7
Disaster Preparedness

The day before September 11, 2001, the cover story of U.S. News and World Report described an emergency care system in critical condition as a result of demand far in excess of its capacity (Shute and Marcus, 2001; see Figure 7-1). While the article focused on the day-to-day problems of diversion and boarding, the events of the following day brought home a frightening realization to many. If we cannot take care of our emergency patients on a normal day, how will we manage a large-scale disaster? Federal, state, and local government entities have since realized the importance of hospitals, particularly emergency departments (EDs), in planning for such events, and significant progress has been made on integrating inpatient resources into planning for disasters (Schur, 2004). More than 4 years after September 11, however, Hurricane Katrina revealed how far we have to go in this regard. While Katrina was unusual in its size and scope, the capacity of the emergency care system to respond effectively even to smaller disasters is still in question (GAO, 2003a).

Disaster response involves many different community resources—from police and fire to medical providers, structural and environmental engineers, and transportation and housing experts. The hospital plays a small but crucial role in this larger picture. It is the epicenter of medical care delivered to those who are injured. Running a hospital is an enormously complex task under the best of circumstances; preparing a hospital for a disaster is infinitely more complicated. Planning for disasters involves a range of difficult questions: For what types of disaster events should hospitals prepare? Should every hospital prepare for disasters, or should medical response be regionalized? When does “busy” rise to the level of disaster, who makes that



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Hospital-Based Emergency Care: At the Breaking Point 7 Disaster Preparedness The day before September 11, 2001, the cover story of U.S. News and World Report described an emergency care system in critical condition as a result of demand far in excess of its capacity (Shute and Marcus, 2001; see Figure 7-1). While the article focused on the day-to-day problems of diversion and boarding, the events of the following day brought home a frightening realization to many. If we cannot take care of our emergency patients on a normal day, how will we manage a large-scale disaster? Federal, state, and local government entities have since realized the importance of hospitals, particularly emergency departments (EDs), in planning for such events, and significant progress has been made on integrating inpatient resources into planning for disasters (Schur, 2004). More than 4 years after September 11, however, Hurricane Katrina revealed how far we have to go in this regard. While Katrina was unusual in its size and scope, the capacity of the emergency care system to respond effectively even to smaller disasters is still in question (GAO, 2003a). Disaster response involves many different community resources—from police and fire to medical providers, structural and environmental engineers, and transportation and housing experts. The hospital plays a small but crucial role in this larger picture. It is the epicenter of medical care delivered to those who are injured. Running a hospital is an enormously complex task under the best of circumstances; preparing a hospital for a disaster is infinitely more complicated. Planning for disasters involves a range of difficult questions: For what types of disaster events should hospitals prepare? Should every hospital prepare for disasters, or should medical response be regionalized? When does “busy” rise to the level of disaster, who makes that

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Hospital-Based Emergency Care: At the Breaking Point FIGURE 7-1 U.S. News and World Report, cover story on September 10, 2001. SOURCE: Reprinted from Shute and Marcus, 2001, with permission. decision, and how does a large, complex organization shift from routine to disaster mode? How does a hospital protect itself and its staff from chemical or biological agents when patients are contaminated? This chapter examines these and other questions, and considers the current level of hospital disaster preparedness. It also explores the special problems associated with rural hospitals, and presents the committee’s recommendations for enhancing hospital preparedness. DEFINING DISASTER The term “disaster” denotes a low-probability but high-impact event that causes a large number of individuals to become ill or injured. The In-

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Hospital-Based Emergency Care: At the Breaking Point ternational Federation of Red Cross and Red Crescent Societies defines a disaster as an event that causes more than 10 deaths, affects more than 100 people, or leads to an appeal for assistance by those affected (Bravata et al., 2004b). This report expands that definition in the context of hospital-based emergency and trauma care to include any event that creates a significant, short-term spike in the demand for emergency care services that requires extraordinary measures to address adequately. Disasters can range from large multiple-vehicle crashes to massive events such as the North Ridge earthquake, Hurricane Katrina, and the terrorist attacks of September 11. Disasters can be natural, such as earthquakes, floods, and disease outbreaks; or they can be man-made, such as transportation incidents, terrorist bombings, and biological or chemical attacks. The federal government has grouped terrorist threats into five categories—chemical, biological, radiological, nuclear, and explosive (CBRNE)—which are also useful for classifying general threats (see Box 7-1). Each type of threat presents different challenges to hospitals, which must able to respond to each in some capacity. Given finite resources, however, hospitals must attempt to focus their resources on the most likely and potentially serious scenarios. Bombings are the most common form of terrorist attack (Frykberg, 2004). They often result in the worst forms of both blunt and penetrating trauma in addition to burns, as shown by recent experience; examples include the train and subway attacks in Madrid (Gutierrez de Ceballos et al., 2004) and London, Oklahoma City bombing (Teague, 2004), and the Atlanta Centennial Olympics bombing (Feliciano et al., 1998). Worldwide, there were more than 500 terrorist bombings between 2001 and 2003, resulting in 4,600 deaths (U.S. Department of State, 2005a,b,c). Over the past 25 years, few acts of global terrorism have involved the use of chemical or biological agents. In contrast, explosives and/or firearms have been used to commit countless acts of terrorism in Israel, Egypt, Kenya, Argentina, Colombia, Bali, Yemen, Russia, the United Kingdom, Germany, France, Italy, and many other countries. The possibility of bioterrorism or a nuclear attack is also real, however, and the impact of such incidents on public health would be catastrophic. To some degree, each region must prioritize its response preparedness according to the likelihood of the different types of events it could face. Thus New York City should probably spend more resources than Topeka, Kansas, on preparation for biological or nuclear attack; Topeka, on the other hand, should focus more of its preparedness efforts on tornados. The scope of various types of disasters is illustrated by selected recent events, which are summarized in Table 7-1. The federal government has promoted the idea of preparing for “all hazards.” But federal disaster planning has paid much more attention to biological and chemical threats than to explosive attacks by terrorists or,

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Hospital-Based Emergency Care: At the Breaking Point BOX 7-1 Classification of Terrorist Threats The federal government groups terrorist threats into five categories— chemical, biological, radiological, nuclear, and explosive—commonly referred to as CBRNE. Each type of threat has unique characteristics and medical impacts: Chemical. A chemical emergency occurs when a hazardous chemical has been released, and the release has the potential to harm people’s health. In the United States, 60,000 chemical spills, leaks, and explosions involving more than 300 deaths occur each year (Geiger, 2001; Kaji and Waeckerle, 2003). Many hazardous chemicals are used in industry (for example, chlorine, ammonia, and benzene). Chemical releases can be unintentional, as in the case of an industrial incident, or intentional, as in the case of a terrorist attack. Examples are nerve agents, such as sarin; mustard gas; and choking agents, such as phosgene. Others are found in nature (for example, poisonous plants). Biological. This category includes bioterrorism agents, such as anthrax, smallpox, botulism, and plague. In the nonterrorism context, it can include outbreaks of infectious disease with a high risk of transmission and serious health effects, such as severe acute respiratory syndrome (SARS) and avian influenza. Radiological. Widescale exposure to radiation could result from a dirty bomb, in which radioactive material is dispersed through an explosive device, or by a compromise of the containment of nuclear power stations or nuclear storage facilities. Nuclear. Resulting from the detonation of a nuclear device, this type of incident can result in a wide range of injuries, including explosive, radiological, and burns. Explosive. Explosive injuries can include blunt and shock wave– induced trauma, as well as burns, hearing loss, and injuries from shrapnel and the secondary collapse of structures. until Hurricane Katrina, to natural disasters (Arkin, 2005). Of the 15 National Planning Scenarios introduced by the Department of Homeland Security (DHS) to guide disaster preparation efforts, only two involve natural disasters and only one an attack using explosives (see Box 7-2). Following Hurricane Katrina, however, DHS altered the selection process for its Urban Area Security Initiatives grants to ensure that the program would place as much weight on cities under threat from natural disasters as those likely to be terrorism targets (Jordan, 2006).

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Hospital-Based Emergency Care: At the Breaking Point Because of the unpredictability of demand for emergency services, hospitals face fluctuations in utilization on an hourly, daily, and weekly basis. With many hospitals already operating at or near full capacity (as detailed in Chapter 2), temporary surges can exacerbate chronic ED crowding, boarding, and ambulance diversion. While these surges in demand can severely stretch the resources of a hospital’s staff and diminish the quality and safety of patient care, hospitals generally maintain their normal standard of care through these surges. In a disaster situation, however, hospitals may need to shift to a sufficiency-of-care mode, in which the focus is on saving as many lives as possible rather than ensuring that each patient receives the usual standard of care (AHRQ, 2005). In the most extreme cases—for example, a full-blown influenza pandemic such as that experienced worldwide in 1918—this could mean assigning the most severely ill or injured patients to “expectant care,” a strategy that withholds treatment for those who have TABLE 7-1 Recent Disaster Events (United States and Worldwide) Type Examples Locations No. of Deaths Natural Hurricane (Katrina) New Orleans/Louisiana/ Mississippi/Alabama (2005) 1,326 Avian influenza 6 countries (2005–2006) 118 (as of October 20, 2005) Earthquake Kashmir (2005) 73,000 (69,000 injured) Tsunami 12 countries (2004) 212,611 SARS 25 countries (2002–2003) 774 Earthquake Northridge, California (1994) 57 (5,000+ injured) Man-made Subway bombing London (2005) Madrid (2004) 52 (700 injured) 191 (2,000 injured) Nightclub fire Rhode Island (2003) 100 (200+ injured) Nightclub bombing Bali (2002) 202 Anthrax Washington, D.C. (2001) 5 (13 injured) Terrorist attacks of September 11 New York and Washington, D.C. (2001) 2,752 Embassy bombings Nairobi and Tanzania (1998) 224 (4,000+ injured) Release of sarin gas Tokyo, Japan (1995) 12 (5,000 injured) SOURCES (in order listed): Associated Press, 2006a; BBC News, 2006b; Times Foundation, 2005; CNN.com, 2005a; IOM, 2004; Insurance Information Network of California, 2006; CNN.com, 2005b; Gutierrez de Ceballos et al., 2004; Associated Press, 2006b; BBC News, 2006a; CNN.com, 2002; Hirschkorn, 2003; Rand Corporation, 2004; Accountability Review Boards on the Embassy Bombings in Nairobi and Dar es Salaam, 1999; BBC News, 2005.

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Hospital-Based Emergency Care: At the Breaking Point BOX 7-2 Department of Homeland Security’s 15 National Planning Scenarios Nuclear Detonation: 10-Kiloton Improvised Nuclear Device Biological Attack: Aerosol Anthrax Biological Disease Outbreak: Pandemic Influenza Biological Attack: Plague Chemical Attack: Blister Agent Chemical Attack: Toxic Industrial Chemical Chemical Attack: Nerve Agent Chemical Attack: Chlorine Tank Explosion Natural Disaster: Major Earthquake Natural Disaster: Major Hurricane Radiological Attack: Radiological Dispersal Device Explosives Attack: Bombing Using Improvised Explosive Devices Biological Attack: Food Contamination Biological Attack: Foreign Animal Disease (Foot and Mouth Disease) Cyber Attack SOURCE: DHS, 2005b. very little chance of survival to focus resources on saving the largest possible number of lives. A hospital’s decision to switch from routine to disaster mode has enormous implications. When to make that decision and what actions to take as a result are complex. A number of initiatives are exploring these questions. For example, within the Department of Health and Human Services (DHHS), the Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control, Division of Injury Response, is developing a consensus report describing the detailed actions to be taken by hospital and trauma center departments and personnel in the event of an explosive mass casualty event (CDC National Center for Injury Control and Prevention, 2006). The Agency for Healthcare Research and Quality (AHRQ) has sponsored research, convened expert panels, and published guidance for hospitals and communities on preparing for biological and other terrorist events. The Health Resources and Services Administration’s (HRSA) Bioterrorism Hospital Preparedness Program specifically targets hospital preparedness, with a focus on the development and implementa-

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Hospital-Based Emergency Care: At the Breaking Point tion of regional plans to improve the capacity of hospitals to respond to bioterrorist attacks. CRITICAL HOSPITAL ROLES IN DISASTERS Evaluations of ED disaster preparedness consistently yield the same finding: EDs are better prepared than they used to be, but still fall short of where they should be (Schur et al., 2004). A survey conducted by CDC in 2003 gives a comprehensive picture of hospital preparedness in the years following September 11 (Niska and Burt, 2005). Hospitals vary widely in the degree to which they have prepared for the range of possible threats. At the time of the survey, almost all hospitals (97.3 percent) had plans for responding to natural disasters because holding natural disaster drills is a requirement for accreditation by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO). More than 80 percent of hospitals had plans for chemical (85.5 percent) and biological (84.8 percent) threats, and more than 70 percent had plans for nuclear and radiological (77.2 percent) and explosive (76.9 percent) threats. The remainder of this section reviews the current status of and recommended actions for enhancing hospital preparedness across five critical hospital roles during disasters: maintaining surge capacity, carrying out planning and coordination with the wider health and public safety communities, conducting training and disaster drills, protecting the hospital and its staff, and performing surveillance. Surge Capacity Hospitals in most large population centers are operating at or near full capacity. In many cities, hospitals and trauma centers have problems dealing with a multiple-car highway crash, much less the volume of patients likely to result from a large-scale disaster. During emergencies, hospitals can do a number of things to free up capacity and extend their resources, but there are serious physical limitations on this expansion of their capabilities. Surveys indicate that the numbers of available beds, ventilators, isolation rooms, and pharmaceuticals may be insufficient to care for victims of a large-scale disaster (Kaji and Lewis, 2004). The Rhode Island nightclub fire (discussed further below) demonstrated that even medium-sized incidents can overwhelm local hospital capacities (Hick et al., 2004). The frequent ambulance diversions and ED boarding discussed earlier in this report also signal limitations on hospital surge capacity. The issue of capacity is an immediate problem because many hospitals and their EDs are already maximizing their existing capacity after years of capacity shedding designed to reduce costs. According to the American

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Hospital-Based Emergency Care: At the Breaking Point Hospital Association (AHA), 60 percent of hospitals were operating at or over capacity in 2001 (The Lewin Group, 2002). Many hospitals have already opened up additional beds in an effort to alleviate overcrowding, but continue to face nursing shortages and staffing issues in supporting the existing beds (Derlet and Richards, 2000; Asplin and Knopp, 2001). The limiting factor in the ability to respond to a disaster will vary by hospital and by type of disaster. An important limiting factor is the availability of specialists who can treat the types of cases resulting from a disaster event. For an event involving a rare biological or chemical agent, there may be limited expertise in the community. For more common types of events, such as blast injuries, the limitation will likely be an inadequate supply of surgical specialists (including neurosurgeons, orthopedic surgeons, and burn surgeons) to treat the volume of cases requiring their specialized services. While other staff, such as emergency physicians, critical care specialists, and nurses, are important, they are less likely to represent a major constraint on the ability to treat additional patients. One way in which hospitals can alleviate staff shortages is to use emergency medical services (EMS) personnel as physician extenders. In many disaster scenarios, the prehospital component is over in 1–2 hours, making a large number of EMS personnel available just as hospital activity is peaking. Physical space is an important consideration, but probably not the most critical factor. Hospitals can add to available capacity on short notice by halting elective admissions and discharging noncritical patients. In addition, they can sometimes use ED hallways, inpatient hallways, and nonclinical areas to house victims in an emergency. According to the CDC survey, however, only 61 percent of hospitals had developed plans for the use of nonclinical space in such cases (Niska and Burt, 2005). In some instances, particularly a more circumscribed disaster, hospitals can make room for patients by transferring existing inpatients to more distant facilities. But the CDC study revealed that only 46 percent of hospitals had agreements with other hospitals to accept patients in the case of a disaster (Niska and Burt, 2005). Intensive care unit (ICU) beds are much more difficult to empty on short notice than other beds and are probably the key limiting factor in terms of physical capacity, as they often are in day-to-day crowding (GAO, 2003a). Another physical limitation is the number of negative pressure rooms needed to prevent the spread of airborne pathogens. Limitations in available equipment, such as mechanical ventilators and decontamination showers, are also important. The committee concludes that the lack of adequate hospital surge capacity is a serious and neglected element of current disaster preparedness efforts.

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Hospital-Based Emergency Care: At the Breaking Point Planning and Coordination When a disaster occurs, the normal operating assumptions about patients, responses, and treatments often must be jettisoned. Depending on the type of event, some of the nonroutine things that can happen include the following (Ackermann et al., 1998; Auf der Heide, 2006): Victims who are less injured and mobile (the so-called “walking wounded”) will often self-transport to the nearest hospitals, quickly overwhelming those facilities. Casualties are likely to bypass on-site triage, first aid, and decontamination stations. EMS responders will often self-dispatch. Providers from other jurisdictions may appear at the scene and transport patients, sometimes without coordination or communication with local officials. In some cases, local facilities are not aware of the event until or just before patients start arriving. Hospitals may receive no advance notice of the extent of the event or the numbers and types of patients they can expect. There may be little or no communication among regional hospitals, incident commanders, public safety, and EMS responders to coordinate the response regionwide. Consider the regional response needed after the Rhode Island nightclub fire in February 2003. During a concert, a fire broke out on the stage in the small venue and quickly spread throughout the nightclub before many patrons could escape. The fire consumed the building in 3 minutes, and 96 people were killed. It took 160 firefighters from 15 communities to put out the flames; 65 ambulances also responded (Gutman et al., 2003; Ginaitt, 2005). The first patients began to arrive at local hospitals minutes after the fire broke out. Most hospitals received notification from EMS before patients began to arrive, but several others said they received no notification, or there was limited or incorrect information regarding the number of patients to expect. A total of 273 victims sought care at hospitals. The closest hospital to the nightclub (3 miles away), Rhode Island’s second largest, is a 359-bed acute care hospital that handles 58,000 ED visits per year. It received 82 patients, 25 percent of whom were admitted and 25 percent of whom were transferred to other hospitals. A level I trauma center located 12 miles away from the nightclub received 68 patients; approximately 63 percent were admitted (Gutman et al., 2003). A number of other Rhode Island hospitals, as well as Massachusetts General, University of Massachusetts Medical Center, and Shriners Hospital for Children, also received patients. It was only the second time that Shriners had opened its doors to adult patients (Ginaitt, 2005).

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Hospital-Based Emergency Care: At the Breaking Point However, there was limited communication between hospitals and no means for hospital coordination and prioritization of helicopter transfers of patients to burn centers. As a result, 10 transfers by helicopter occurred from four different hospitals within the first few hours. All air medical resources available in New England were used that evening (Gutman et al., 2003). The amount of regional resources needed to respond to this medium-sized emergency incident is striking. It demonstrates the need for hospitals to coordinate planning with each other as well as other responders, including prehospital providers and air medical personnel. This often means working and planning with groups across state lines to decide on and implement the surge capacity, workforce training, protective equipment, and surveillance and communications systems appropriate for the region. Coordination among Local, Regional, State, and Federal Entities The underlying philosophy of disaster management is that every event is handled at the lowest possible geographic, organizational, and jurisdictional level (DHS, 2004). When a disaster event becomes larger than can be handled adequately by local response capabilities, the state usually gets involved, enabling the allocation of statewide resources to the affected area. The state government has ultimate responsibility for the health and wellbeing of its citizens, and can allocate funding and statewide emergency resources, utilize National Guard troops, and draw on state supplies of drugs and vaccines. When an event becomes too big to be handled at the state and local levels, it may be declared an “incident of national significance.” In this case, the command structure shifts to the federal response outlined by the National Incident Management System (NIMS) through DHS, opening the way for federal resources, including federal stockpiles, disaster management assistance teams (DMATs), and federal dollars, to be deployed to support operations. Most agree that for disaster response to be effective, incident control must be clear, communications good, and providers at the local level involved in the process. In the event of a disaster, local emergency providers must respond as additional resources are mobilized at state or federal levels. The medical care component of most disasters is usually over after a few hours, so even if these additional resources can be assembled, they may arrive too late to be of much help (Waeckerle, 1991). Further, only regional and local planning can adequately anticipate and address local utilization patterns that will impact the execution of disaster plans. Therefore, all hospitals must be prepared to receive patients suffering from any type of illness, injury, or exposure. To respond effectively, hospitals must interface with incident command at multiple levels and be prepared to deal with transitions between levels, for

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Hospital-Based Emergency Care: At the Breaking Point example, when incident command shifts from the local to the state or federal level. Each hospital should be familiar with the local office of emergency preparedness and know how hospitals are represented at the emergency operations center during an event, whether through the hospital association, the health department, the EMS system, or some other mechanism. Using an existing program, such as the Hospital Emergency Incident Command System (HEICS), can aid hospitals in internal preparedness and coordination with the rest of the system. HEICS is a standardized approach to disaster management—essentially an internal hospital application of NIMS—that was developed and has been used nationwide for a decade. Regionalization Current federal preparedness funding has been geared toward preparing all hospitals to respond at some level to all hazards. Because the range of possible threats is so broad, the feasibility of meaningfully preparing all hospitals is unrealistic. Regionalization of certain aspects of preparedness may facilitate a more timely and effective response (Bravata et al., 2004a). The benefits of regionalizing disaster response include consolidation of inventories of drugs and vaccines; surveillance to identify outbreaks of disease; efficiency of concentrating certain types of medical response at fewer hospitals; and improved communications, command, and control associated with regionwide events (GAO, 2003a). Regionalization is also likely to benefit triage, medical care, outbreak investigations, security management, emergency management, and training. Regional trauma systems are critical to planning for the care of severely injured patients during a disaster. While 47 states have developed or are developing a statewide trauma system plan and 38 states now designate trauma systems, there is wide variation across states in the level of development of these systems and in the degree of coordination with disaster planning. In one example of a regional approach to disaster planning, Connecticut developed a statewide system for hospital preparedness for bioterrorism that was built on the trauma system (Jacobs et al., 2003). The Connecticut Department of Public Health contracted with two level I trauma centers, which were designated as regional centers of excellence for bioterrorism preparedness. The existing trauma system and communications network provide the basic infrastructure for the system, which links to the Metropolitan Medical Response System centered in Hartford. The two centers of excellence serve to coordinate all aspects of medical disaster response activities within their regions, including surveillance, training, planning, facilities, equipment, and supplies. This model is based on the realization that resources are too scarce for a haphazard approach—disaster funding should be targeted to those regions and hospitals where it will do the most good for the community

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Hospital-Based Emergency Care: At the Breaking Point with skin rash, diarrhea with dehydration, visual or swallowing difficulties/ slurred speech or dry mouth, and acute respiratory distress syndrome. The information is then faxed to the local health department at the end of each nursing shift (Henning, 2003). Because of underreporting by hospitals and the time lag between the diagnosis and the health department’s receipt of information, active systems are not effective in identifying a rapidly spreading outbreak at its earliest stage (GAO, 2003c). Other regions use passive systems, in which information is automatically collected in the course of patient care, and either automatically reported or “mined” by public health workers to solicit information from hospitals (GAO, 2003c; Schur, 2004). Passive systems tend to provide more complete reporting of surveillance data than a system that is fully dependent on voluntary reporting (GAO, 2003c). In an effort to improve disease surveillance capabilities, some hospitals use electronic surveillance systems to passively collect surveillance data and automatically transfer the data from the ED to health departments. Electronic systems are beneficial in that they allow more timely transmission of data, but are inappropriate for local health departments that do not have adequate resources to manage, analyze, and interpret large influxes of data (Bravata et al., 2004b). CDC funds three ongoing electronic surveillance system networks that collect data from a sample of hospitals. One of these is EMERGency ID NET, which collects data from 11 academically affiliated EDs that cumulatively account for approximately 1 percent of all ED visits (Talan et al., 1998; Barthell et al., 2002). The data are collected during evaluation of patients with specific clinical syndromes; entered into the program’s software within 1 day of a patient visit; and electronically stored, transferred, and analyzed at a central receiving site. With these data, research on emerging infectious disease can be conducted (Talan et al., 1998). But data from systems such as EMERGency ID NET may be limited in that the systems collect data only on certain types of patients, collecting all the data is difficult and time-consuming, distribution to individuals assigned to analyze the data may be delayed, and findings may have little relevance for local efforts (Barthell et al., 2002). This type of system is too slow to trigger rapid response by public health officials. Some surveillance systems, whether manual or electronic, capture syndromics. Syndromic surveillance is surveillance for disease syndromes (signs and symptoms), rather than for specific clinical or laboratory-defined diseases (Henning, 2003). It is a relatively new concept in public health surveillance. The problem with nonsyndromic systems is that outbreaks of disease may be difficult to diagnose, and delays in diagnosis can result in a larger number of casualties and a more prolonged outbreak. Syndromic surveillance may improve early detection of an outbreak (Henning, 2003). The key is to have systems that can help staff recognize index cases (i.e., the

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Hospital-Based Emergency Care: At the Breaking Point first one to three patients), as well as clusters of cases presenting to different hospitals in an area. The most sophisticated of surveillance systems are real-time syndromic surveillance systems. Several large cities (New York, Chicago, Boston, Seattle) began operating such systems, beginning largely in 1999, with special funding from CDC (Henning, 2003). An example is Insight, a computer-based clinical information system at the Washington Hospital Center (WHC) in Washington, D.C., designed to record and track patient data, including geographic and demographic information. The software proved useful during the 2001 anthrax attacks, when it enabled WHC to send complete, real-time data to CDC while other hospitals were sending limited information with a lag of one or more days. The success of Insight attracted considerable grant funding for its expansion; WHC earmarked $7 million for Insight to link it to federal and regional agencies and integrate it with other hospital systems (Kanter and Heskett, 2002). Although most public health officials are quickly embracing surveillance systems, particularly syndromic systems, more research is needed on their effectiveness. Bravata and colleagues (2004b) recently undertook a review of surveillance systems to evaluate their utility for detecting illnesses and syndromes related to bioterrorism. Researchers reviewed 115 systems (at EDs and other locations), including 9 syndromic surveillance systems. The authors found that few surveillance systems have been comprehensively evaluated; therefore, information is lacking on the ability of such systems to facilitate decision making by clinicians and public health officials (Bravata et al., 2004b). CHALLENGES IN RURAL AREAS The focus of emergency preparedness has been on urban areas in part because of the perceived increased risk of terrorism in these areas. However, there is a danger associated with neglecting rural areas. Indeed, one might argue that rural areas may be even more vulnerable to a terrorist attack. Many nuclear power facilities, hydroelectric dams, uranium and plutonium storage facilities, and agricultural chemical facilities, as well as all U.S. Air Force missile launch facilities, are located in rural areas and are potential targets for attack. Additionally, if individuals with infectious diseases, such as smallpox, enter the country through Canadian or Mexican borders, rural providers may be the first to identify the threat (ORHP, 2002). Although fewer individuals may be harmed by an incident in a rural area as compared with an urban area, mass disasters are relative, depending on the size of the local population and hospital capacity. The demand for health and hospital care by 200 people could overwhelm a 20-bed facility (AHA, 2001). The emergency preparedness challenges EDs face are exacerbated in

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Hospital-Based Emergency Care: At the Breaking Point rural areas because rural hospitals often lack the resources and staff needed to respond swiftly to a catastrophic event (ORHP, 2002). In fact, results of several studies indicate that urban areas are generally further along in bioterrorism preparedness planning than rural areas because they have more experience in dealing with public health emergencies and more resources upon which to draw (Schur et al., 2004). Rural facilities tend to be limited in medical supplies, life-sustaining equipment (such as ventilators), and auxiliary power sources (Gursky, 2004). Additionally, rural hospitals have even more limited surge capacity than hospitals in urban areas; 500 rural hospitals are Critical Access Hospitals, which are limited to 15 beds (ORHP, 2002). Rural hospitals also tend to lack decontamination facilities. In a 2001 study of hospitals in Federal Emergency Management Agency (FEMA) region III, none of the 22 rural hospitals had decontamination stations that could process 10 to 15 patients at a time; 4 of those hospitals had no decontamination plans in place (Treat et al., 2001). Some rural hospitals rely on local EMS personnel to perform decontamination; however, this is concerning because past experience has shown that the vast majority of disaster victims seek care in emergency rooms without accessing EMS (Treat et al., 2001). Moreover, communications systems in rural EDs tend to be unreliable and interrupted by terrain and weather (Gursky, 2004). Staffing is another crucial problem for rural hospitals. Although the American Hospital Association (AHA) and other groups recommend that rural hospitals develop a reserve staff (retired health workers, persons in training), existing shortages make it difficult to do so. Additionally, some hospital personnel, particularly nurses, work part-time in nearby urban areas and may not be available in the event of a crisis. Training of staff in emergency preparedness is often complicated by the fact that training meetings are frequently held in urban areas that may be quite far away from rural hospitals. One day of training may require 2 or 3 days away from the hospital to accommodate travel time (Schur et al., 2004). Additionally, rural hospitals that rely heavily on contract staff may be reluctant to invest in training opportunities for those individuals since they may not continue working at that hospital in the long term. Rural hospitals may not have access to the same federal funding for bioterrorism as urban hospitals. This may be particularly problematic because many rural hospitals are older and more isolated, making preparedness measures more expensive (Schur et al., 2004). Rural hospitals have not benefited from Metropolitan Medical Response System (MMRS) funding since that funding is targeted to metropolitan areas. On the other hand, rural hospitals have access to other funding streams not available to urban hospitals; in 2003, DHHS allocated $45 million in federal grants for rural and frontier hospitals (Gursky, 2004).

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Hospital-Based Emergency Care: At the Breaking Point FEDERAL FUNDING FOR HOSPITAL PREPAREDNESS Total federal preparedness funding has increased substantially in the 5 years since September 11, 2001. Emergency preparedness funding in DHHS, for example, rose from $237 million in fiscal year 2000 to $9.6 billion in fiscal year 2006 (Broder, 2006). But while the vast majority of terrorist events worldwide have involved conventional explosives and nonbiological agents, federal spending on preparedness has focused heavily on bioterrorism at the expense of other priorities (DePalma et al., 2005). Furthermore, the proportion of these dollars allocated to hospitals for infrastructure, technology, equipment, and training enhancements has been very limited. Federal preparedness funding has been made available indirectly to hospitals primarily through two programs: MMRS and the Bioterrorism Hospital Preparedness Program. A review of each of these programs indicates that the amount provided to hospitals specifically for improving preparedness efforts has been small (IOM, 2002). MMRS was created in 1996 to enhance and coordinate local and regional response capabilities for highly populated areas that could be targeted by a terrorist attack using WMD. A total of 124 jurisdictions receive funding under the program. The organizing principles and resources of the program are also applicable to large-scale incidents, such as hazardous material incidents, natural disasters, and disease outbreaks. MMRS was funded at $50 million for both fiscal years 2003 and 2004, and was reduced to $30 million in both fiscal years 2005 and 2006. Each of the 124 jurisdictions will receive $232,030 for fiscal year 2006. Hospitals are aided indirectly through this program by participation in preparedness planning. However, hospitals initially did not participate in the program; it took several years before they were integrated into MMRS planning (DHS, 2005a). MMRS was transferred from DHHS to DHS in 2003 and now resides in the Office of Grants and Training (GAO, 2003b). The Bioterrorism Hospital Preparedness Program is targeted more specifically to hospital preparedness. The primary focus of the program is on developing and implementing regional plans to improve the capacity of hospitals to respond to bioterrorist attacks. The program made its initial awards in 2002, and the funding is distributed through cooperative agreements with states and selected municipalities, which have considerable flexibility in determining how the funding is allocated across hospitals. The cooperative agreements consist of two phases. In phase I, states are required to develop a needs assessment for a comprehensive bioterrorism preparedness program for hospitals and other health care entities and to begin the initial implementation of the plan. In phase II, states are required to submit more detailed implementation plans, including how they are going to address a series of critical benchmarks outlined by HRSA (GAO, 2003a). Funding for this program grew from $125 million in 2002 to $498 million in fiscal

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Hospital-Based Emergency Care: At the Breaking Point year 2003 and $515 million in fiscal year 2004 (Gursky, 2004), but fell to $491 million in fiscal year 2005 (HRSA, 2006). The amount going directly to hospitals varied greatly by state, and in many cases hospitals received only a limited amount of the funding. According to one study, the “typical” award to hospitals was approximately $5,000–10,000, though some hospitals received funding in the range of $50,000–100,000 (McHugh et al., 2004). The funding under the program has generally not been sufficient to purchase the equipment needed for one critical care room or to retrofit an airborne infection isolation room in one hospital (Hick et al., 2004). In addition, CDC funds 52 Centers for Public Health Preparedness (CPHPs). CPHPs are academic institutions that provide a focal point for planning, training, and collaboration between health departments and other community partners in preparing for public health crises. The allocation of preparedness funding across states has been controversial. The 2005 appropriations bill allocated “hospital preparedness” funding to states on a per hospital bed basis, rather than on the basis of the likelihood of disaster. Critics argue that this apportionment is essentially “pork” rather than an attempt to allocate preparedness dollars rationally according to need. States facing limited risk can receive substantial funding under this approach, while cities such as Washington, D.C., which face a much greater risk, receive a lesser share (ER One, 2005). Trauma systems also represent a critical component of disaster response. Federal support for the development of these systems and their coordination with other regional disaster planning efforts does not appear to reflect recognition of this fact. Federal funding for state trauma system development and planning has been inconsistent; it was recently dealt a blow with the defunding of the Trauma/EMS Systems program for fiscal year 2006. States and communities should play an important role in determining how they will prepare for emergencies. To the extent that they are supported in this effort through federal preparedness grants, the critical role and vulnerabilities of hospitals must be more widely acknowledged, and the particular needs of hospitals and hospital personnel must be taken explicitly into account. Therefore, the committee recommends that Congress significantly increase total preparedness funding in fiscal year 2007 for hospital emergency preparedness in the following areas: strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical services’ response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons terrorism.

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Hospital-Based Emergency Care: At the Breaking Point SUMMARY OF RECOMMENDATIONS 7.1: The Department of Homeland Security, the Department of Health and Human Services, the Department of Transportation, and the states should collaborate with the Veterans Health Administration (VHA) to integrate the VHA into civilian disaster planning and management. 7.2: All institutions responsible for the training, continuing education, and credentialing and certification of professionals involved in emergency care (including medicine, nursing, emergency medical services, allied health, public health, and hospital administration) should incorporate disaster preparedness training into their curricula and competency criteria. 7.3: Congress should significantly increase total preparedness funding in fiscal year 2007 for hospital emergency preparedness in the following areas: strengthening and sustaining trauma care systems; enhancing emergency department, trauma center, and inpatient surge capacity; improving emergency medical services’ response to explosives; designing evidence-based training programs; enhancing the availability of decontamination showers, standby intensive care unit capacity, negative pressure rooms, and appropriate personal protective equipment; and conducting international collaborative research on the civilian consequences of conventional weapons terrorism. REFERENCES Accountability Review Boards on the Embassy Bombings in Nairobi and Dar es Salaam. 1999. Report of the Accountability Review Boards on the Embassy Bombings in Nairobi and Dar es Salaam on August 7, 1998. Washington, DC. ACEP Nuclear, Biological and Chemical Task Force (American College of Emergency Physicians Nuclear, Biological and Chemical Task Force). 2001. Developing Objectives, Content, and Competencies for the Training of Emergency Medical Technicians, Emergency Physicians, and Emergency Nurses to Care for Casualties Resulting from Nuclear, Biological, or Chemical (NBC) Incidents. Dallas, TX: Department of Health and Human Services, ACEP. ACEP. 2005. Nuclear, Biological, and Chemical Terrorism. [Online]. Available: http://www.acep.org/webportal/PatientsConsumers/HealthSubjectsByTopic/NuclearBiologicaland-ChemicalTerrorism/default.htm [accessed July 7, 2005]. Ackermann RJ, Kemle KA, Vogel RL, Griffin RC Jr. 1998. Emergency department use by nursing home residents. Annals of Emergency Medicine 31(6):749–757. AHA (American Hospital Association). 2001. Public Health System’s Capacity to Respond to Bioterrorism. Committee on Government Reform: Subcommittee on Technology and Procurement Policy. Chicago, IL: AHA.

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