5
Coordination and Integration Across Response Platforms

Throughout the workshop participants discussed the challenges rural healthcare systems face because of resource realities and the impact these challenges have on responding to a mass casualty incident (MCI). Participants suggested strategies to address the challenges (summarized in Boxes 5-1 and 5-2). Chief among this discussion was the topic of regionalization and its ability to both harness and hamper rural response in times of emergency. MCIs, especially those in rural settings, often require the support of surrounding resources. Ensuring coordination across response platforms and health systems is critical, but it also poses significant hurdles. Thus, the following sections not only characterize these challenges but relate models of success. The benefits of establishing an effective systemwide incident command structure are addressed as a potent mechanism for response systems’ integration (a summary of strategies discussed is provided in Box 5-3).

REGIONALIZATION

Regionalization, as used in this summary, refers to the establishment of healthcare coalitions that extend beyond immediate local responders and providers to include those of neighboring localities, regional public health entities, and other private and public organizations that may contribute to MCI preparedness and response (Courtney et al., 2009). Regionalization seeks to respond to the potential for, or occurrence of, an MCI whose resource requirements for emergency medical services (EMS) personnel, equipment, and hospital capacity exceed that of any one hospital or EMS service. Thus, the coalition is meant to serve as a centralized communica-



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5 Coordination and Integration Across Response Platforms Throughout the workshop participants discussed the challenges rural healthcare systems face because of resource realities and the impact these challenges have on responding to a mass casualty incident (MCI). Partici- pants suggested strategies to address the challenges (summarized in Boxes 5-1 and 5-2). Chief among this discussion was the topic of regionalization and its ability to both harness and hamper rural response in times of emer- gency. MCIs, especially those in rural settings, often require the support of surrounding resources. Ensuring coordination across response platforms and health systems is critical, but it also poses significant hurdles. Thus, the following sections not only characterize these challenges but relate models of success. The benefits of establishing an effective systemwide incident command structure are addressed as a potent mechanism for response sys- tems’ integration (a summary of strategies discussed is provided in Box 5-3). REGIONALIZATION Regionalization, as used in this summary, refers to the establishment of healthcare coalitions that extend beyond immediate local responders and providers to include those of neighboring localities, regional public health entities, and other private and public organizations that may contribute to MCI preparedness and response (Courtney et al., 2009). Regionaliza- tion seeks to respond to the potential for, or occurrence of, an MCI whose resource requirements for emergency medical services (EMS) personnel, equipment, and hospital capacity exceed that of any one hospital or EMS service. Thus, the coalition is meant to serve as a centralized communica- 45

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46 RURAL MASS CASUALTY INCIDENT BOX 5-1 Participant-Identified Challenges Facing Rural Healthcare Systems Potential problems with a regional approach to response · Geographic barriers (e.g., mountains) · Infrastructure (e.g., lack of roads connecting areas in the region) · isparities across the region in funding, weather, population density, and D seasonality (i.e., seasonal influx of tourists) · ear among departments that regionalization will result in something being F taken from them (e.g., control, resources) Planning and response hurdles · evel of staffing does not allow personnel to take time away from day-to-day L responsibilities · Costs associated with training, lack of funding for travel to training · mphasis on cost containment in health care affects surge capacity (e.g., lack E of beds) · eople working in rural healthcare and EMS wear multiple hats, cover multiple P responsibilities · Lack of integration with emergency management and public health · pervasive attitude in communities that “it is not going to happen to us” nega- A tively impacts the ability to gather all of the stakeholders for proactive planning · Defensive medicine” (costs associated with conduct of unnecessary advanced “ imaging or other expensive procedures on patients with minimal or vague complaints) tion and information network that can provide standardized, real-time information to all involved in an MCI response. The ultimate goal of regionalization is to improve patient outcomes through the best, most ef- ficient use of collective resources. Regionalization should strengthen, rather than detract from, individual EMS preparedness as it provides a framework for immediate and streamlined assistance should a locality be overwhelmed. Regional coalitions can be informal cooperatives or structured, formal hierarchies. Participants suggested that regional coalitions are successful in improving integration and collaboration by what they view as common priorities and goals, rather than how they specifically accomplish them. Panelists discussed models within a broad spectrum, from EMS systems and volunteer first response agencies aggregated under one umbrella with a single director for an entire county, to loose coalitions that revolve around the coordination of a few prominent organization directors. Workshop participants highlighted that especially in rural settings, a one-size-fits-all regional model is not feasible. Emblematic of this concept was the initial vocalization by some participants that in rural areas, small incidents can be

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47 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS BOX 5-2 Suggestions for Overcoming the Challenges · evelop an MCI model that could be realistically applied in rural areas with D limited resources. · evelop a planning and preparedness process for EMS departments that D mirrors the Assistant Secretary for Preparedness and Response hospital pre- paredness program. · Create regions using common sense and local input: o Identify and respect naturally occurring barriers and dividing lines. · rovide equipment and education to regions to facilitate proper triage and P treatment. · old regional meetings and financially support participation by EMS H departments. · Use similar radio communications across the region. · Ensure adequate day-to-day response capability. · Maintain local hospital-based or clinic-based resources in rural areas. · ake acceptance of (facility-appropriate) trauma patients a condition of licen- M sure or funding for all accredited healthcare facilities in the region. · Develop regional guidelines to aid facility decision making on patient transfer. · stablish regional communication and triage centers (where triage and patient E destination decisions are made by an impartial third party). · nstitute a regional quality improvement process to assess effectiveness I postresponse. · Make telemedicine a requirement for all level I and level II trauma centers. · rovide hospital ERs with county pagers so they can follow the status of P incidents. · Foster an understanding that small incidents can be major in a rural area. · onsider children and special needs populations when planning for MCI C response. major. Others provided examples from their own experiences that ranged from multiple skiing injuries from a seasonal tourist population in rural Colorado to the trend of illegal, migrant workers to travel 40 people to a vehicle, with the potential to overwhelm any rural Arizona emergency room with a single vehicle crash. Regionalization Is About Relationships Not only does regionalization improve overall response to incidents it also offers to expand the relationships individual clinical centers have with other local providers. An example of these types of partnerships is the Colorado Foothills Regional Emergency Medical and Trauma Advisory Committee (RETAC), which is directed by Timothy Bohlender, medical

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48 RURAL MASS CASUALTY INCIDENT BOX 5-3 Suggestions to Improve Coordination and Integration Across Response Platforms Collaboration · Face-to-face meetings to establish personal connections · Regular conversations/meeting · Partnerships, MOUs · Regional exercises involving all stakeholders · States should play a supportive role o Provide education, facilitate planning, establish communications o Mobilize and deploy resources and coordinate outside help Resources · xpand recruitment into demographics with the required skill sets that may E not have been previously considered (e.g., doctors and nurses may volunteer during their off hours). · dentify resources in the community (people, equipment, vehicles, communica- I tions systems). · urvey people for certifications/education/experience they may have beyond S their primary jobs. · Assign staff whose jobs are nonessential in a disaster to other supportive roles. · xplore integrating trauma surgeons into the larger system (e.g., a pre- E registered, pre-credentialed, rapidly mobilized force of surgeons bringing sur- gery to the scene). · eek federal, state, and private grant opportunities to fund equipment pur- S chases and education: o Assistance to Firefighters Grants program § Staffing for Adequate Fire and Emergency Response (SAFER) grant o Rural Fire Assistance Program o State EMS grants o Insurance company grants (Fireman’s Fund, Allstate Foundation, etc.) Planning and Exercises · Plan and implement as many drills and exercises as possible. · Integrate the public in preparedness exercises that are interesting and fun. · Include special needs populations in planning and exercises. · A leadership succession plan should be part of incident management planning. · Explore and establish backup communications strategies ahead of time. Education · Community education prior to an event can save lives · Include interested high school students

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49 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS director at St. Anthony Granby Medical Center in Grand County. The RETAC has been critical in coordinating preparedness and response in five adjacent Colorado counties. It does this by formalizing relationships between medical centers and EMS, and between trauma centers, including children’s hospitals. The RETAC has also helped coordinate air transport and specialty ambulance providers. However Aimee Binning, a member of the board of directors of the National Association of Emergency Medical Technicians (NAEMT) and owner of CVC Training, Inc., cautioned that broadening the scope of MCI response relationships through regionalization should not compete with strengthening local, nontraditional relationships. Using her own experience, Binning explained that while regionalization can provide greater response capacity over the course of an MCI, long distances between neighboring resources increases the time it will take these additional resources, however well-prepared, to arrive at the scene. Therefore it is crucial to engage local corporations and their personnel in response planning to ensure all avail- able community resources are quickly mobilized to provide coverage in the gap before regional resources can be recruited. Communications Challenges When establishing regional coalitions, boundaries must be defined based on tangible barriers that may not always correlate to county or state boundaries. For example, local industries and available resources all impact potential partnerships and should be considered when establishing coalitions, commented Bohlender. To maximize the value of rural regional coalitions, as well as waylay fears of centralization, the issues of commu- nication must be addressed when establishing and maintaining coalitions. Robust communication systems that integrate and facilitate informa- tion sharing between EMS and local providers are critical when developing and maintaining coalitions as well as during incident response. As already described, unreliability of cell towers, or the lack thereof, pose a significant obstacle. The establishment of a central phone number for communication and agreements to notify each other early in the course of an incident have been successful improvements in the Kansas Major Emergency Response Group (MERGe) described by Randy Easter, EMS director for McPherson EMS and Safety Office for Memorial Hospital. Jerry Johnston, the im- mediate past president of the National Association of Emergency Medical Technicians (NAEMT) and EMS director of Henry County Health Center in Iowa, offered another successful strategy used in Henry County. With one dispatch tone, everyone who carries a pager in the county receives all of the dispatch information simultaneously. Johnston and Easter both said that their local hospitals and other facilities have county alphanumeric

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50 RURAL MASS CASUALTY INCIDENT pagers and can follow the whereabouts of the ambulances. This improves situational awareness and provides the hospital the opportunity to prepare for incoming patients, without having to exclusively communicate with the first responders in the field who are providing care. Whether informal or formal, bolstering communication systems can help to assuage individual fears that regionalization equates to inefficient centralization. INTEGRATING TRAUMA SURGEONS Leonard Weireter, Jr., is the Arthur and Marie Kirk Family Professor of Surgery at Eastern Virginia Medical School, medical director of the Shock Trauma Center at Sentara Norfolk General Hospital, and current chair of the Disaster Preparation Committee for the American College of Surgeons, Committee on Trauma. Weireter said that the College of Surgeons recog- nizes there is a huge void in knowledge among its members about disaster preparedness. Surgeons work at the definitive care end of the spectrum, and the mindset is generally one of waiting for patients to be delivered. There are nearly 1,200 counties in the United States without a general surgeon. The long distance traversed to reach a surgeon presents the major problem of time lost from the previously discussed “golden hour” (see Chapter 4). The College of Surgeons has been grappling with how to better integrate trauma surgeons into the larger system. Studies indicate that about 20 per- cent of the casualties in a mass casualty incident are critically injured; the quandary is figuring out who they are, and getting them to definitive care. Strategies to Integrate Trauma Surgeons Finding the right solution is challenging. In Iraq and Afghanistan, the military brings surgery to the patient, stabilizing them with limited, rapid operative care, then transporting them to higher-level care. The aver- age time from battlefield injury to immediate surgical care is slightly less than 30 minutes. If the patient survives the first level of care, their overall chance of survival is about 97 percent. While participants have heretofore mentioned military models as potential examples for rural policy makers to follow, in the case of trauma surgery, there is a key difference. The establish- ment of forward military operating bases means personnel and materials are pre-positioned in short proximity to a known high-risk environment. Yet in rural traumas, predicting where an event will occur over a vast dis- tance is often impossible. Several issues need to be addressed to make integration work. One is whether it is feasible to establish a force of surgeons that could be rapidly mobilized. A participant suggested that the first step would be a voluntary pre-registration and pre-credential process for surgeons willing to be part

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51 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS of such a force. If that proved a reasonable option, the next issue to address is from where to pull the surgical resources. In an urban environment it is relatively easy to find surgeons in emergency medicine, but in rural America it is much harder. Regionalization of resources may be the solution such that an event in a given location mandates a response from the 100-mile surrounding area. But how can rural emergency planners deal with the issue of training these surgical specialists to respond on very short notice? Weireter suggested that unlike in the comparison of prepositioned sur- gical resources, perhaps the issue of training a rapid-response surgical force might benefit from a military model. When military units change over, the arriving and departing units patrol together, the veteran unit walks point and the incoming unit follows to learn and understand the environment and its challenges. Then they transition, and the new unit walks point as the veteran unit follows. The surgical world needs to learn how to walk point in a rural incident from fire departments and EMS, Weireter said, to bring our surgical resources to the rural environment. Demonstration projects are needed to examine difference models to test strategies and establish best practices. ADDRESSING INTEGRATION CHALLENGES THROUGH INCREASED RECRUITMENT AND EDUCATION Leadership Through Transition While the merits of consistent and updated education were a theme across the presentations, several participants noted the importance that trained individuals ensure their leadership can be replicated when they are no longer actively engaged (due to retirement or relocation). Roy Alson, medical director of Forsyth County EMS and medical director of Disaster Services for the North Carolina Office of EMS, again turned to the military model for potential solutions. In the military, subordinates are specifically trained to lead should the situation arise. Gaines drew attention to the fact that the Incident Command System (ICS), the National Incident Manage- ment System, and other command and control operations are built on delegation of authority and defining specific roles within a hierarchical organizational plan, and therefore are a natural aid of succession planning. He agreed with Alson that it is the responsibility of a leader to incorpo- rate continuous leadership training into any preparedness strategy. Dan Hanfling posited the need for ways to incentivize this type of planning.

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52 RURAL MASS CASUALTY INCIDENT Bolstering Local Fire Departments There are numerous challenges facing this country’s primary emergency responders: the volunteer fire system. Money is tight, and donations are down. Glenn Gaines, deputy U.S. fire administrator at the Federal Emer- gency Management Agency (FEMA) pointed out that approximately 70 to 75 percent of fire services in the United States are volunteer, and about 60 percent of those are in small communities of less than 2,500 residents. Standards are being increased, and there is constant pressure to bring medi- cal care to the scene faster and more efficiently. At the same time, Gaines said, fire departments are losing members, in part because of the economy. Volunteers are now working part-time jobs or seeking overtime and are no longer available. MCIs in rural areas are high-risk, low-frequency events. Gaines listed several challenges to operations preparedness, including the absence of skill sets in MCI management, sophisticated equipment, training and skills in triage, advanced trauma care skills and training, and certification and skill sets to implement standing orders when communications channel are poor or lacking. In addition there is a need for improved liaison with local trauma centers or hospital ERs, as there is a lack of routine MCI exercises involving all stakeholders. To begin to address these challenges, Gaines encouraged expanding recruitment into demographics that already possess the required skill sets. People who are dedicated to the care of others, such as nurses, physician assistants, and physicians, may be interested in giving back to the commu- nity beyond their office hours. The goal of the recruitment effort is to raise prehospital skills, and expand standing orders by incorporating personnel qualified to implement them. The key is education, and Gaines suggested rural fire services seek grants such as those from the Assistance to Firefighters Grant program, the Rural Fire Assistance Program, the Fireman’s Fund, state and regional EMS or medical councils, and local community and state colleges. For volunteer fire departments especially, Allstate and other insurance companies offer specific grants to assist in obtaining equipment. Another approach is to leverage regional peer skills and equipment, consider joint equipment pur- chases with other local squads, and conduct regional training and exercises. Local physicians and emergency departments could also serve as training resources. Gaines emphasized that broad and creative thinking, in the con- text of systems integration, were essential to securing new opportunities at the federal, state, and regional levels, as well as in the public, nonprofit, and private sectors.

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53 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS Education, Training, and Coordination: The MERGe Example One participant suggested that building relationships between EMS and medical providers to ensure a cooperative approach to preparedness is necessary, but not sufficient. Incident command and cooperation during an emergency is often the difference between life and death. Where education and training opportunities are limited, many suggested that insights could be gained from analyzing and discussing previous examples of coordinated response efforts. It was suggested that mechanisms need to be established to bring together all stakeholders involved in emergency response to help ensure improved future capabilities. Randy Easter, EMS director for McPherson EMS and safety officer for Memorial Hospital in McPherson, Kansas, provided an overview of MERGe, the Major Emergency Response Group in Kansas EMS Region III. Easter explained that responders around the region had developed informal agreements over the years to provide assistance to each other, but EMS directors within Region III saw the need to “develop, facilitate, and main- tain a system of preparation, response, and recovery for major emergency medical events effecting licensed ambulance service in EMS Region III.” Easter described how they started meeting informally, as a group of friends, to define the issues that were important to their services and counties. Scenarios reviewed included hospital evacuations, mass transit accidents, floods, explosions, and tornados. They established a central phone number for communication and agreed to notify each other early in the course of an event. The duty officer at the central number would clarify the response location and needs, and advise of the resources responding. The focus of MERGe is planning, education, and response. The team has a clear philosophy about their role as EMS advisors: “MERGe will not take ownership for you or from you; MERGe is not designed to take over, rather it is designed to help out; MERGe is not an ambulance resource, it is an expertise and management resource that at times can bring ambulances.” Overall, Easter emphasized that rural EMS departments and their locals hospitals need to be integrated with regard to disaster planning processes and MCI strategies. Coordinated funding of both EMS and hospital pre- paredness activities is vital. Easter recommended holding regional EMS meetings, and financially supporting rural departments for travel to and participation in the meetings. As many local and regional responders are already working within limited budgets, some participants also suggested dedicating specific funds to acquire and stockpile excess equipment and supplies to be easily accessible during an MCI response.

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54 RURAL MASS CASUALTY INCIDENT STATE-LEVEL SUPPORT Rural communities often integrate across fire, police, EMS, emergency management, and public health services. They understand that disaster response is the “ultimate team sport,” remarked Roy Alson. The challenge is coordinating response at all levels. For example, it can be difficult to get hospitals that are competing for market share to collaborate. Alson noted that although rural areas may have limited resources, manpower, and equipment deficit, they do not always request help from the states. Therefore state agencies should be particularly cognizant of ways in which they can support the mission of local EMS by providing training, planning, or establishing communications. For example, Alson pointed out that the state of North Carolina established the North Carolina State Medical Response System to develop an all-hazards medical response to disasters. Like Utah’s Bureau of EMS and Preparedness, whose role in coordi- nating regional response to the Mexican Hat incident was discussed in Chapter 2, North Carolina is one of many states that requires each county to have an EMS system plan that covers MCIs. Each system is also re- quired to have a medical director and a trauma triage plan that designates a trauma center to which they will transport patients whose injuries exceed the capability of the community hospital. As part of that, ambulance strike teams, which Mexican Hat responders considered crucial in retrospect to both their incident response as well as the provision of EMS to nonrelated emergencies, have been established across the state of North Carolina in three regions to provide not only additional units to respond to the scene, but also units to backfill community EMS so they can continue regular operations. For North Carolina, the state office of EMS is the lead in the regional medical plan, with public health agencies as key partners. The approach has been to support disaster preparedness at a regional level. The state is developing a regional disaster medical plan for each trauma region. One of the tools the state maintains for emergency management is the State Medi- cal Asset Resource Tracking Tool (SMARTT), an online system in which hospitals update their bed status on a daily basis, and agencies update their equipment and supplies status on a regular basis. In disaster situations the system can operate in real time, providing resource updates to the incident commander. However Alson emphasized that the state role is not to directly ad- minister MCI response, but to support the community and the region by mobilizing and deploying resources and coordinating outside help. Other programs the state is working on include a mass fatalities response system and a regional burn plan. The state supports several interoperable com-

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55 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS munications systems including a statewide 800 MHz radio network tied in with the highway patrol, a state medical radio network that provides communication with hospitals and agencies, and satellite phones for all deployable assets. North Carolina also has uniform statewide EMS pro- tocols, which ensure standardization of care and effective oversight, and a statewide triage guideline using a one-tag system across the entire state. SPURRING REGIONAL COLLABORATION AND PLANNING Jennifer Hamerlinck, a public health nurse and director of the Emer- gency Management Agency in Mercer County, Illinois, observed that there are two scenarios that create a demand for integration: prospectively in the form of regionally funded disaster planning sessions or retrospectively from “lessons learned” during an emergency response. Regional Preplanning Sessions Conducted by the Centers for Disease Control and Prevention (CDC), Hamerlinck’s Mercer County was selected as the regional community lead for the Community Partnerships for Pandemic Influenza Planning Project. Funded through the Illinois Department of Health, the project conducted a series of five tabletop exercises focused on engaging a number of different sectors and agencies to examine essential healthcare services, legal and ethi- cal implications, shared services and resources, communication and triage, home health care, and campus response at universities. Together, project participants collaborated to plan for necessary essential services during a pandemic influenza outbreak. Action items identified at the workshops were the need for a regional taskforce, memoranda of understanding, expanded partnerships, and education, as well as the need to incorporate untradi- tional local resources like faith-based groups, school superintendents, and private physicians. The five exercises boasted over 250 participants from the region, with approximately 60–100 attendees at each exercise represent- ing the Emergency Management Agency, EMS, hospitals, physicians, public health, local officials, law enforcement, coroners, and others. One of the tools developed from the project that Hamerlinck found particularly useful was a “determining essential services spreadsheet” that allows an agency to determine the number of essential and nonessential staff on any given day by incorporating staffing and patient census vari- ables. This tool could cross over into any response planning by changing the labels, Hamerlinck said. Dedicated federal grant funds proved essential to integrating emergency response efforts in Montana as well, described the emergency services co- ordinator for Chouteau County, Linda Williams. In 2004, a Homeland Se-

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56 RURAL MASS CASUALTY INCIDENT curity grant allowed the rural, regional, and state response communities to learn from exercises simulating terrorist-caused MCIs. Williams related that while the exercise in and of itself was valuable, more so was the nonthreat- ening and cooperative environment in which it was conducted. The 167 participants from county, state, and federal agencies in six counties were able to identify the gaps and opportunities for synergy in their response system. Lessons from the seamlessly administered bicentennial commemo- ration of the Lewis and Clarke trek, which saw 50,000 attendants, held between Montana and 15 other U.S. sites proved crucial three years later in 2005, when faced with unexpected flooding. Williams emphasized that the positive experience with integrated planning her region had witnessed provoked further grant applications. Though prior strategizing improved actual response, Hamerlinck and Williams admitted, they still learned important lessons from gaps in integra- tion during real disaster situations. In June of 2008, flooding in the city of Keithsburg (population 700) resulted in Mercer County being designated a federal disaster area. Hamerlinck noted that from a host of other disaster responses, like those necessitated by ice storms, tornadoes, and extended power outages, the county developed integrated plans for shelter prepared- ness, culminating in MOUs with nine county shelters. Because agency responses were led from around the region and state, a unified ICS was deemed critical to the efficient evacuation and provision of shelter, food, security, and flood-stemming efforts. Having to integrate such a widespread response provided valuable tools to coordinate across geographic boundar- ies, disciplines, and sectors. Including Is Empowering: Building Trust from Administrators to the General Public Locally Driven Integration Integration means more than coordination. True collaboration between responders, Hamerlinck stressed, involves building relationships. In Mercer County, Illinois, she credited face-to-face meetings, regular conversations, MOUs, and conducting joint exercises with building trust and perpetuat- ing mutually productive partnerships among those tasked with disaster response. Repetition really does work to build skills, confidence, and trust, she said, and everyone brings a different asset to the table. But administrators are just part of a response that spans EMS and law enforcement personnel and community leaders. No one wants to feel “nonessential,” Hamerlinck noted. During a disaster it is inevitable not everyone’s primary job may be essential to the disaster response, yet there may be other nontraditional roles to fill. Ensuring that personnel are fully

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57 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS utilized, Hamerlinck encouraged sectorwide interviews of anyone poten- tially involved in disaster response. For example, Hamerlinck discovered that one of the local pastors was a certified mental health counselor. That is a valuable resource in a county that does not have a mental health provider. In 2008, Williams and Chouteau County, Montana, went one step fur- ther to empower the entire community through inclusion in preparedness planning. The county’s “Operation June Bug,” was a three-day exercise involving the public in multiple events including a point of dispensing sce- nario “treating” 250 people; an MCI to test hospital surge capacity; and a “survivor challenge” that tested sheltering components of the emergency operations plan by asking volunteers to camp in the city park for 3 days. There was even a scavenger hunt that taught participants where to collect contents for survival kits from local businesses. A website was set up, and all of the events were shown on YouTube™, generating 1,000 hits. Similarly, in 2009, Chouteau County specifically targeted youth partici- pation in planning for an agricultural-based MCI. Students from the high schools were given 5 weeks of orientation in ICS and the roles of emergency response agencies. The students drew diagrams of the fairgrounds and ani- mal shelters, and put together animal decontamination protocols and fact sheets for zoonotic diseases. At the end of 5 weeks they participated in a avian influenza exercise where they played the role of emergency respond- ers. Williams noted that the students took the exercise very seriously, in part because H1N1 was in the news at the time. She found the community buy-in and increased awareness of disaster planning invaluable to integrat- ing response efforts across the population. CDC Healthcare Preparedness Activity Similar to local outreach endeavors, the federal government also strives to improve MCI preparedness through broad inclusion, mentioned several participants. The Centers for Disease Control and Prevention’s Division of Healthcare Quality Promotion (DHQP), in partnership with the Oak Ridge Institute for Science and Education (ORISE) seeks to develop universally adaptable guidance and toolkits based on the expertise and experience of regional coalitions. Workshop chair Robert Bass, Executive Director of the Maryland Institute for Emergency Medical Services Systems, explained that the ongoing work of this joint CDC-ORISE effort engages a wide range of stakeholders at all levels of response, including clinical EMS staff, local public health departments, pharmacists, school districts, long-term nurs- ing care facilities, faith-based organizations, and other private and public organizations. He said the CDC’s Healthcare Preparedness Activity (HPA) focuses on best practices solutions to coordinate response efforts in the areas of patient management, resource identification, successful leadership

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58 RURAL MASS CASUALTY INCIDENT strategies for regional coalitions, and the role of alternative care systems in cases when traditional surge capacity is exhausted. From this work, the HPA has developed numerous materials for local communities that address the needs of special populations (e.g., pediatrics), concerns of individual provider groups (e.g., primary care physicians and emergency responders), and integrated communications and information sharing strategies (CDC, 2009a). Thus, building trust among MCI responders is the work of local, regional, state, and federal efforts. Native American Reservations: Coordination and Collaboration Overcome Amplified Obstacles The National Highway Traffic Safety Administration (NHTSA) has rated the county around Window Rock and Fort Defiance, Arizona, as hav- ing the highest rate of single vehicle rollover accidents in the nation. Work- ing the night shift in a small hospital on the reservation, with one nurse and one technician, it takes very few victims to overwhelm the system, notes Glenn Mitchell, especially when someone has to drive 15 miles to wake up the surgeon and bring them back to the hospital. Though currently chief medical officer of the Sisters of Mercy Health System, with hospitals in Ar- kansas, Oklahoma, Kansas, and Missouri, Mitchell speaks from experience with the Indian Health Service at Fort Defiance, Arizona. Mitchell explained that the basic problems of responding to causalities in a rural environment are compounded on a reservation. The largest area in the United States without cell phone coverage is the Navajo reservation in Northern Arizona. Tribal boundaries, law enforcement jurisdictions on and off the reservation, difficulties between tribal and federal officials, and a lack of adequate resources for any EMS-related planning, education, or even daily mission execution plague reservation communities. Native Amer- ican reservations are also home to amplified societal problems like pervasive alcoholism, diabetes, poverty, and the delivery of inadequate medical care. Yet despite these considerable hurdles, Mitchell related how the plan- ning and execution of a mass vaccination/pandemic emergency preparedness exercise employed integration to meet its metrics of success. An intergov- ernmental, multiagency taskforce convened in Window Rock with the goal of developing a broad mechanism to respond to a pandemic crisis across the 27,000 square miles of the Navaho Nation and adjoining lands in Ari- zona and New Mexico. Comprehensively inclusive, the planning group was composed of participants from tribal, county, state, and federal agencies; the New Mexico and Arizona state governments; the county governments in the adjoining Apache and McKinley Counties; and nonprofit groups like school boards, public safety agencies, and the Boy Scouts. Inclusion came not only in the form of an invitation to attend, but an opportunity for each

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59 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS organization to detail its barriers to and goals for participation to the task- force. Mitchell credits this participant buy-in with the taskforce’s success. Effectively removing cross-jurisdictional barriers, participants worked via conference call and in person to organize 15 vaccination sites, ensuring a broad mechanism to respond to a pandemic crisis or biological event. The CDC’s Strategic National Stockpile was used, and the unified incident command post setup followed National Incident Management System’s ICS structure. Texas A&M University photo-documented the exercise and recorded all of the metrics. Volunteers were critical, Mitchell said, includ- ing people from the school boards, community faith-based organizations, Navajo veterans associations, Rotary, Kiwanis, Medical Corps Reserve, and others. On the day of the exercise, using seasonal flu vaccine as the proxy, 22,611 Navajo citizens (over 10 percent of the reservation) were immunized in less than 5 hours. The DHHS secretary’s office took part via a direct video feed to the unified command post. Approximately 500 patients per hour were processed at each of the points of dispensing. There were no adverse events, and 86 percent of the patients rated their satisfaction with the event as a 4 or 5, on a 5-point scale. Though deemed a success, communications and improved access for special needs residents were identified as areas for future progress. This project demonstrated that despite long-held community divisions, effective cooperation is an attainable goal. IMPROVING RURAL RESPONSE BY MAINTAINING SURGE CAPACITY As a trauma surgeon, Winchell concurred with others that the single best approach to ensuring a good mass casualty response is to have a very good day-to-day response. There is no surge capacity if the system is al- ready beyond capacity, and people cannot be expected to respond quickly and under extreme pressure, if they don’t have the capacity to respond routinely. The efforts of EMS are wasted if they don’t have access to an appro- priate destination for the patient, Winchell said. The majority of patients, even in an MCI, will not require the resources of the highest-level trauma center. Most could be treated quite well without being transported out of the region (and such transport comes at potentially significant cost to their social support systems and to the EMS transportation systems). Those pa- tients that do urgently need the highest-level trauma care are not likely to survive if they are more than an hour away from the trauma center. The key, Winchell said, is maintaining local hospital-based or clinic- based resources in rural areas. Whether it is a single car accident or a

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60 RURAL MASS CASUALTY INCIDENT multicasualty incident, more lives will be saved if the local resources are maintained. The challenge is that hospital-based health care is be- ing pushed the other way. Many small hospitals abdicate responsibility for trauma care; it is expensive to maintain and many providers are not available during off hours. Larger urban hospitals need to take a sup- portive approach and work with rural hospitals on training programs and system-based components to enable them to be prepared. There are a lot of resources in local hospitals that can be mobilized. Larger hospi- tals also need to assure rural hospitals that when the patient needs to be transferred, they are ready to take care of them. For those that still resist accepting trauma patients, a stronger approach is making acceptance of trauma patients a condition of licensure or funding for all accredited healthcare facilities in the region. North Dakota and other states have rules, regulations, or statutes that require healthcare facilities to participate in trauma care at a facility-appropriate level. Not every fa- cility will be a level I center, Winchell said, but all are going to have basic responsibilities and will know what to do when a trauma patient appears at the door. Across the board, that sometimes means adjusting privileges and responsibilities. If a clinic cannot be staffed with a doctor, perhaps it can employ a nurse practitioner or a community paramedic, but it must find some way to keep that facility available. Understanding Available Resources The second key, Winchell said, is making sure that facilities are used in a way that is commensurate with their capabilities; keeping those patients that they can treat, and transferring those that should be transferred. There may be a need for regional guidelines to aid facility decision making on who stays and who goes. One innovative solution is regional communication and triage centers. An impartial third party, who knows what resources each hospital has, helps to make the triage decision and determines where the patient will be sent. But maintaining a working knowledge of a region’s resources available in an emergency response should not be limited to just medical resources. For instance, Ken Knipper related an incident in which a worker who had fallen into a water tank he was cleaning, required a crane for extraction. Fortunately, in Kentucky, they had compiled an equipment resource information list and knew exactly where to get a crane. Another incident involving a tractor on a hillside required a wrecker. Because they had a prior agreement set up, when the local wrecker service heard the call, he automatically headed to the scene. Whether rural or urban, incidents will happen for which you simply do not have the resources, Knipper said. Therefore mutual aid agreements and regional planning are necessary.

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61 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS TELEMEDICINE Telemedicine has the potential to support regionalization and facilitate the sharing of cognitive resources with local hospitals, allowing patients to be treated locally, avoiding the added costs of transportation, while allow- ing them to stay close to family support systems. In addition, the technol- ogy has the potential to positively impact many of the challenges to rural MCI response that were identified throughout the workshop, noted several panelists. Some participants believed that telemedicine communications between first responders at the incident scene and hospitals could facili- tate triage and transportation decisions; telemedicine technology aboard ambulances might counterbalance the long travel time between the scene and the hospital to positively affect patient outcomes; common technology platforms could assist communication of best practices between rural emer- gency responders and caregivers across regional jurisdictions; and telemedi- cine technology might even ease the burden of providers to measure and record outcomes and quicken metrics development by aggregating the data automatically and centrally. While some participants heralded the poten- tial of such advances, others remained concerned about issues of funding, feasibility, and ethics not yet resolved. As highlighted during discussions, currently there are more impediments to implementation than solutions, e.g. of cost, reimbursement, frequency of use, credentialing, and others. The Arizona Example To illustrate the potential of telemedicine for rural health systems, Rifat Latifi, director of the Southern Arizona Teletrauma and Telepresence Program, and vice chair of International Relations in the Department of Surgery at the University of Arizona, presented the case of an 18-month- old female who arrived at Southeast Arizona Medical Center in Douglass, Arizona, 3 hours after a motor vehicle crash. Complicating the treatment of her severe injuries, including severe head trauma, was the fact that it was a new ER physician’s first day on the job. Via the telemedicine link, Latifi was able to review the patient’s X-rays and direct care remotely from University Medical Center. With a series of interventions, some proposed remotely by Latifi, the child was stabilized, and ultimately recovered. This case was actually the first use of the new telemedicine system, and there were many practical lessons learned, Latifi noted, such as the need for earpieces rather than speakerphones, to allow for private consultation between the surgeons. In addition to the interhospital telemedicine and telepresence network, Latifi said the “ER Link” program has 17 of the ambulances, from the Tucson Fire Department, that are equipped with video and audio equipment to connect with the hospital.

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62 RURAL MASS CASUALTY INCIDENT Latifi contended that the “golden hour” in trauma medicine is really a “desperation hour.” But this can change, he said. Latifi reported that the Arizona teletrauma program offers a constant virtual trauma presence; it allows for early trauma intervention, and thus both a decrease in morbidity and mortality, and an increase in patient and provider satisfaction (Latifi et al., 2009). The program also helps prevent unnecessary air or ambulance transfers of patients, creating the potential for significant cost savings. Several participants expressed the hope that telemedicine will be a require- ment for all level I and level II trauma centers, perhaps becoming as basic as having a phone. In the future, improved technologies will enable wire- less transmission of data, and secure Internet connections may allow access from anywhere. Latifi asserted that distance education and community involvement are important components to reaping the current and future benefits of telemedicine. Credentialing, Malpractice Coverage, and Telemedicine Latifi and Robert Winchell, director of the Division of Trauma at Maine Medical Center, addressed credentialing, malpractice coverage, and billing for telemedicine as important aspects of formally integrating re- gional resources. In Winchell’s Maine, like Latifi’s Arizona, there is a recip- rocal credentialing system in place. There is an agreement document that states that the teletrauma consultant is a trauma surgeon with credentials and privileges at hospital X, and those credentials are accepted at hospital Y. Hospitals are billed for the telemedicine consultation. Trauma surgeons are credentialed on a courtesy basis at each of the hospitals with which they perform telemedicine. They do not bill for the service because the telemedicine program is supported as a system resource by input from each of the hospitals within the healthcare system. Every several years, recreden- tialing is done in association with the health systemwide recredentialing. Moreover, neither could name an appropriately documented episode of care via telemedicine that had been the subject of a malpractice suit in recent memory, leading other participants to suggest that telemedicine could in fact reduce the malpractice rate in these small hospitals. A participant noted that in Northern Virginia, they use an electronic intensive care unit (eICU) program where physicians help manage criti- cal care patients across the health system, and are therefore credentialed systemwide. They are now using funding from the office of the Assistant Secretary for Preparedness and Response to extend the eICU program outside of the Inova health system, to include two rural hospital partners that are part of the trauma system. They are developing a memorandum of understanding (MOU) that during a mass casualty event when the trauma surgeon’s services are required, there will be blanket liability coverage.

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63 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS The preceding descriptions of the telemedicine systems in Southern Ari- zona, Maine, and Virginia demonstrate the benefits of employing telemedi- cine in response to rural MCIs; however, the widespread implementation of the technology remains in a nascent stage, remarked a participant. Many issues still remain to be determined by individual communities: streamlined funding sources; documentation requirements; provider comfort with the technology and the need for training; cost and provision of technology maintenance; integration with existing technology; and ethical implications of use. Telemedicine should not distract from the need for an increase in well-trained, emergency medicine physicians in rural communities, noted one participant. In response, several suggested demonstration projects as appropriate venues for EMS, regional, and state officials to explore these issues in the future. THEMES IDENTIFIED BY WORKSHOP PARTICIPANTS In addition to the challenges previously cited (geographic barriers, long distances, weather, communications, infrastructure, education, training, funding), rural healthcare systems are facing a general fear of regionaliza- tion among departments and concerns about what they will potentially lose or have to give up in the process. Several participants noted that regional- ization is not centralization. Regionalization involves the building of rela- tionships in advance of a disaster, and cooperative, coordinated planning and education. A participant reiterated the point that the best approach to ensuring a competent mass casualty response is to have a stable, capable day-to-day response. A recurrent theme in the discussions of coordination and integration across platforms was the importance of leadership, and specifically, train- ing for and implementing the ICS. A unified incident command is the key to coordinating across geographic boundaries, disciplines, and sectors (and could be the link to regionalization). Another topic of discussion was what the trauma system of the future needs to look like and how trauma surgeons could be better integrated into the current system. A participant noted that not everyone needs to be sent to the top-level trauma center. Establishing connections and building personal relationships prior to a disaster fosters collaboration during an MCI. People whose primary jobs are nonessential in a disaster can be deployed to fill nontraditional roles. There are also likely to be people within the community who have relevant skills and certifications beyond the scope of their primary job. Essential identification of the available community resources (e.g., people, equip- ment, vehicles, communications systems) and coordination of regional drills

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64 RURAL MASS CASUALTY INCIDENT and exercises are driven by administrators from the local to the federal level. Finally, panelists Hamerlinck and Williams stated that state and federal support is needed to promote and achieve cross-jurisdictional integration. Grants and incentives can be directed toward education, training, planning, or establishing communications. States can also support the community and the region by mobilizing and deploying resources and coordinating outside help during an MCI.