FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR CATASTROPHIC EVENTS

Preparedness and Response to a Rural Mass Casualty Incident

Workshop Summary

Kristin Viswanathan, Theresa Wizemann, and Bruce M. Altevogt, Rapporteurs

Forum on Medical and Public Health Preparedness for Catastrophic Events

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington D.C.
www.nap.edu



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FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR CATASTROPHIC EVENTS Preparedness and Response to a Rural Mass Casualty Incident Workshop Summary Kristin Viswanathan, Theresa Wizemann, and Bruce M. Altevogt, Rapporteurs Forum on Medical and Public Health Preparedness for Catastrophic Events Board on Health Sciences Policy

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians, the American Hospital Association, the American Medical Association, the American Nurses Association, the Association of State and Terri- torial Health Officials, the Centers for Disease Control and Prevention (Contract No. 200- 2005-13434 TO #6), the Department of the Army (Contract No. W81XWH-08-P-0934), the Department of Health and Human Services’ Agency for Healthcare Research and Qual- ity (Contract No. HHSP233200800498P), the Department of Health and Human Services’ National Institutes of Health (Contract No. N01-OD-4-2139 TO #198), the Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Re- sponse (Contract Nos. HHSP233200900680P, HH5P23320042509X1), the Department of Homeland Security’s Office of Health Affairs (Contract No. HSHQDC-07-C-00097), the Department of Homeland Security, Federal Emergency Management Agency (Contract No. HSFEHQ-08-P-1800), the Department of Transportation’s National Highway Traffic Safety Administration (DTNH22-10-H-00287), the Department of Veterans Affairs (Contract No. V101(93)P-2136 TO #10), the Emergency Nurses Association, the National Association of Chain Drug Stores, the National Association of County and City Health Officials, the National Association of Emergency Medical Technicians, the Pharmaceutical Research and Manufactur- ers of America, the Robert Wood Johnson Foundation, and the United Health Foundation. The views presented in this publication are those of the editors and attributing authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-17717-7 International Standard Book Number-10: 0-309-17717-0 Additional copies of this report are available from The National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2011 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine). 2011. Preparedness and Response to a Rural Mass Casualty Incident: Workshop Summary. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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WORKSHOP PLANNING COMMITTEE* ROBERT BASS (Chair), Maryland Institute for Emergency Medical Services Systems, Baltimore, MD JOHN CHIARAMONTE, Booz Allen Hamilton, McLean, VA DIA GAINOR, Idaho EMS Bureau, Boise, ID MICHAEL HANDRIGAN, Emergency Care Coordination Center, HHS Office of the Assistant Secretary for Preparedness and Response, Washington, DC KELLY HARDY, American Association of State Highway and Transportation Officials, Washington, DC EILEEN HOLLORAN, Health Resources and Services Administration Office of Rural Health Policy, Rockville, MD RICHARD C. HUNT, Division of Injury Response, National Center for Injury Prevention and Control Center, Atlanta, GA JERRY JOHNSTON, Henry County Hospital Center EMS, Mt. Pleasant, IA JON KROHMER, Department of Homeland Security, Washington, DC DEBORAH LEVY, Centers for Disease Control and Prevention, Atlanta, GA ROBERT POLLACK, Federal Highway Administration, Washington, DC NELS SANDDAL, Critical Illness and Trauma Foundation, Bozeman, MT JOLENE WHITNEY, Utah Bureau of Emergency Services, Salt Lake City, UT GAMUNU WIJETUNGE, National Highway Traffic Safety Administration, Washington, DC IOM Staff BRUCE ALTEVOGT, Preparedness Forum Director CLARE STROUD, Program Officer ANDREW POPE, Director, Board on Health Sciences Policy ALEX REPACE, Senior Program Assistant *IOM planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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FORUM ON MEDICAL AND PUBLIC HEALTH PREPAREDNESS FOR CATASTROPHIC EVENTS* ROBERT KADLEC (Co-Chair), PRTM Management Consultants, Washington, DC LYNNE KIDDER (Co-Chair), Center for Excellence in Disaster Management and Humanitarian Assistance, Tripler AMC, Hawaii ALEX ADAMS, National Association of Chain Drug Stores Foundation, Alexandria, VA DAMON ARNOLD, Association of State and Territorial Health Officials, Arlington, VA GEORGES BENJAMIN, American Public Health Association, Washington, DC D. W. CHEN, Office of Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC VICTORIA DAVEY, Department of Veterans Affairs, Washington, DC JEFFREY DUCHIN, Public Health–Seattle & King County and University of Washington, Seattle ALEXANDER GARZA, Department of Homeland Security, Washington, DC JULIE GERBERDING, Merck Vaccines, West Point, PA LEWIS GOLDFRANK, New York University Medical Center, New York LYNN GOLDMAN, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (until September 2010) DAN HANFLING, Inova Health System, Falls Church, VA JACK HERRMANN, National Association of County and City Health Officials, Washington, DC JAMES JAMES, American Medical Association, Chicago, IL JERRY JOHNSTON, National Association of Emergency Medical Technicians, Mt. Pleasant, IA BRIAN KAMOIE, The White House, Washington, DC LISA KAPLOWITZ, HHS Office of the Assistant Secretary for Preparedness and Response, Washington, DC ALI KHAN, Centers for Disease Control and Prevention, Atlanta, GA MICHAEL KURILLA, National Institute of Allergy and Infectious Diseases, Bethesda, MD JAYNE LUX, National Business Group on Health, Washington, DC *IOM forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vii

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ANTHONY MACINTYRE, American College of Emergency Physicians, Washington, DC ANGELA McGOWAN, Robert Wood Johnson Foundation, Princeton, NJ MARGARET McMAHON, Emergency Nurses Association, Williamstown, NJ MATTHEW MINSON, Texas A&M University, College Station, TX ERIN MULLEN, Pharmaceutical Research and Manufacturers of America, Washington, DC CHERYL PETERSON, American Nurses Association, Silver Spring, MD STEVEN PHILLIPS, National Library of Medicine, Bethesda, MD ROSLYNE SCHULMAN, American Hospital Association, Washington, DC RICHARD SERINO, Federal Emergency Management Agency, Washington, DC SHARON STANLEY, American Red Cross, Washington, DC ERIC TONER, University of Pittsburgh Medical Center, Pittsburgh, PA REED TUCKSON, UnitedHealth Group, Minneapolis, MN MARGARET VANAMRINGE, The Joint Commission, Washington, DC GAMUNU WIEJETUNGE, National Highway Traffic Safety Administration, Washington, DC IOM Staff BRUCE ALTEVOGT, Project Director CLARE STROUD, Program Officer KRISTIN VISWANATHAN, Research Associate ALEX REPACE, Senior Program Assistant ANDREW POPE, Director, Board on Health Sciences Policy viii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Aimee Binning, National Association of Emergency Medical Technicians, CVC Training Inc. Rick Jones, National Emergency Number Association Kevin McGinnis, National Association of State EMS Officials Drexdal Pratt, North Carolina Division of Health Service Regulation, (former) North Carolina Bureau of Emergency Medical Services Joseph Schmider, Bureau of Emergency Medical Services, Pennsylvania Department of Health Christopher Tilden, Mountain States Group Tim Wiedrich, Emergency Preparedness and Response North Dakota Department of Health Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of this report ix

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x REVIEWERS before its release. The review of this report was overseen by Jeff Runge, the Chertoff Group. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Contents 1 INTRODUCTION 1 Background, 2 Organization of the Report, 5 2 CASE EXAMPLES: 2008 MEXICAN HAT, UTAH, INCIDENT 2010 AND ALBERT PIKE, ARKANSAS, FLOOD 7 NTSB Mexican Hat Investigation, 7 The 2008 Mexican Hat, Utah, Incident and Response: Local Perspective, 8 The 2008 Mexican Hat, Utah, Incident and Response: State and Regional Perspectives, 13 The 2010 Albert Pike, Arkansas, Flooding, 15 Themes Identified by Workshop Participants, 18 3 9-1-1 ACCESS AND COMMUNICATIONS 21 Challenges, 21 Improving Response, 27 Themes Identified by Workshop Participants, 29 4 CHALLENGES FACING THE PREHOSPITAL SYSTEM 31 Discerning and Addressing Local Challenges, 31 Rethinking and Retasking Available Resources, 35 The Human Resource, 38 Themes Identified by Workshop Participants, 42 xi

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xii CONTENTS 5 COORDINATION AND INTEGRATION ACROSS RESPONSE PLATFORMS 45 Regionalization, 45 Integrating Trauma Surgeons, 50 Addressing Integration Challenges Through Increased Recruitment and Education, 51 State-Level Support, 54 Spurring Regional Collaboration and Planning, 55 Improving Rural Response by Maintaining Surge Capacity, 59 Telemedicine, 61 Themes Identified by Workshop Participants, 63 6 ESTABLISHING METRICS TO ASSESS RISK AND CAPABILITIES 65 Assessment Models, 65 Data Sources for Developing Metrics to Assess Risks and Capabilities, 67 Trauma System Data and Metrics, 71 Systematic Approaches to Metrics Development, 73 Themes Identified by Workshop Participants, 75 7 IMPROVING RURAL MASS CASUALTY RESPONSE IN THE UNITED STATES 77 Addressing the Issue of Funding, 77 The Role of Government, 82 Themes Identified by Workshop Participants, 84 8 NEEDS AND OPPORTUNITIES 87 APPENDIXES A References 89 B Workshop Agenda 91 C Biographical Sketches of Invited Speakers and Panelists 105