Nationwide Response Issues After an Improvised Nuclear Device Attack: Medical and Public Health Considerations for Neighboring Jurisdictions: Workshop Summary (2014)

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I Role of Regional Health Care Coalitions in Managing and Coordinating Disaster Response A white paper prepared for the January 23–24, 2013, workshop on Nationwide Response to an Improvised Nuclear Device Attack, hosted by the Institute of Medi- cine’s Forum on Medical and Public Health Prepared- ness for Catastrophic Events together with the National Association of County and City Health Officials. The au- thor is responsible for the content of this article, which does not necessarily represent the views of the Institute of Medicine. By: Dan Hanfling, M.D. Special Advisor, Emergency Preparedness and Response, Inova Health System Clinical Professor, Department of Emergency Medicine, George Washington University Contributing Scholar, UPMC Center for Biosecurity The cars come crawling toward the District. The backup from the west on Route 66 inside the beltway (7 miles to GZ) contains the usual mix of single commuters and slugs looking to settle into another day of work in the city. From the south comes the line of cars slowly making its way past the Occoquan (20 miles to GZ), transitioning from the outer suburbs into Fairfax County. Interstate 95 is full of cars and trucks headed south from Baltimore toward DC, and as it meets the Beltway (12 miles from GZ), cars can either head east or west around the road that 213 

214 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK rings the city. There is no quick and easy way into the city during rush hour. On this beautiful, crisp, clear winter morning, life around the city is shaping up much like any other day in the Nation’s Capital. Kids are off to school. Congressional hearings are an hour or so from starting. Offic- es are coming to life, and talk inevitably, turns back to the successes and failures of the Redskins. First comes the intensely bright flash. It is brighter than the flash of a million flashbulbs all going off at the very same time. Many of those on the highways headed into town are blinded, their retinas seared by the intense light. Cars driving at speed plow into others that are already slowing because of the start again–stop again rush hour traffic. The highways are instantly made impassable, with hundreds of mangled cars littering the roadways. Where the flash is not seen, close in to the city, there is an eerie howl, followed immediately by breaking glass and flying debris. Closer to ground zero, there is utter devastation. Buildings are collapsed in the immediate vicinity of the explosion. Many of those that are standing are on fire. An ill-defined plume of smoke, ash, and dust begins to rise over the city. 1600 Pennsylvania Avenue is no more. There have been a number of significant planning efforts focused on response to and recovery from the terrorist use of an improvised nuclear device (IND). The White House Office of Science Technology Policy led the creation of a first and second national planning guidance for IND response. [1,2] The National Labs contributed key inputs related to im- portant mitigation steps that could save thousands of lives—a message so simple it may be easy to deliver but hard to convince. [3] HHS/ASPR brought together subject matter experts to help describe many of the key health and medical response elements that will need to be implemented [4], illustrated the basic approach to the spontaneous formation of triage and treatment areas, [5] and has continued to promote the development of crisis standards of care as part of a systems approach to catastrophic disaster response. [6,7] The intent of this paper is to highlight the role that health care coalitions will play in an event of this magnitude. “A primary purpose for any health care coalition is to promote optimal situa- tional awareness for its member organizations through the collection, aggregation, and dissemination of incident information.” [8] This paper will explore a number of issues related to catastrophic disaster event planning and response. The IND detonation scenario rep- resents one of the most compelling examples of a sudden onset, no- 

APPENDIX I 215 notice catastrophic event. The public health and health care issues and challenges that are forced upon the “collar communities,” those areas that are located outside of the blast zone but are geographically adjacent to the affected region, will require close coordination and prioritization of available resources within the emergency response system. The decade- long history of coalition development in the National Capital Region (NCR), with different efforts and approaches in each of the three juris- dictions, Maryland, DC, and Northern Virginia, will be reviewed. De- scription of the optimal framework for coordinating response between existing health care coalitions and emergency management infrastruc- ture, including emergency operations centers and community reception centers, will be detailed. Finally, the paper will explore how coalitions that organize to form regional networks can improve communications of resource needs and provide situational awareness. The goal of such net- works will be to enhance the response regarding management of the un- structured intake of arriving patients as well as providing for the intensive medical support irradiated patients will need under such cir- cumstances. How can the “collar community” outlying health care coali- tions coordinate with each other across jurisdictional lines in order to relieve the sudden surge in demand for care while helping those commu- nities most severely impacted by the attack to begin the important pro- cess of recovery? CREATING THE COALITION MODEL̾DEVELOPING COALITIONS IN DC, MARYLAND, AND VIRGINIA In the immediate aftermath of the 9/11 and anthrax attacks, the need for better coordination and cooperation among hospitals, EMS agencies and public health departments across the Washington, DC, metro region was quickly recognized. Prior to the 2001 attacks, planning efforts relat- ed to disaster preparedness and response within the three distinct juris- dictions was occurring at a varied pace. In the few years preceding that fateful fall, planning efforts focused on regional response were promoted in part by some of the initial Nunn-Luger-Domenici WMD grant fund- ing. These efforts were encouraged by strong personalities and leaders whose vision for improved processes and procedures for hospital disaster response were being slowly heeded. Front and foremost were the efforts of the DC Hospital Association (DCHA) which was responsible for de- veloping and implementing a city-wide hospital mutual aid radio system 

216 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK (HMARS), developed what became the prototypical hospital mutual aid agreement that linked DC hospitals as response partners in event of an overwhelming crisis, [9] and commissioned one of the first municipal bioterrorism response plans in the nation, completed in August 2001. [10] The events of 2001 changed everything. Hospitals across the region recognized the importance of planning for disaster. The anthrax attacks proved that large-scale disaster could essentially present as a public health and health care delivery event, with significantly less response actions required of the traditional first response agencies. And from this, the notion of developing a “coalition” of response agencies was born. How would public health, health care institutions, and the traditional first responder agencies, police, fire, and EMS, coordinate their efforts to en- act a uniform and unified response to such events? In the immediate aftermath of the events of the fall of 2001, an effort to promote these interdisciplinary linkages in northern Virginia was initi- ated. The Northern Virginia Emergency Response Coalition (NVERC) was created in October 2001, driven by the need to unify response efforts among the many hospitals and public health agencies affected by the surge in demand for screening and care related to inhalational anthrax cases. In addition, there was great interest in and concern regarding the need for specific training and expertise required for the response to fu- ture disaster events. It was developed under the auspices of the existing regional EMS council. Efforts that took hold in northern Virginia were indeed modeled directly upon the very successful planning and coordina- tion efforts spearheaded by the DCHA. Three foundational elements of the DC effort can be seen in hospital coalitions that have developed across the country in the ensuing 10 plus years since the Northern Vir- ginia effort crafted its own approach to coordinating hospital planning and response for disaster events. DCHA involved each of the District hospitals in their effort, including participation of the Veterans Hospital (VAMC) and the flagship Army military treatment facility (Walter Reed Medical Center) with the private institutions and public hospital (DC General) located across the city. They pursued the development of HMARS in the mid-1990s, a radio system that linked all of the DC hos- pitals in real time, and developed a protocol for daily testing and infor- mation exchange. And in the context of intense health care business competition, DCHA developed and implemented a Hospital Memoran- dum of Understanding that governed the exchange of resources in times of crisis—it went so far as to assign “buddy” hospitals across the city so 

APPENDIX I 217 that no single institution was left unpaired. This DC hospital memoran- dum of understanding (MOU) became the prototype for the MOU shared across the nation by the American Hospital Association. The coordina- tion of planning efforts across private and public institutions, the devel- opment of an MOU, and the establishment of a linked radio system were some of the first efforts in the United States to coordinate hospitals in the context of disaster planning and response, and were the foundations for the efforts that followed in northern Virginia. Northern Virginia The Northern Virginia Hospital Alliance (NVHA) was formed in October 2002, an effort initiated by two of the three recognized leaders of the NVERC. Although the NVERC “coalition” focus was deemed vi- tally important and was very successful during its relatively brief dura- tion, it became clear that specific needs of the northern Virginia hospitals regarding planning and response required a different approach than that required by their municipal public health, law enforcement, fire, and EMS partners. NVHA is comprised of 14 member hospitals and 6 free- standing fully functional emergency departments in the northern Virginia suburbs of Washington, DC. It includes facilities that serve a population of more than 2.5 million residents over 3,000 square miles—ranging from suburban to exurban to rural communities. The hospitals have more than 3,500 acute care beds, and provide more than 700,000 ED visits and more than 170,000 hospital admissions (2009 data). As a conglomerate, the NVHA member hospitals have over 40,000 employees, making them the largest private-sector employer in northern Virginia. [11] The organization was conceived as both a planning and response en- tity, with an initial focus placed on creating the sort of real-time infor- mation sharing and management system that was noted to be sorely lacking during the 2001 attacks. A regional hospital coordinating center (RHCC) was developed, and an 800 MHz radio system was put in place as the result of a public/private partnership entered into with northern Virginia’s largest municipality, Fairfax County. Other key efforts includ- ed development of a regional focus on chemical event preparedness, with coordinated purchasing of a regional cache of personal protective equip- ment (PPE), development of an integrated approach to surge capacity and capability that has included an element of telemedicine to assure immediate availability of medical expertise and oversight, and a robust 

218 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK pharmaceutical and materials acquisition, storage, and logistics plan, in- cluding the development of a warehouse capacity, to ensure availability of key resources separate from state or federal stockpiles. The NVHA remains a robust and vital planning and response organization to the pre- sent time, led by an Executive Director and governed by an active Board of Directors comprised of the CEOs or senior most administrators of each of the region’s 14 hospitals. In the aftermath of the 9/11 and anthrax attacks, Arlington County, Virginia, which was one of the last of the original 120 MMRS-funded “cities,” brought forward the recommendation to expand its MMRS pro- gram to include some of its northern Virginia neighboring jurisdictions. In 2005, the Northern Virginia Emergency Response System (NVERS) was created, representing 25 towns, cities, and counties with approxi- mately 2 million residents. NVERS supports “a regional approach to co- ordinated preparedness, response, mitigation and recovery across jurisdiction and discipline boundaries during day-to-day emergencies and multi-jurisdictional and/or multi-disciplinary incidents through strategic planning, priority-setting, information sharing, training, exercises, equipment acquisition and policy-making.” [12] It provides for coordina- tion on planning and integration of response capabilities across law en- forcement, fire and rescue, emergency medical services, hazardous materials, emergency management, hospitals, public health, public in- formation and information technology. It coordinates closely with its state partners in the Commonwealth of Virginia, as well as with its re- gional partners in the State of Maryland and the District of Columbia, and partners closely with many of those same entities who help to com- prise the Metropolitan Washington Council of Governments. Suburban Maryland The focus on planning and response to disaster events in the State of Maryland preceded those outlined for the District of Columbia and the Commonwealth of Virginia. The Maryland Institute for Emergency Med- ical Services System (MIEMSS), founded by the Governor of Maryland in 1973, placed emphasis on the development of a “system” that coordi- nates the delivery of emergency pre-hospital and hospital-based care. The central role played by MIEMSS in organizing out-of-hospital and hospital emergency capabilities has led to a different approach to the de- velopment of regional hospital coalitions. In the years prior to the 9/11 

APPENDIX I 219 attacks, these efforts developed in parallel with the hospital-specific planning efforts of the DCHA and EMS focused disaster planning occur- ring in northern VA. MIEMSS created a seamless statewide radio net- work linking the state’s hospitals that has been in operation for nearly three decades. The state Emergency Medical Resource Center (EMRC) was founded in 1974, representing one of the first systems in the nation to emphasize and develop coordination of EMS and hospital communica- tions, for use both day-to-day and during disaster events. In the aftermath of the region’s experience with the 9/11 attacks, an information man- agement platform focused on facility resources data collection an infor- mation sharing system was put into place. Given the strong state influence on planning, efforts at coalition building have been somewhat limited compared with the DC and VA efforts. In 2004, the Bethesda Hospitals’ Emergency Preparedness Part- nership (BHEPP) was established, creating a planning and response link among the local community hospital, which is an accredited Level 2 trauma center, and the federal medical facilities at the National Institutes of Health (NIH) and the National Naval Medical Center (formerly Be- thesda Naval Medical Center, now renamed the Walter Reed National Military Medical Center). [13] In addition, the National Library of Medicine, co-located on the NIH campus, is an active member of the partnership. This geographically concentrated effort has conducted and participated in numerous exercise events focused on coordinating municipal, regional, and federal emergency response agencies. By coordinating their response capabilities, they have effectively developed a significant capacity to manage a sudden influx in patient care needs. They have been an active and engaged partner in planning efforts occurring across the National Capital Region. More recently, the Suburban Maryland Hospital Coalition has been established, comprised of the 10 hospitals located in the close in Mary- land suburbs of Washington, DC, located in Montgomery and Prince George’s Counties (and incorporating the three aforementioned hospitals comprising the BHEPP). This entity is a planning group only, focused on the coordination of ASPR/HPP-related funding opportunities. However, the central Maryland area hospitals signed a regional sharing agreement for the first time in 2012, including four hospital signatories from the suburban Maryland region, in order to support a disaster event affecting Baltimore hospitals. The voluntary Baltimore Health Care Facilities Re- gional Mutual Aid System’s MOU has formalized the process of collabo- rating in the event that one hospital becomes overwhelmed during a 

220 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK disaster. This agreement allows all participating hospitals to work to- gether during an emergency to share staff, beds, equipment, and supplies. [14] District of Columbia As previously described, the DCHA played a crucial role with regard to coordinating the DC hospitals for disaster planning and response. However, 5 years after the 2001 attacks, the leadership provided by DCHA in the emergency preparedness efforts of the DC hospitals transi- tioned to the DC Emergency Health Care Coalition (DCEHC), which was funded by an ASPR grant in 2007. Membership includes seven acute care hospitals and a combination of 40 skilled nursing facilities and community health centers. DCEHC was developed along the parameters established in the Medical Surge Capacity and Capability Health Care Coalition in Emergency Response and Recovery handbook. [15] It is staffed by a Health Care Coalition Response Team (HCRT), Senior Poli- cy Group, and has created a Coalition Notification Center (CNC) which utilizes an on-call Duty Officer. The CNC rotation among three DC hos- pitals facilitates information exchange to Coalition members and external partners by use of the HMARS radio system and a health information management platform. By doing so, the DCEHC has come into sync with the NVHA and its Regional Hospital Coordination Center (RHCC) and the State of Maryland’s EMRC, in being able to communicate in real time among and between the three regional health care partners of the NCR during day-to-day alerts, and in support of response to disaster events (see Table I-1). 

TABLE I-1 NCR Health Care Coalition Communications Network Operational Coordination Communications Coalition Center Capabilities On-Call Linkages DCEHC (regional) Coalition Notification Hospital Mutual Aid Radio Duty Officer Coordinates with DC Dept. Center (CNC) System (HMARS); Health of Health, DC Fire/EMS, Information System Emergency Management (EOC) NVHA (regional) Regional Hospital MEDCOMM Radio Net- Incident Commander Coordinates with Virginia Coordination Center work; Virginia Health Care and Operations Chief Dept. of Health Communi- (RHCC) Alerting and Status System cations Centers, local juris- (VHASS) dictional emergency management (EOCs) MIEMSS (state) Emergency Medical Radio and microwave link- Field Operations Coordinates with EMS, Resource Center ages; HC Standard plat- Support Team Hospitals, 911 centers, (EMRC) form Maryland Joint Operations Center (MJOC) Serves as contact point for CNC and RHCC NOTE: An HMARS Radio unit and antennae are located and monitored at both Inova Fairfax Hospital Medical Campus and the Northern Virginia RHCC, ensuring additional redundancy to the communications networks that link the three DC regional health care coalitions. 221 

222 APPENDIX I Coordinating Across the NCR Because so many planned events occur in the Nation’s Capital—the presidential inauguration every 4 years, the yearly State of the Union presidential address, and July 4 celebration—and because Washington’s buildings and their occupants remain high threat targets for terrorists seeking to inflict damage, coordinating communications and response activities across the NCR is of critical importance. FEMA’s after-action report detailing the planning and response activities related to the 2009 Presidential Inauguration of Barack H. Obama highlighted, among other items, the unprecedented degree of planning coordination and coopera- tion that occurred in support of this historic event, particularly in the pub- lic health and medical sectors: Hospital coalitions and individual institutions took a wide range of steps to plan and prepare for the Inaugu- ration. The DC Emergency Health Care Coalition (DCEHC), the DC Hospital Association (DCHA), and the Northern Virginia Hospital Alliance (NVHA) devel- oped plans and worked with their members to prepare for the Inauguration. These entities developed emergen- cy operation plans, incident action plans and other doc- uments to coordinate their members’ response activities. Northern Virginia hospitals integrated their planning activities to a degree that exceeded their previous ef- forts. Further, the DCEHC led efforts to create a NCR hospital incident information sharing procedure for the Inauguration. [16] In addition to coordinating the planning efforts, the operational ele- ments required to ensure close synchronization of response efforts were also put into place. The DC Department of Health Health Emergency Coordination Center (HECC) was utilized during the Inauguration week- end to serve as a coordinating point for information relevant to the NCR hospitals and public health agencies, and was staffed by members com- prising the DC, MD, and northern VA hospital coalitions, health depart- ments, and EMS agencies. The recommendation from the FEMA report was that “NCR hospital and EMS partners should identify opportunities to institutionalize these processes in order to prepare the region for large- scale, no-notice events.” [17] Similar efforts will have been used in 

APPENDIX I 223 coordinating planning and response to this year’s 2013 Presidential Inauguration. One area in which the FEMA report noted a need for improvement was in developing consistency among NCR hospitals with regards to sharing a common set of terms and definitions to describe their ability to accept patients. The three different jurisdictions each utilized words and phrases that were not in use by the other jurisdictions: “Open, Special Diversion, and Closed”; “Green, Yellow, and Red”; and “Baseline, Stressed, and Overwhelmed” were all used to describe hospital surge capacity status. As a result, “during the Inauguration, officials unfamiliar with the terminology disseminated an announcement predicated on an erroneous understanding of hospital status. This incident illustrates how officials unfamiliar with the differing terminology may make erroneous assumptions and conclusions about hospital status.” [18] As a direct result of this experience, the NCR coalition partners have undertaken efforts to standardize hospital terminology throughout the region, and have drafted an “NCR Hospital Event Information Sharing Procedure.” It is intended to provide guidance to the hospital coordina- tion centers located in DC, suburban Maryland, and northern Virginia in the procedures required to facilitate effective information sharing during planned events and major incidents. This draft policy establishes the notification criteria that would warrant region wide information sharing (see Box I-1). [19] BOX I-1 Notification Criteria for National Capital Region Hospital Information Sharing, from “NCR Hospital Event Information Sharing Procedure,” Draft Document, June 19, 2012 x Judgment by Health Care Coordinating Center leadership that notifi- cation of the other NCR Coordinating Centers (VA—RHCC, MD— EMRC, DC—CNC) is warranted. x A single, mass casualty event that involves 40 or more patients that will require transportation to specialty hospitals (pediatrics, trauma) throughout the NCR and/or where hospitals outside of the host juris- diction will receive patients. x A single HAZMAT event involving 30 or more patients that will/may require decontamination. 

224 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK x An event involving a suspected or confirmed Category A biological agent. x A fire/EMS agency has activated a Mass Casualty Unit, Task Force or equivalent, for an event occurring in the NCR. x An agency or health care facility has accessed and/or requested a CHEMPACK or MMRS pharmaceutical cache. BUILDING THE EMERGENCY RESPONSE SYSTEM—A FRAMEWORK FOR CATASTROPHIC DISASTER RESPONSE The examples of health care and hospital coalition development in the NCR over the past two decades serve as useful illustrations of how the emergency response system has evolved over time. The progress rep- resented by these concrete efforts has been purposefully orchestrated by leaders in the NCR who recognize the importance of implementing a “systems approach” to emergency preparedness and response. Indeed, these efforts are the substrate necessary for developing the optimal framework required for coordinating response between existing health care coalitions and the emergency management infrastructure. A large- scale event, especially a no-notice event such as that posed by an IND detonation, will require coordination amongst local, regional and state emergency operations centers (EOCs). Furthermore, specific to the IND event, the utilization of community reception centers, where evacuating patients will be initially assessed or reassessed, re-triaged and if needed, referred for more definitive medical assessment and care, will require an entire community’s emergency response system to be able to implement. While the health and medical functions will be of paramount importance in helping to manage the expected casualties resulting from such an at- tack, the overarching coordination of such events will be managed through respective emergency management agencies, and the exchange of critical information is going to occur in EOCs. In addition, the estab- lishment of community reception centers, or “assembly centers,” for those patients who are ambulatory and evacuating from the site of the detonation or its fallout, will require significant logistical support, spear- headed by emergency management authorities. 

APPENDIX I 225 Including Health as Part of the Emergency Response System As described in the IOM report detailing the development of crisis standards of care, coordination of the entire emergency response system is required in order to best mitigate the consequences arising from a cata- strophic disaster event. [20] This “system” includes those elements tradi- tionally considered to be a part of emergency response—police, fire, and EMS agencies, but must also include other partners, as well. Hospitals, public health agencies, and the private practice medical community are also key components. Early planning efforts funded under the Metropoli- tan Medical Response System grants of the late 1990s, followed by the weaknesses exposed by the 9/11 and anthrax attacks of 2001, highlighted the importance of bringing health and medical entities to the table as full partners in planning and response. Thus, the emergency response system is now intended to be inclusive of public health agencies and strives to include those elements involved in the delivery of acute medical care— hospitals, clinics, and the private practice community. However, inclu- sion of the private practice health care practitioners in the emergency planning and response process remains mostly elusive. [21,22] Nonethe- less, as exemplified by the NCR coalition development experience, the transition to a comprehensive systems approach to preparedness and re- sponse is slowly occurring in communities across the nation. Health care coalitions may be in the best position to help broker such change. The intent of federal grant funding, particularly that coming from the ASPR/Hospital Preparedness Program, is focused to ensure that such connectivity continues to be developed and planned for. The en- hancement and maturation of such connections are vitally important to the success of any response to a catastrophic event. As the National Guidance for Health Care System Preparedness document highlights, “health care coalitions, in coordination with health care organizations, emergency management, ESF (emergency support function) # 8, relevant response partners and stakeholders (must) develop a plan to ensure health care organizations are represented in incident management decisions dur- ing an incident.” [23] The health care coalition may be uniquely able to plan for disaster response needs irrespective of the jurisdictional issues that can often hamper planning within many of the municipality-based emergency re- sponse agencies. Coalition membership is often comprised of health care systems that have their facilities located in more than one jurisdiction. As a result, these are often organizations that are used to routinely coordi- 

226 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK nate basic public health, EMS, and related public safety issues among multiple jurisdictional agency partners. Given that the health care coali- tions also chiefly represent privatesector entities, more latitude in the procurement process can often hasten acquisition of key planning re- sources. Many times such resources may be provided by “in-kind” con- tributions, of both personnel and resources, which further helps to promote the planning effort. For example, the RHCC in Northern Virgin- ia is co-located within Inova Health System’s eICU telemedicine nerve center, providing a location for a command center that takes advantage of additional functionality provided by the broadband connectivity needed for this critical care service. Given this potential benefit, the health care coalition can help to serve as a convener of emergency response entities, much the way the DCHA and the original NVERC, and later the NVHA, did in the Nation- al Capital Region. Planning must be based upon known or perceived hazards, and must focus on the steps needed to ensure safe, timely, and evidenced-based responses to the identified risks. Such planning must take into account the ability to surge in demand for health care services, and must include plans that recognize the potential shift in care delivery across the surge spectrum from conventional to contingency to crisis surge response. [24] Across the varied risks that might be planned for, the health care coalition must be prepared to help manage and promote not only communications, information sharing, and situational aware- ness, as previously described, but other key issues, as well. Key attrib- utes and functions of a robust health care coalition are described in Table I-2. TABLE I-2 Core Functions and Capabilities for Health Care Coalition Development Core Mission Areas Examples Regional planning and collaboration Serves as multiagency coordinating center focused on acute care hospi- tals and health care organizations Communication and information Interoperable voice and data commu- management nications systems to share situational awareness; bed status board; resource tracking board; mass notification and alerting; patient tracking 

APPENDIX I 227 Core Mission Areas Examples Training, education, and exercises Focus areas: incident command; me- dia and crisis communications; active shooter; decontamination procedures; burn and trauma care; radiological response, others Personal protective equipment (PPE) Regional acquisition of biological (N-95 masks, elastomeric masks, gowns, gloves) and chemical (pow- ered air purifying respirators [PAPR], chemical protective clothing, boots) PPE; interchangeable across coalition Critical infrastructure protection Water system resiliency, including emergency water pumping and potable water storage systems; electrical power system resiliency, including installation of emergency generator transfer panels (“quick connect”), ensure adequate backup generator power and fuel to support generators Decontamination and detection Decontamination showers (fixed fa- cilities represent preferred approach, when possible); radiation detection portals Surge capacity and capabilities Development of “immediate bed availability” surge plans, utilizing strategies including implementation of reverse triage protocols, estab- lishment of “discharge lounges” and implementation of telemedicine solu- tions; exploration of regional staffing models Pharmaceuticals and materials man- Acquisition of key equipment, sup- agement plies and pharmaceuticals used to support surge response efforts includ- ing: temporary beds, EMS/transport ventilators, portable vacuum suction units, IV pumps, “crash” carts, 

228 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Core Mission Areas Examples HEPA air scrubbers; colocation of CHEMPACK cache Security Augmentation of security protocols and information sharing among coali- tion members Mass fatality management Procurement of materiel and equip- ment to support mass fatality man- agement, coordinated planning to help mitigate placement of decedents in setting of large numbers of casual- ties Organization and leadership Leadership, both administrative and clinical (with incorporation of subject matter experts to help lead policy development); focus on fiduciary goals and fiscally prudent and defen- sible decisions Development of a regional health care operations policy, one that details the allocation and sharing of key resources, and plans for their utilization across the rainbow of potential scenarios, will be an important step taken in the direction of codifying the basic procedures that will govern a response to mass-casualty, mass-exposure, and public health emergency. The purpose of such a plan ought to be to describe the sys- tems, tools, and organizational structure by which the health care coali- tion will execute its basic responsibilities. As noted previously, these include facilitating communications, information sharing, and response between coalition partners and other relevant response partners at the local, regional, and state level (i.e., law enforcement, fire/EMS, public health, emergency management, and others); coordinating the manage- ment and distribution of patients from a mass casualty incident to receiv- ing hospitals with the public safety and EMS agencies, both municipal and private; promoting coordinated and consistent strategies and tactics across the responding coalition members; and facilitating resource sup- port to the coalition members, to include mutual aid/cooperative assis- 

APPENDIX I 229 tance, deployment of regional stockpiles (see Table I-3), governmental assistance, and the management of spontaneous volunteers or donations. THE ROLE OF REGIONAL HEALTH CARE COALITIONS IN IND RESPONSE As the region begins to take account of what has happened—buildings in downtown DC collapsed and on fire, glass from high-rise offices and apartments blown out for miles around, roads and highways made impass- able by the twisted steel of multiple car crashes, large snow-like dust particles beginning to settle back down to the ground—public safety radios may begin to crackle, text messages may begin to flow, WTOP may or may not be on the air. Most people will have no idea what has occurred, nor what is in store. Many thousands are dead; many more thousands are critically injured. Tens of thousands are at risk for radioactive exposure, and if they are not directed to shelter immediately, the number of casualties from this explosive event will be signifi- cantly larger. Patients will begin to come to hospitals, clinics, and other acute care facilities. The ability to de- liver stabilizing care will become quickly overwhelmed. Many more will begin to attempt to evacuate the city and close-in suburbs seeking care elsewhere. The exodus has begun. TABLE I-3 Example of Health Care Coalition Resource Stockpiling (from NVHA Regional EOP) Personal Protective Equipment: N95 respirators, procedural masks [adult and pediatric], replacement filters for elastomeric respirators, protective gowns Temporary Hospital Beds: portable hospital beds that can be deployed and used to augment surge capacity at hospitals or alternate care sites managed by local authorities. Linen and Staff Scrubs: disposable linen to include blankets, pillows, hospital sheets, patient gowns [adult and pediatric sizes], diapers, and staff scrubs. 

230 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Basic Medical Supplies: suture kits, splints, bandages, dressings; divided into 5 identical “caches” that are each subdivided into rolling hospital carts for improved mobility and deployment. Ventilator Supplies: ventilator circuits that can be used to support the disaster EMS/transport ventilators deployed to coalition member hospitals. Hydration Fluid and Supplies: 12,000 1 liter bags of normal saline and IV starter kits/catheters [in a variety of gauge sizes]. Drinking Water: 25,000 individual 1-gallon bottles of drinking water. Decontamination Supplies: filters, breathing hoses for PAPRs and spare Level-C DECON suits. Building health care coalitions into the matrix of emergency re- sponse “systems” is critically important, particularly in helping to miti- gate the health and medical consequences arising from a catastrophic event such as that caused by a nuclear detonation. Those coalitions that are in the immediate impact zone will have particular challenges as they begin to mount a response to the sudden disaster. In the context of an attack in downtown DC, it is likely that the DCEHC may simply cease to function. The NVHA and Maryland coalitions are more likely to be able to respond immediately, and their ability to respond will also likely trig- ger the activation of protocols by health care coalitions adjacent or oth- erwise virtually connected to them (i.e., the other five health care coalitions located across the Commonwealth of Virginia, and the notifi- cation of the entire emergency response system in the State of Mary- land). Coalitions will need to focus on key functions related to their role as a member of the emergency response system, although these imple- mentation priorities may not all be easily accomplished, given the cir- cumstances at hand (see Table I-4 at the end of the paper). The key functions that are described will be required of those coalitions close to the impact zone as well as those located farther away from ground zero. Given the sudden onset, no-notice circumstances under which such ef- forts must be mounted, it is likely that the farther away from the impact zone, the better organized the health and medical response will be, given mostly to the opportunity to implement established protocols and the dis- tance that separates those outlying communities from the chaos and con- fusion wrought by the terrorist attack. In their description of the RTR system for spontaneous coordination of an improvised response to an IND detonation or other acute radiologi- cal emergency, Hrdina et al. note the importance of establishing not only 

APPENDIX I 231 spontaneously located triage and treatment sites, but based upon their location, utilizing predetermined assembly sites based on geographical proximity to render more definitive stabilizing care and initiate transport to definitive medical facilities. [25] This conceptual approach to develop- ing a spontaneous response to events as disruptive as an IND detonation can be implemented only with coordination of all of the emergency re- sponse system elements described previously. Emergency management agencies will need to help coordinate the “reception” of incoming casual- ties, most of whom are evacuating under their own power, some of whom will require medical attention, treatment, diagnosis, and manage- ment. Law enforcement presence will be important to coordinate people movement and to keep order. EMS transport units will be necessary to help move more severely affected patients to definitive care sites. Medi- cal personnel will be required to initiate life stabilizing and sustaining care. Public health authorities will be needed to help track patient expo- sures, get contact information for sharing of further public health infor- mation, particularly information related to potential exposure concerns. Emergency management leadership will likely be needed to help coordi- nate the colocation of such services, helping to identify the sites, and the resources required to manage the delivery of care under such circum- stances. This is particularly important, as one of the key early actions required of emergency management will be coordination of messaging regarding the importance of shelter-in-place strategies that are anticipat- ed to be able to save thousands of lives and contribute to limiting the ab- solute number of patients who may ultimately require health and medical evaluation and treatment. By being linked into this emergency response system, the health care coalition will be able to take advantage of the information management and communications tools utilized by emergency management. In addi- tion to using these platforms to share actionable information with the affected population, direct coordination with the EOC will also be im- portant in helping to procure the additional resources needed to respond to the catastrophic event. It is important to emphasize that by coordinat- ing such messaging, the EOC, which will already be overwhelmed with information and data input, can better prioritize the request for resources that come as “bundled” requests from health care coalitions, and not as disparate requests for the same types of resource needs repeated by hos- pital after hospital in any given region. Linkages to the EOC, where there will also be public health participation and representation, can be used to broadcast early information regarding special medical considerations, 

232 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK such as describing the specific needs of suspected or confirmed irradiated patients. Such information would be particularly important to share with outlying communities who are likely to see the migration of patients away from the epicenter of the event and toward those communities, and could begin to prepare for the arrival of irradiated patients. It would also serve as the opportunity to begin to mobilize other “specialty network coalitions,” coalitions of response organizations that can provide specific surge capability, for example those related to burn care and radiation injury management. Two regional burn consortia that could provide assistance to the NCR include the Eastern Regional Burn Disaster Consortium, based at the Burn Center at St. Barnabas Hospital (New Jersey), which includes 27 burn centers along the East Coast locat- ed from Maine to DC/Maryland [26] and the Southern Burn Disaster Program, operationally based in Birmingham, Alabama, and incorporat- ing burn facilities located from Virginia to Texas. [27] In addition, the Radiation Injury Treatment Network (RITN), which provides compre- hensive evaluation and treatment of radiation injured patients, and has been extensively engaged in IND planning and response efforts, would also be activated. [28] Whereas the close-in health care coalitions would likely be over- whelmed with patient care delivery, acquisition of needed resources, and protection of existing infrastructure, the ability to relay this situational awareness to the State EOC would help to facilitate activation of the aforementioned coalitions, and would likely trigger the request for acti- vation of the National Disaster Medical System (NDMS) and invoke the participation of the Federal Coordinating Center (FCC) to assist in the receipt, triage, staging, tracking, and transport of victims of this large- scale catastrophic event. [29] Assisting Response and Recovery—“Network-Centric” Coalitions The IND detonation scenario will result in infrastructure damage limited to a circumscribed geographical area and, depending on prevail- ing weather conditions, creation of a dangerous fallout zone that will ex- tend for a much larger distance, posing danger to many more citizens who will quickly be at risk for radiation exposure. Given that the charac- teristics of such an event will change rapidly over time, and in light of the importance of public messaging described earlier, a very important aspect of the response, and recovery, will be how effectively critical in- 

APPENDIX I 233 formation will be authenticated, broadcast, and updated. The progression of health care coalition development and cross-jurisdictional coordina- tion, as exemplified in the progress being made by the DC, suburban Maryland, and northern Virginia health care coalitions, demonstrates the importance of pursuing the concept of “networks of networks” in achiev- ing the capabilities required for robust and resilient community response to catastrophic disaster. Network centric, or “netcentric,” refers to the development of a “continuously-evolving, complex community of people, devices, infor- mation and services interconnected by a communications network to op- timize resource management and provide superior information on events and conditions needed to empower decision makers.” [30] A concept of network centric warfare was introduced to the Department of Defense in the mid- to late 1990s. [31] There are four distinct components of this approach: (1) A robustly networked force improves information sharing; (2) information sharing and collaboration enhance the quality of infor- mation and shared situational awareness; (3) shared situational awareness enables self-synchronization; and (4) the above dramatically increase mission effectiveness. The deemphasizing of traditional hierarchical command and control approaches to incident management, and the recognition that spontaneous decision making will be effective in the setting of horizontal information flow, matches well with the potential role that health care coalitions could and should play in response to an IND event. Health care coalitions that organize to form regional networks can improve communications of resource needs and provide situational awareness. The goal of such networks will be to enhance the response regarding management of the unstructured intake of arriving patients as well as providing for the intensive medical support irradiated patients will need under such circumstances. In the first hour to hours, during which time event characterization will be important, effort will be fo- cused on projecting the location and direction of the fallout plume and sharing this information with the public. Hours after the detonation, to the first day or days, information provided to those who require radiation screening, or more definitive medical attention, will become most im- portant. While this information will be of significant importance in the close-in communities affected by the blast, because of the forecast popu- lation movement anticipated as occurring as a result of such an attack, the surrounding communities will play an increasingly important role in supporting the needs of this migrating population. 

234 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Those close-in communities that are geographically adjacent to the ground zero impact zone will struggle to accomplish the emergency re- sponse functions related to security, fire suppression, search and rescue, patient care delivery, and other fundamental response efforts. Those communities that are farther away from ground zero, the unaffected “col- lar communities,” will have an enormous responsibility to support com- mand and control functions, both hierarchical and vertical, and to support the lost infrastructure in the affected communities. This may include not only the communications infrastructure, but much of the emergency re- sponse mechanism that may either be directly impacted by the event or consumed by the enormous response that is likely to be required. Collar- community health care coalitions may be able to broaden their network of communications capabilities, coordinating communication and alloca- tion requests that accommodate the needs of the impact communities. Perhaps most importantly, collar-community coalitions will be required to ramp up procedures for managing the influx of surge patients (trauma, radiation, combined, non-affected but requiring “routine” emergency care, etc.) that are certain to present seeking medical care and attention. As patients, care needs become better defined, and the stratification of care is conducted along the surge capacity framework ranging from con- ventional surge to contingency and crisis surge responses, the outlying health care coalitions will be able to prioritize information shared with the state EOC and federal government regarding resource allocation needs. This coalition-to-coalition networking and coordinated response, as well as coalition-to-state coordination, is only possible with the devel- opment of robust, mature health care coalitions that are fully integrated partners in their community emergency response system. CONCLUSION A catastrophic emergency, of which an IND detonation may be the prototypical example, demonstrates the importance of developing robust emergency response systems that have the capacity and capability to manage a complex set of response requirements. In this type of event, the impact area affected by the detonation will be surrounded by an intact infrastructure. The role of the health care coalitions will be particularly important in helping to coordinate information flow supporting real-time situational awareness, and interpreting data pertaining to resource utiliza- tion and initiating the request for resource needs. Acquiring and sharing 

APPENDIX I 235 such data will need to occur with the support of affiliated emergency management agencies. Such efforts will be critically important to the public health and health care response faced by communities that are ge- ographically situated immediately outside of the blast zone following an IND attack. Lessons learned from the decade-long maturation of health care coalition development in and around the National Capital Region—in the District of Columbia, northern Virginia and the close in suburbs of Maryland—highlights the attributes of such coalitions and establishes some of the benchmarks that may be useful to other communities seeking to develop the same level of capability and coordination. In the event of catastrophic attack or natural disaster that disrupts civil society, the prior- ity to return to normalcy, or at least a “new normalcy,” will be of utmost importance. And the attempt to minimize the adverse health care conse- quences related to such an event will make the difference between whether or not a response is viewed as successful. Strong, robust, and well-managed health care coalitions will play an important role in en- hancing the response to any catastrophic event, and may be uniquely po- sitioned to be able to coordinate key response actions that cross jurisdictional lines. By doing so, they will be immensely useful in assist- ing to relieve the burden on those areas most severely impacted. TABLE I-4 Health Care Coalition Functions, Roles, and Challenges in IND Response Implementation Core Coalition Priorities in IND Functions Response Potential Challenges Regional planning Establish situational Early priorities will include and collaboration awareness amongst participation of emergency coalition members, response system partners in and across regional assisting coalition boundaries to include members—assistance from neighboring coalitions; public safety agencies to coordinate strategic manage surge response and and tactical security needs; assistance health/medical re- from Public Health authori- sponse plans ties to establish patient regis- try and contact tracing mechanism; emergency man- agement for assistance in 

236 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Implementation Core Coalition Priorities in IND Functions Response Potential Challenges resource procurement via coordination with lo- cal/regional/state EOCs; lo- cal/regional/state government leadership in establishing key crisis messaging regarding life-saving and sustaining actions Communication Report bed, staff and Communications networks and information resource availabilities; for both voice and data may management coordinate with local, be significantly impaired regional and state EOCs Personal protective Establish uniform pro- Relatively limited supplies of equipment (PPE) tocols for staff protec- PPE may be rapidly exhaust- tion from radiological ed; tactical decisions regard- hazards; coordinate ing greatest need for PPE with other members of may occur amongst emergen- emergency response cy response system partners, system (public safety possibly resulting in re- agencies) assignment of available resources Critical infrastruc- Ensure safety of drink- Water pressures likely to be ture protection ing water sources; low; widespread power out- implement backup ages expected, requiring sus- power support; assess tained operations with limited structural integrity of water and requirement for health care facilities backup power generation; re- located closest to im- supply of water and fuel not pact area likely; lack of fuel will sig- nificantly hamper responder relief efforts, including the need to transport patients to outlying facilities Decontamination Decontaminate incom- Water may not be available and detection ing patients per estab- for decontamination; health lished protocols; care facilities have limited implement radiation capability to provide dry de- detector capabilities at contamination; few health 

APPENDIX I 237 Implementation Core Coalition Priorities in IND Functions Response Potential Challenges health care institutions care facilities have portal (portal or hand-held); radiation detectors, hand held ensure that staff are survey monitoring will be appropriately decon- time consuming taminated, and priori- tize public safety staff decontamination, if needed Surge capacity and Implement surge Health care facilities will capabilities response strategies face unprecedented demands accounting for crisis for service care delivery, yet standards of care must also maintain services response—transition to existing patients and those to contingency and who present with other emer- crisis surge response gencies unrelated to the im- protocols mediate effects of the detonation event Pharmaceuticals Access and distribute Transportation infrastructure and materials available local/regional may impede physical move- management equipment, supplies ment of materiel from central and pharmaceuticals; warehouse to health care fa- initiate requests for cilities; ability to develop additional materiel demand forecasting based on based on actual and projected needs limited projected patient care needs Security Need to establish secu- Limited personnel will not be rity of health care fa- able to be augmented by law cilities; need to enforcement agencies, which promote passage of will be otherwise engaged in hospital staff, both the response; staff without direct health care pro- proper credentialing may viders and non-health have difficulty crossing po- care support service lice lines; spontaneous vol- employees, across unteers will require police lines to be able management and coordina- to report to work tion, including credentialing (numbers of volunteers may be limited due to concern 

238 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Implementation Core Coalition Priorities in IND Functions Response Potential Challenges regarding potential exposure to radiation) Mass fatality Prepare for mass fatal- May be overwhelming de- management ities that result from mand for external service IND attack support; health care facilities will have to be prepared to store and catalogue decedents from an event, including those that may have radiolog- ical contamination, on site REFERENCES 1. Homeland Security Council Interagency Policy Coordination Sub- committee for Preparedness and Response to Radiological and Nu- clear Threats. Planning Guidance for Response to a Nuclear Detonation. 1st ed; January 2009. 2. National Security Staff Interagency Policy Coordination Subcommit- tee for Preparedness and Response to Radiological and Nuclear Threats. Planning Guidance for Response to a Nuclear Detonation. 2d ed; June 2010. 3. Buddemeier BR, Valentine JE, Millage JE, Brandt LD, National Capital Region Key Response Planning Factors for the Aftermath of Nuclear Terrorism. Performed under the auspices of the US Depart- ment of Energy by Lawrence Livermore National Laboratory for FEMA and Department of Homeland Security, November 2011. 4. Murrain-Hill P, Coleman CN, Hick JL, et al. Medical Response to a Nuclear Detonation: Creating a Playbook for State and Local Plan- ners and Responders. Disaster Med Public Health Prep. 2011; 5(1): S89-S97. 5. Coleman CN, Weinstock DM, Cassagrande R, et al., Triage and Treatment Tools for Use in a Scarce Resources—Crisis Standards of Care Setting after a Nuclear Detonation, Disaster Med Public Health Prep. 2011; 5(1):S111-S121. 

APPENDIX I 239 6. Gostin LO, Hanfling D, National preparedness for a catastrophic emergency: crisis standards of care. JAMA. 2009 Dec 2; 302(21):2365-2366. 7. Hanfling D, Altevogt BM, Gostin LO, A Framework for Cata- strophic Disaster Response. JAMA 2012 Aug 15; 308(7):675-676. 8. Barbera JA, MacIntyre AC. Medical Surge Capacity and Capability: A Management System for Integrating Medical and Resources Dur- ing Large-Scale Emergencies. 2nd ed. Washington, DC: US Dept of Health and Human Services; 2nd edition, 2007. 9. American Hospital Association, Model Hospital Mutual Aid Memo- randum of Understanding, available at http://www.aha.org/ content/00-10/ModelHospitalMou.pdf, accessed on January 13, 2013. 10. Metropolitan Washington Council of Governments, Planning Guid- ance for the Health System Response to a Bioevent in the National Capital Region, September 2001. 11. Northern Virginia Hospital Alliance, 9/11/01–9/11/11, available at http://www.novaha.org/nvha/assets/File/9.11.01%20to%209.11.11.pdf accessed on January 13, 2013. 12. Northern Virginia Emergency Response System, available at http://nvers.org/about accessed on January 13, 2013. 13. Henderson DK, Malanoski MP, Corapi G, et. al. Bethesda Hospitals’ Emergency Preparedness Partnership: a model for transinstitutional collaboration of emergency responses. Disaster Med Public Health Prep. 2009; 3(3):168-173. 14. State of Maryland, Department of Health and Mental Hygiene, avail- able at http://dhmh.maryland.gov/newsroom/Pages/First-Regional- Hospital-Mutual-Aid-Agreement.aspx, accessed on January 13, 2013. 15. Barbera JA, MacIntyre AC. The Health Care Coalition in Emergency Response and Recovery. Washington, DC: US Dept of Health and Human Services; May 2009. 16. 2009 Presidential Inauguration Regional After-Action Report Sum- mary, prepared under the auspices of FEMA Grant Programs Direc- torate, US Department of Homeland Security, August 2009. 17. Ibid. p. 30. 18. Ibid. p. 32. 19. NCR Hospital Event Information Sharing Procedure, personal com- munication, Zachary Corrigan. 

240 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK 20. Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC, The National Academies Press, 2012. 21. Hanfling D, When the Bells Toll: Engaging Health Care Providers in Catastrophic Disaster Response Planning, Southern Med Journal 2013; 106(1):7-12. 22. Carrier E, Yee T, Cross DA, Samuel DR, Emergency Preparedness and Community Coalitions: Opportunities and Challenges, HSC Re- search Brief No. 24, Center for Studying Health System Change, November 2012. 23. Office of the Assistant Secretary for Preparedness and Response, Hospital Preparedness Program, National Guidance for Health Care System Preparedness, Capability 1, January 2012. 24. Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conven- tional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009; 3:S59-S67. 25. Hrdina C, Coleman CN, Bogucki S, et al. The “RTR” Medical Re- sponse System for Nuclear and Radiological Mass Casualty Inci- dents: A Functional Triage-Treatment-Transport Medical Response Model, Prehospital Disast Med 2009; 24(3):167-178. 26. Eastern Regional Burn Disaster Consortium, available at http://www. burndisasterconsortium.com/aboutus.htm, accessed on January 13, 2013. 27. Kearns R, Holmes J, Cairns B. Burn Disaster Preparedness and the Southern Region of the United States. Southern Med Journal. 2013; 106(1):69-73. 28. Radiation Injury Treatment Network (RITN), Concept of Operations. Available at: http://ritn.net/WorkArea/DownloadAsset.aspx?id=2147 483905, accessed on January 13, 2013. 29. National Disaster Medical System, Federal Coordinating Center Guide, June 2010. 30. Net-centric definition, Wikipedia. Available at http://en.wikipedia.org/ wiki/Net-centric, accessed on January 13, 2013. 31. Department of Defense, Net-Centric Environment Joint Functional Concept, Version 1.0, April 2005.