• Provide direct caregiver support to meet health care organization mental health and other personal needs.
• Support the provision of decontamination federal and state government capabilities in each hospital. hospitals community organization
• Assure direct caregiver access to current health care organizations information about the emergency on a community organization continuing basis.
25 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Delivering mothers will still need access to Their privacy will be compromised, but their hospital obstetric and neonatal units, cancer wounds will still be treated. Care and access patients to radiotherapy units, stroke patients to caregivers may even become rationed. to rehabilitative services, and so on. In the The goal of graceful degradation is to avoid face of the requirement for a sustained having the health system become a victim of response to an emergency, and once every the assault – from becoming incapacitated option has been exercised for the transfer and unable to deliver care of any kind. The and treatment of patients in various settings hospital, in essence, must engineer its failures and at various levels of care, something less – those that it can allow – while maintaining than the usual standard of care in the affect- its ability to provide care. ed community must become acceptable. At the same time that graceful degradation of Graceful Degradation health care services is occurring, the care Like the electrical utility that plans for providers and health care organizations must “brown-outs” in order to avoid “black-outs,”33 be exempted from the day-to-day rules of hospitals and other provider organizations – operation and regulations that otherwise when stretched beyond their limits, must would prohibit them from caring for patients begin to plan to engineer their failures. The in such fashions. Indeed, they must be goal of such efforts is to achieve “graceful legally protected from reciprocal actions that degradation” of the health care system’s care may occur, for instance, for violations of capabilities as opposed to catastrophic privacy or delivery of sub-standard care once failure of its services. Under such a state of emergency has been declared. scenarios, patients may need to be treated and boarded in hallways.
Tactics Accountability
Meeting the Care Needs of All Patients
•Maintain the ability to provide routine health care professionals care. health care organizations community organization
•Make provisions for the graceful health care organizations degradation of care in all emergency community organization preparedness plans.
• Provide for waiver of regulatory require- federal and state government agencies ments and other standards expectations accrediting bodies under conditions of extreme emergency.
26 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
4. Manage the Incident sharing vital information, and managing the Often referred to as “command-and-control” logistics of an integrated response. The or incident command systems, the incident management system should also established authorities that have taken on establish the common terminology that responsibilities for managing emergency community participants in the emergency responses have often taken on an management program are expected to use, unnecessarily militaristic tone.34 Command in order to reduce the risk of and control may, indeed, be necessary, but so miscommunications. too are effective coordination and communi- cation. The basic need is for an integrated Although definitive studies have not been response that is managed through either an conducted to establish the evidence base for incident command system or, when the incident command system approach, it circumstances warrant, a unified proved to be an integral element of the management approach. generally effective responses to the earthquake and fire disasters that have The variability of emergencies and the historically beset California, and in the evolution of responses to them over time September 11 attacks in New York City and necessitate that the incident management Washington D.C. system provide for fluidity of authority to adjust to changing needs. These characteris- The importance of such systems is also tics of emergency management may also emphasized by their absence. During the require that there be multiple, but unified 2001 anthrax attacks, there was no incident authorities managing the response. management system of any kind. Nor was Application of such an incident management there any coordinated response among vari- system does not preclude others from having ous authorities within localities or across authority and responsibility within their multiple jurisdictions. So disjointed was the domains of expertise or experience. Rather, it response that differing information was pro- assures that there is an emergency manage- vided by various responsible public health ment structure in place that is responsible offices as to how to recognize and treat for coordinating resource deployment, anthrax infections.
Tactics Accountability
Incident Management • Adopt incident management approaches community organization that provide for simultaneous management involvement by multiple authorities, and fluidity of authority as a function of the scale and nature of the emergency situation.
27 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Recognizing the need for a functional con- that individuals need not be in the vicinity of duit of accurate information, the District of a catastrophic event to experience substan- Columbia Hospital Association worked with tial event-related stress.39 With eyes glued to emergency physicians across the National the graphic television coverage across the Capital Region to organize daily conference nation, 90 percent of adults surveyed calls that created interfaces among the reported having some symptoms of stress.40 health care providers, local public health While 60 percent of those in close proximity representatives, the D.C. Department of to the sites of attack reported high degrees Health, and the CDC.35 of stress, 36 percent of respondents living more than 1,000 miles away from the World 5. Consider the Threat to Mind, as well as Trade Center also reported substantial Body stress.41 Significant consideration must be given to the psychological effects of a disaster. It is Though initially traumatized, the vast estimated that for every one physical casual- majority, through their own resiliency, will ty caused by a terrorism incident, there are suffer no significant residua;42 however, some four to 20 psychological victims.36 The will manifest symptoms of post-traumatic September 11 attack has been described as a stress disorder (PTSD). Even then, most “mental health catastrophe.”37 In just one of PTSD sufferers typically recover rapidly.43 the hospitals proximate to the attack in New However, in the rare event that PTSD York City -- St.Vincent’s Catholic Medical persists, it requires evaluation and Center -- staff in the psychiatric department treatment.44 Other trauma-related disorders provided counseling and support to more are more common.45 These include than 7,000 people and received more than unexplained physical symptoms, sleep 10,000 calls to their help line during the first disturbances, increased use of alcohol and two weeks following the disaster.38 cigarettes, and increased family conflict and violence.46 But, because these symptoms are Results of a survey conducted by the RAND often associated with the stresses of daily Corporation three to five days after the living, they may easily be overlooked and not September 11 attack clearly demonstrated associated with the traumatic event.47
Tactics Accountability
Mental Health Management •Make provisions for accommodating and mental health professionals managing the substantial acute mental health care organizations health needs of the community when a community organization natural or terrorist event occurs.
28 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Psychological victims often also include sense of security. A recent incident in which those involved in treating the physical 250 people were exposed to radioactive casualties. In fact, disaster responders, material in Goiannia, Brazil illustrates the including medical personnel, are a high-risk psychological impact of a terrorizing event. group for developing trauma-related Five thousand of the first 60,000 people who disorders. In addition to assuring access to sought medical care after awareness of the personal protective equipment (PPE), incident spread, though unexposed, vaccination and prophylactic treatments for developed the physical symptoms (rash and first responders and frontline health care nausea) that mimicked those of radiation workers, health care organizations need to exposure. All told, 125,000 people sought direct attention to mitigating the medical screening for radiological stress-related psychological effects of contamination – a 500-to-1 ratio of patients disaster response on these individuals. screened to patients exposed.51
Throughout the duration of the response, Fear, though, can be assuaged through responders should be given – even if it must targeted education, application of be mandated for some – rest periods. risk-reduction strategies, and the teaching Over-dedication is a risk factor for of coping skills.52 developing PTSD.48 Further, care providers should be encouraged to “naturally debrief” – 6. Enlist the Public that is to talk with their colleagues, friends While the fear bred by a disaster or terrorist and families about their experiences.49 First incident may far exceed the deleterious responders and other high-risk groups effects of the occurrence itself, it would be should also be evaluated over time following unfair to characterize that fear as the disaster to monitor their recovery and unreasonable. In the face of real threats to detect any signs of an “abnormal response.”50 safety and the absence of credible and helpful information, public fear may indeed The preparedness program should also be reasonable.53 But, contrary to common anticipate and address the “fear factor” perception, widespread panic is rare in inherent in terrorism. The goal of terrorism response to disasters.54 is, after all, to instill fear and erode society’s
Significant consideration must be given to the psychological effects of a disaster.
29 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Nevertheless, prospective, and later The public may indeed assume even more concurrent, education and information basic life-saving roles in emergency sharing is an essential element of strategies situations. In a mass casualty event, rescuers to ensure calm and promote constructive and emergency medical services may quickly behaviors, particularly in the event of an become overwhelmed. When this has unprecedented attack.55 A recent report occurred, members of the public have, in issued by the National Academy of Sciences fact, saved the majority of victims in the emphasizes that, in the event of a terrorist search and rescue phase of a disaster incident, it is essential that trusted response.58 Lay individuals may, and often spokespersons inform the public immediate- do, become active caregivers when medical ly and with expert authority, to both educate resources become thin – visiting the ill in the public and assuage public concerns.56 their homes, distributing antibiotics, even conducting epidemiological investigations Ideally, the public should be enlisted as a and outbreak reporting.59 capable, active partner in the preparedness system.57 An educated public plays a It almost goes without saying that the mass potentially vital role in infectious disease media can and should play a central role in containment and bioterrorism surveillance. conveying information that will permit the When individuals are aware of the signs and general public to optimize their contribu- symptoms of a suspected biological agent, tions to the emergency response. Civic they are more likely to seek medical organizations, professional networks and attention when it is warranted, and not social groups are also potential conduits for otherwise unwittingly overwhelm the health information, as well as resources that can be system and hinder its ability to care for those enlisted to aid in a response effort.60 most in need. They are also then able to engage in risk reduction activities to help contain an infectious outbreak.
Tactics Accountability
Public Engagement • Provide public education about federal and state governments emergency preparedness. community organization
• Actively engage the public in emergency community organization preparedness planning.
30 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
7. Identify Communication and Immediately following the World Trade Information Needs and Meet Them Center attack, telephone lines were down, Information management -- the ability to and cell networks became jammed. New communicate, what to communicate, to York-area hospitals were deluged by calls whom and when – lies at the heart of the from families and friends of the missing who, emergency response. For health care without a centralized patient locator system, organizations, the information needs of its were virtually impossible to find on a constituents – the general public, patients real-time basis. and their families, the staff and their families, first responders, the media, community This experience dramatized the need for officials, and public health agencies, among redundant communications capabilities in others – should be anticipated. emergency situations. Various options for backing up telephone communications exist. The experiences of September 11 and the These include two-way radios and dedicated subsequent anthrax attacks underscored the channels, wireless personal digital assistants criticality of communications in mounting an (PDAs), cell phones, satellite phones, pagers, effective emergency response. In this and Internet connectivity and designated situation, vulnerabilities in the communica- Web sites. tions infrastructure quickly surfaced.
Tactics Accountability
Information Management
•Anticipate the information needs of community organization community organization participants and the public.
• Create redundant, interoperable federal and state governments communications capabilities. community organization
• Develop a centralized community-wide community organization patient locator system.
• Prospectively identify trusted community organization spokespersons to communicate with the public in the event of a natural or intentional disaster.
• Engage the mass media in the emergency community organization preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions.
• Develop an “information stockpile” to community organization support communications activities.
31 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Protocols for using various communications with the medical community, is a key aspect modalities should be pre-determined and of effective communications and underlies consistent across the preparedness system, the ability to elicit the desired responses. and all should be inter-operable. A central- Sources of scientific and relevant expertise ized patient locator system, such as that should be prospectively identified to ensure being developed under the leadership of the the authenticity of the information being Greater New York Hospital Association in imparted. New York, is another vital communications infrastructure asset. The news media can be a critical partner in the dissemination of information, and are A critical issue in the analysis of the 2001 logical additional participants in the anthrax response is the way in which development of community-based information was – and was not -- managed emergency preparedness plans. In any and communicated. This resulted in a event, it is essential to involve media crisis in confidence in the public health representatives early in communication and system.61,62,63 Information was not being information-sharing processes. Media coordinated among public health agencies understanding of the information and the involved in the response, nor between public underlying issues offers the greatest prospect health agencies and the medical community for accurate, sensitive, and constructive charged with evaluating and treating reporting to the public. The media may also potential anthrax victims.64,65,66 Attempts by – by default – become the principal initial the authorities managing the response to conduit of clinical information for medical “spin” the information to reduce perceptions care providers. In this regard, an “informa- of risk, and perhaps to gloss over errors or a tion stockpile”68 of credible information that lack of expertise, served to erode is available in various formats – public public trust.67 service announcements, brochures, fact sheets,Web communications – should also The identification and use of credible, be developed to support outreach efforts. expert spokespersons to take the lead in communicating with the public, as well as
The news media can be a critical partner in the dissemination of information, and are logical additional participants in the development of community-based emergency preparedness plans.
32 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
8. Test, Learn, Improve and Be Ready Further, the more realistic the drill is, the The Joint Commission emergency better the learning and improvement management standards require each accredit- opportunities will be. Indeed, some have ed health care organization to conduct drills suggested that if a drill is not planned to of its emergency management plan at least truly inconvenience the participants and the twice yearly. While such drills are sometimes community – as a real emergency would – viewed as “make-work,”they are in fact a then its value is already compromised.69 At critical element of the emergency prepared- the same time, it bears recognition that ness process. And as the complexity of the mini-emergencies – often occasioned by planning process escalates from an emergency department overcrowding across individual organization basis to a community communities – are everyday realities in many base, the need for carefully crafted, full-scale parts of the country and certainly provide drills in which all of the participants are ample justification for activation of basic involved becomes even greater. Further, the elements of a community’s emergency drill is more than just an exercise; it is a preparedness plan. Such activation can both special opportunity to learn how the help to address temporary clinical care crises preparedness plan and response can be and also permit continuing refinement of improved. In that regard, it is essential that preparedness plans. appropriate metrics for drill evaluation be prospectively identified.
Tactics Accountability
Emergency Preparedness Program Testing
• Regularly test, at least yearly, community community organization emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan.
• Prospectively establish appropriate community organization metrics for objectively assessing the effectiveness of the plan.
• Assure the inclusion of all community community organization emergency preparedness program participants in plan tests.
• Activate the preparedness plan in community organization response to real-world health care crises, e.g. community-wide emergency department overcrowding.
33 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Of the two drills the Joint Commission The University of Maryland Medical System requires each year, one is expected to be a recently conducted a full-scale drill, dubbed community-wide drill. Such drills can be “Free State Response,”in partnership with costly. As a means to cost-share or defray the the U.S.Air Force and the Maryland costs, accredited health care organizations Emergency Management Authority. All told, are encouraged to seek partners in the the drill cost between $200,000 and community who will also benefit from the $300,000, but in the view of the medical drill. Local government, public health system, that money bought “profound authorities, emergency medical services, fire knowledge.”70 In addition to revealing where and police – all of the key participants in existing vulnerabilities lay, the drill the local preparedness system -- should be inculcated the emergency management plan involved in and share in the accountability into the minds of the medical system’s staff for community-wide drills. – where it could more easily be retrieved during an actual disaster.71
Recommendations
Tactics Accountability Surge Capacity • Determine standardized, universal federal and state government agencies measures of surge capacity. community organization
• Prospectively define point-in-time and community organization longitudinal surge capacity at the community level.
• Identify latent space and human resources community organization capacities.
• Establish mutual aid agreements among health care organizations community hospitals and other health community organization care organizations.
• Ensure a 48-72 hour stand-alone capability health care organizations through the appropriate stockpiling of community organization necessary medications and supplies.
• Standardize equipment, supplies and health care organizations medication doses to facilitate the pharmaceutical companies provision of safe, efficient care. community organization
• Fund and facilitate the creation of a federal government credentialing database to support a national emergency volunteer system for health care professionals.
34 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Tactics Accountability
Direct Caregiver Protection • Make direct caregivers the highest priority health care organizations for training and for receipt of protective community organization equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures.
• Provide direct caregiver support to meet health care organization mental health and other personal needs.
• Support the provision of decontamination federal and state government capabilities in each hospital. hospitals community organization
• Assure direct caregiver access to current health care organizations information about the emergency on a community organization continuing basis.
Meeting the Care Needs of All Patients •Maintain the ability to provide routine health care professionals care. health care organizations community organization
•Make provisions for the graceful health care organizations degradation of care in all emergency community organization preparedness plans.
• Provide for waiver of regulatory require- federal and state government agencies ments and other standards expectations accrediting bodies under conditions of extreme emergency.
Incident Management • Adopt incident management approaches community organization that provide for simultaneous management involvement by multiple authorities and fluidity of authority as a function of the scale and nature of the emergency situation.
Mental Health Management •Make provisions for accommodating and mental health professionals managing the substantial acute mental health care organizations health needs of the community when a community organization natural or terrorist event occurs.
35 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Tactics Accountability
Public Engagement • Provide public education about federal and state governments emergency preparedness. community organization
• Actively engage the public in emergency community organization preparedness planning.
Information Management •Anticipate the information needs of community organization community organization participants and the public.
• Create redundant, interoperable federal and state governments communications capabilities. community organization
• Develop a centralized community-wide community organization patient locator system.
• Prospectively identify trusted community organization spokespersons to communicate with the public in the event of a natural or intentional disaster.
• Engage the mass media in the emergency community organization preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions.
• Develop an “information stockpile” to community organization support communications activities.
Emergency Preparedness Program Testing • Regularly test, at least yearly, community community organization emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan.
• Prospectively establish appropriate community organization metrics for objectively assessing the effectiveness of the plan.
• Assure the inclusion of all community community organization emergency preparedness program participants in plan tests.
• Activate the preparedness plan in community organization response to real-world health care crises, e.g. community-wide emergency department overcrowding.
36 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems
A Question of Accountability agencies, both as recipients of significant With the current heavy focus on emergency funding and as critical participants in the preparedness planning, little attention is development of community preparedness being paid to mechanisms for assessing the initiatives, also lack the objectivity necessary actual readiness of communities for emer- to thoroughly assess the functionality of gencies. Indeed, states have been required to community preparedness programs in their submit “plans for planning” for emergency states. preparedness as the principal condition for receipt of federal funding. However, actual The appropriate time to establish an effec- readiness will not be defined simply by the tive, objective oversight mechanism for eval- creation of a plan or even by its periodic uating community emergency preparedness testing. Readiness must eventually be programs and assuring that they are meeting assessed by objective parties against reasonable standards expectations is not prospectively established standards. Such after this country has experienced multiple standards must include expectations for plan failures. There are already sufficient evidence of maintenance of readiness over lessons from the past to underscore the time. importance of preventive measures in this area as well. The issues of accountability and oversight currently hover in the background. Sustainable Funding Governors have been defined as being Following the 2001 terrorism attacks, accountable for submitting their state Congress appropriated $40 billion to be emergency preparedness work plans to expended through 2002 on terrorism pre- DHHS. This at least creates presumptive paredness efforts; $135 million of these accountability on the part of individual funds were earmarked for hospitals. Most governors for state-wide emergency hospitals are still awaiting receipt of those preparedness. At the same time, it very funds, which, owing to the manner in which much leaves open the issue as to how the states allocate such funds, are currently unac- individual governors will simultaneously and counted for or are hung-up in state budget objectively determine the effectiveness of hearings.72 that preparedness. State public health
Tactics Accountability
• Develop and implement objective federal government evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans and the actual readiness of community organizations to manage disasters and terrorist events.
37 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
In the President’s 2003 budget, $535 million term, there is clearly a need for a sustainable is earmarked for hospital preparedness.73 funding mechanism to support their The budget also includes $3.5 billion in ter- emergency preparedness efforts. As the most rorism preparedness funds for first respon- critical care delivery component of a tightly ders to acquire new technologies, equipment woven preparedness system, hospitals will and communications systems, and to con- require funding for development, as well as duct drills among first responder agencies. for maintenance and fortification of their Unfortunately for hospitals, the President’s preparedness programs. In the absence of budget limits the definition of first respon- adequate federal funding, and with hospitals’ ders to firefighters, local law enforcement, inability to rely on private funding to bolster rescue squads, ambulances and emergency their preparedness efforts, some have medical personnel.73 suggested exploration of creative “taxation” approaches, such as a hospital surcharge on All FY2003 terrorism preparedness funding, patient visits, to provide a sustained funding though, remains “on the table” in anticipation stream that will permit hospitals to meet of budget allocation hearings. Many expect public expectations of their emergency that with a potential war with Iraq and the preparedness capabilities. Indeed, if “at the stumbling U.S. economy, the level of funding end of the day, it is medical care that will be for preparedness activities will likely be needed,”77 hospitals and other organizations reduced.76 in the care continuum are going to require the means to provide it. While it remains to be seen what actual funding hospitals will receive in the near
Tactics Accountability
•Provide funding at the local level for federal and state governments emergency preparedness planning, specifically including adequate funding for hospitals, and assure that the funds actually reach the local level.
• Explore alternative options for providing hospitals sustained funding for hospital emergency federal and state governments preparedness activities.
• Initiate and fund public-private sector federal and state governments partnerships that are charged to conduct academic health centers research on and develop relevant, scal- established community organizations able templates for emergency prepared- accrediting bodies ness plans that will meet local community needs in a variety of urban, suburban, and sparsely populated settings.
38 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Guiding the Effort executive director of the State Bioterrorism There is – as already noted – also the need Preparedness and Response Program; for credible guidance, in the form of tem- establishment of an advisory committee that plates or models, to jumpstart and facilitate includes representatives from state and local community preparedness program health departments, other appropriate development. Many involved in developing government agencies, emergency medical community-wide preparedness programs services, police and fire departments, have little idea as to what constitutes an hospitals, community health centers, and acceptable, let alone, ideal model. And the other health care providers, among others; fact is that response capabilities and basic and the preparation of a timeline for needs and structure vary substantially among development of both state and regional plans urban, suburban, and rural communities and for responding to incidents of bioterrorism, even within those communities. other infectious diseases, and other public health threats and emergencies. Each state A nascent national template for emergency is also to establish a hospital planning management has now emerged through the committee, designate a coordinator for enactment of the “Public Health Security and hospital bioterrorism planning, and develop Bioterrorism Preparedness and Response a plan for a potential epidemic involving at Act.” Preceding the enactment of the bioter- least 500 patients. While these macro state rorism legislation, all states were required to plans are necessary, they are far from submit their bioterrorism preparedness work sufficient to meet local community planning plans to DHHS as a prerequisite for alloca- needs. Once again, most disasters and tion of state funding. Among the 17 critical terrorist events will be local, and the benchmarks DHHS required in the state effectiveness of the response will be plans were the designation of a senior public determined at the local level. health official within the state to serve as the
Tactics Accountability
• Disseminate information about existing federal and state governments best practices and lessons learned respecting existing emergency preparedness initiatives to community organizations, hospitals and other health care organizations.
39 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Another template developed by federal features of an all risks ready emergency authorities is the model plan recently facility -- one built specifically for scalability, released by the Centers for Disease Control threat mitigation, and management of the and Prevention (CDC) for vaccinating the medical consequences of terrorism. E.R. One U.S. population following a smallpox out- will utilize new information, building, break. The model plan was sent to all 50 materials and engineering technologies, and states to aid in the rapid creation of volun- will embed concepts of modularity and tary smallpox vaccination clinics that would flexibility so as to be configurable to any permit the vaccination of one million people threat. Leading Project E.R. One is the within 10 days. The plan provides informa- Washington Hospital Center, which is the tion on the supplies and resources that will largest hospital in Washington D.C. The be provided by the federal government; hospital is located less than two miles from security considerations; suggested clinic the U.S. Capitol and so is the likely hospital organization and logistics; estimated person- to receive large numbers of victims from an nel needs; clinical issues and considerations; attack on this country’s seat of government. sample consent forms and public education materials; and a template for delivery of mass Other preparedness models are being patient care should that become necessary.78 developed in the private sector.79 However, The model plan does not, however, provide public-private sector partnerships offer the direction as to the acquisition of resources – best overall prospect for research on and either financial or human – to create and development of relevant, scalable models operate mass vaccination clinics. This too is that will meet local community needs in a a necessary template but one which is variety of urban, suburban, and sparsely targeted to a specific potential problem. populated settings. There is considerable urgency to move this work forward. The federal government is also investing in the creation of a model facility for emergency preparedness. “Project E.R. One” is a federal initiative to develop the design
Indeed, if “at the end of the day, it is medical care that will be needed,” hospitals and other organizations in the care continuum are going to require the means to provide it.
40 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Knowing What Works situations are needed. Such clarifications – if Federal and state governments have practical and realistic – would be welcome additional important roles to play in by the health care community and would advancing emergency preparedness across substantially enhance the credibility of and the country. In addition to the public confidence in the federal government in its education and communications facilitation regulatory role. roles earlier identified in this paper, government agencies are important conduits There is finally a need for coordination of for the dissemination of best practices in domestic and international preparedness. emergency preparedness, as well as lessons After all, germs know no boundaries. A learned. Specific areas with which hospitals, bioterrorism attack in the U.S. could readily in particular, are struggling include decisions spread abroad either accidentally or inten- regarding the types and quantities of person- tionally via international trade, travel or other al protective equipment (PPE) that should be means; likewise what began abroad could stocked, and the design of decontamination wind up in the U.S. The globalization of capabilities. Further, clarification as to the emergency preparedness systems could also application of the Emergency Medical serve as a defense against the increasing Treatment and Active Labor Act threat of naturally occurring infectious (EMTALA)and Health Insurance Portability disease. and Accountability Act (HIPAA) regulations, as well as those of the Environmental Protection Agency (EPA) (e.g. regarding water run-off requirements) in emergency
Tactics Accountability
• Clarify the applications of EMTALA, HIPAA, federal government EPA and other regulatory requirements in emergency situations.
• Coordinate domestic and international federal government emergency preparedness efforts.
41 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Recommendations
Tactics Accountability
• Develop and implement objective federal government evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans and the actual readiness of community organizations to manage disasters and terrorist events.
•Provide funding at the local level for federal and state governments emergency preparedness planning, specifically including adequate funding for hospitals, and assure that the funds actually reach the local level.
• Explore alternative options for providing hospitals sustained funding for hospital emergency federal and state governments preparedness activities.
• Initiate and fund public-private sector federal and state governments partnerships that are charged to conduct academic health centers research on and develop relevant, scal- established community organizations able templates for emergency prepared- accrediting bodies ness plans that will meet local community needs in a variety of urban, suburban, and sparsely populated settings.
• Disseminate information about existing federal and state governments best practices and lessons learned respecting existing emergency preparedness initiatives to community organizations, hospitals and other health care organizations.
• Clarify the applications of EMTALA, HIPAA, federal government EPA and other regulatory requirements in emergency situations.
• Coordinate domestic and international federal government emergency preparedness efforts.
42 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Conclusion
Fulfilling the Promise of a Homeland The potential for intentional, terrorist disas- Defense ters in this country today is great. What if – Hospitals and the communities in which as American Public Health Association they operate have long managed to fulfill Executive Director Georges Benjamin has their obligations to treat and protect speculated – the transmission of anthrax-con- patients, even in the face of dire circum- taining letters had continued further into the stances. Community and hospital fortitude fall of 2001, rather than mysteriously ceasing. has been witnessed in New York City on How difficult could that have been? The September 11, in Houston during the 2001 person who perpetrated this set of terrorist floods, and during the recurrent earthquake acts has still never been found. and fire disasters in California. Whether or not the federal and state However, America’s communities, its public governments and some of the nation’s large health infrastructure, and its health care cities are truly prepared for major disasters delivery system are literally living far closer or terrorist events, the vast majority of to the brink of disaster than they have since America’s communities are not. These often the turn of the 20th century. Public health leaderless entities – the accountable agencies have progressively been shriveled emergency preparedness organizations by decades of underfunding and inattention, referenced throughout this paper – are and the health care delivery system, or non- largely unsophisticated, inexperienced, system as some claim – despite its consump- underfunded and unprepared. These tion of over 14 percent of the Gross communities, where – ready or not – the Domestic Product – has far less relative rubber will actually meet the road if disaster capacity to meet the acute care needs of strikes, are today far more like oil-and-water this country’s citizens than it did three mixtures than well-oiled machines. decades ago. Anyone who is skeptical of this characterization need look no further than The United States was complacent before the results of the recent nationally sponsored September 11. Notwithstanding the bio-terrorism drills,TOP-OFF and Dark occasional Orange alerts since then, the Winter. In both of these drills, the local American mindset again appears to be health care systems were quickly steadily returning to comfortable overwhelmed. complacency. That is a prescription for great danger, if not disaster. The world, and indeed the country, in which Americans live has changed forever. Even if the commitments and actions called However, neither Americans nor their for in this paper were aggressively pursued communities have accommodated to, or beginning today, the amount of resources even accepted, the reality that acts of terror- and the amount of time needed to ready ism which can result in mass casualties are America’s communities is extremely today far closer to them than what once worrisome. This country should not need seemed like strange and barbaric acts in another major disaster in order to distant and distinctly different lands. understand the degree of its vulnerability. The time to begin to develop true emergency preparedness capabilities across America’s communities is now.
43 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Acknowledgements The Joint Commission sincerely thanks the roundtable members for providing their time and expertise in the development of this report. Emergency Preparedness Roundtable Members
Mohammad N.Akhter, MD, MPH Helen Burstin, MD Executive Director (formerly) Center for Primary Care Research American Public Health Association Agency for Healthcare Research & Quality Washington, DC Rockville, MD
Mark Ackermann J. Christopher Farmer, MD Senior Vice President & Chief Corporate Services Mayo Clinic Officer Rochester, MN St.Vincent’s Catholic Medical Center New York, NY Jill Fainter Vice President, Quality Standards R. Scott Altman, MD, MBA, MPH HCA Managing Consultant Nashville,TN Joint Commission International Oakbrook Terrace, IL Ken Frager Assistant Vice President –Executive Affairs Leonard Aubrey University of Maryland Medical System President & CEO (formerly) Baltimore, MD NYU Downtown Hospital New York, NY Edward Gabriel Deputy Commissioner, Preparedness Erik Auf der Heide, MD, MPH, FACEP Office of Emergency Management Medical Officer New York, NY Agency for Toxic Substances & Disease Registry U.S. Dept. of Health & Human Services Margaret Hamburg, MD Atlanta, GA Vice President for Biological Programs Nuclear Threat Initiative Joe Barbera, MD Washington, DC Co-Director Institute for Cr, Disaster, and Risk Management Deborah Hayes Kim, MSN,APRN The George Washington University Program Manager for Emergency Management & Washington, DC Hazardous Material Programs (Formerly) University of Utah Hospitals and Clinics Jim Bentley, Ph.D. Salt Lake City, UT Senior Vice President American Hospital Association Robert R. Knouss, MD Washington, DC Director, Office of Emergency Preparedness National Disaster Medical System Cathy E. Boni, Ph.D, RN, CPHQ Rockville, MD Vice President, Clinical Affairs Hospital Association of Rhode Island Providence, RI
44 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
Kristi L. Koenig, MD, FACEP Mark Smith, MD National Director, Emergency Management Chairman of Emergency Medicine Strategic Healthcare Group Washington Hospital Center & Georgetown Department of Veteran’s Affairs University School of Medicine Clinical Professor of Emergency Medicine Washington, DC George Washington University School of Medicine and Health Sciences Tara O’Toole, MD, MPH Washington, DC Deputy Director, Center for Civilian Biodefense Studies Linda Landesman, DrPh, MSW Johns Hopkins University Assistant Vice President Baltimore, MD Office of Professional Services & Affiliates New York City Health & Hospitals Corp. Robert J. Ursano, MD New York, NY Professor/Chair Department of Psychiatry John Noble, MD Uniformed Services University of Health Sciences Director, Center for Primary Care Bethesda, MD Boston University School of Medicine Boston, MA Joseph F.Waeckerle, MD, FACEP Clinical Professor Dennis S. O’Leary, MD University of Missouri School of Medicine President Editor Emeritus,Annals of Emergency Medicine JCAHO Leawood, KS Oakbrook Terrace, IL Susan Waltman Michael Osterholm, Ph.D, MPH Chief Counsel Director, Center for Infectious Disease, Research Greater New York Hospital Association & Policy New York, NY University of Minnesota Minneapolis, MN Pennington Whiteside, Jr. North Carolina Institute for Public Health Jeff Rubin UNC School of Public Health Chief Deputy Director of EMSA Chapel Hill, NC Disaster Medical Services Division of California Sacramento, CA Paul Zimnik, MD CEO Michael Scotti, Jr., MD Doctrix Senior Vice President Frederick, MD American Medical Association Chicago, IL
45 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
End Notes
1Pear, Robert,“Most states cutting back on Medicaid, survey finds,” New York Times,January 14, 2003 2Pear, Robert,“Government proposing cuts in many Medicare payments,” New York Times, September 22, 2002 3Hudson Thrall,Terese, Scalise, Dagmara,“America’s uninsured,”Hospitals & Health Networks, November 2002: 30-40 4Hart, Gary, Rudman,Warren B., Flynn, Stephen,“America Still Unprepared – America Still In Danger,”report of an independent task force sponsored by the Council on Foreign Relations, 2002: 12. 5Congressional testimony by Dennis S. O’Leary, M.D., before the Committee on Energy and Commerce Subcommittee on Oversight and Investigations, October 10, 2001 6The American Hospital Association,“Cracks in the Foundation:Averting a Crisis in America’s Hospitals,”2002 7Congressional testimony by Thomas Inglesby,“The State of Public Health Preparedness for Terrorism Involving Weapons of Mass Destruction:A Six Month Report Card,”before the Committee on Government Affairs,April 18, 2002 8Dennis Schrader, vice president for project planning and development, University of Maryland Medical System, speaking at the national conference,“Homeland Defense: Blueprints for Emergency Management and Responses,”October 23-25, 2002,Washington DC 9Greater New York Hospital Association Website, www.gnyha.org, viewed October 1, 2002 10Congressional testimony by Thomas Inglesby,“The State of Public Health Preparedness for Terrorism Involving Weapons of Mass Destruction:A Six Month Report Card,”before the Committee on Government Affairs,April 18, 2002 11Inglesby,Thomas, O’Toole,Tara, et al,“Anthrax as a biological weapon, 2002,” JAMA,May 1, 2002: 2236-2252 12Chen, Frederick J., Hickner, John, et al,“On the front lines: Family physicians’ preparedness for bioterrorism,” The Journal of Family Practice, September 2002: 745-750. 13Ibid 14Ibid 15Borio, Luciana, Frank, Dennis,“Death due to bioterrorism-related inhalational anthrax,” JAMA,November 28, 2001 16Chen, Kathy, Hill, Greg, et al,“Seven days in October spotlight weakness of bioterror response,” Wall Street Journal,November 2, 2001 17Ibid 18Inglesby testimony,April 18, 2002 19Chen, Kathy, Hill, Greg, et al 20Ibid 21The American Hospital Association,“Cracks in the Foundation:Averting a Crisis in America’s Hospitals,”2002 22Ibid 23Ibid 24Joint Commission on Accreditation of Healthcare Organizations,“Health Care at the Crossroads: Strategies for Addressing the Evolving Nursing Shortage,”2002: 6 25Buerhaus, Peter, Staiger, Douglas,Auerbach, David,“Implications of an aging RN workforce,” JAMA,June 14, 283 (22): 2948-2954
46 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
26Jerome Hauer, Office of Public Health Emergency Preparedness, DHHS, speaking at the national conference, “Homeland Defense: Blueprints for Emergency Management and Responses,”October 23-25, 2002,Washington DC 27Glass,Thomas, Schoch-Spana, Monica,“Bioterrorism and the people: How to vaccinate a city against panic,” Clinical Infectious Diseases,January 15, 2002: 34. 28Ibid, 56 29Ibid, 56 30Manning,Anita,“Are we prepared for smallpox?” USA Today, March 6, 2003 31Mark Ackermann, senior vice president, St.Vincent’s Medical Center, New York, NY,speaking at the national conference,“Homeland Defense: Blueprints for Emergency Management and Responses,”October 23-25, 2002, Washington DC 32Leonard Aubrey speaking at the Joint Commission roundtable meeting, December 10, 2001 33Dale Woodin, deputy executive director,American Society of Health Care Engineering, speaking at the national conference,“Homeland Defense: Blueprints for Emergency Management and Responses,”October 23-25, 2002, Washington DC 34Joint Commission’s roundtable meeting, December 10, 2001 35Barbera, J.A., Macintyre,A.G.,“Medical and Health Incident Management System:A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management,”Institute for Crisis, Disaster and Risk Management,The George Washington University,Washington D.C., October 2002. 36Warwick, Marion C.,“Psychological effects of weapons of mass destruction,” Missouri Medicine,January 2002. 37Joseph T.English, MD, quoted in Psychiatric News,January 4, 2002: 4-5 38Rosack, Jim,“Mental health effects of terrorism,” Psychiatric News,January 4, 2002: 4-5 39Shuster, M.A., Stein, B.D., et al,“A national survey of stress reactions after the September 11, 2001 terrorist attacks,” New England Journal of Medicine,November 15, 2001 40Ibid 41Ibid 42Ursano, Robert J.,“Post Traumatic Stress Disorder,”editorial, New England Journal of Medicine,vol. 346, No. 2, January 10, 2002: 130-131. 43Ibid 44Ibid 45Ibid 46Ibid 47Ibid 48Robert Ursano, MD, professor and chairman of the Department of Psychiatry, Uniformed Services University School of Medicine, speaking at the national conference,“Homeland Defense: Blueprints for Emergency Management and Responses,”October 23-25, 2002,Washington DC 49Ibid 50Ibid
47 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
51Ibid 52Ibid 53Glass, Schoch-Spana 54Ibid 55Ibid 56National Acadamy of Sciences Committee on Science and Technology for Countering Terrorism, National Research Council,“Making the Nation Safer:The Role of Science and Technology in Countering Terrorism”, National Academy Press,Washington, D.C., June 2002. 57Glass, Schoch-Spana 58Ibid 59Ibid 60Ibid 61Inglesby testimony,April 18, 2002 62Glass, Schoch-Spana 63Chen, Kathy, Hill, Greg, et al, 64Barbara 65Inglesby 66Chen, Kathy, Hill, Greg, et al, 67Glass, Schoch-Spana 68Ibid 69Joint Commission’s roundtable meeting, December 10, 2001 70Schrader 71Ibid 72Hauer 73“Protecting the Homeland,”from the President’s 2003 Federal Budget, 2002: 18 74Ibid, 18 75Ibid, 17. 76Associated Press,“Counties seek more money for efforts against terror,” New York Times,January 21, 2003 77Hauer 78Centers for Disease Control and Prevention,“Smallpox Vaccination Clinic Guide,”September 16, 2002 79Barbara, Macintyre
48 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems
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