state coalition of health departments, children’s specialty hospitals, regional hospitals, emergency responders, first responders, and local community pediatricians who are coming together to provide surge capacity in a region of the country that has very limited surge capacity to deal with children. The network has developed a mission and is working to operationalize and exercise the surge network, pointing to an earlier referenced challenge about the lack of pediatric focused exercises and drills. There are numerous challenges to managing this multistate coalition consisting of a wide variety of players, Rucks said. And while regions are becoming better prepared to deal with large-scale events (e.g., hurricanes), Rucks suggested that they are not as well prepared to deal with the smaller-scale issues that overwhelm the needs of one or more local pediatric specialty hospitals.


Richard Hunt, senior medical advisor for the National Health Care Preparedness Programs at the Office of the Assistant Secretary for Preparedness and Response (ASPR), provided federal-level perspective on health care coalitions. Currently, the U.S. health care delivery system is focused on cost reduction. This includes service retraction, which results in just-in-time operating principles and staffing. Although U.S. health systems emergency preparedness and response mechanisms are established and operational, they are fragmented and are restrained by a just-in-time approach, Hunt said. The country continues to experience overcrowding in emergency departments with limited mechanisms to reallocate patients throughout the hospital or the community. Although the concept of surge capacity has been discussed for well over a decade, a March 2013 Government Accountability Office report still highlights surge capacity as a challenge. Work has been done on allocation of scarce resources and introducing the concept of crisis standards of care, where population outcomes would be optimized over individual patient outcomes (Devereaux et al., 2008; IOM, 2012). Although this difficult conversation is further complicated when children are introduced to the discussion, it is an important piece in planning if a scenario occurred where real limitations were placed on resources or capabilities.

Hunt described some of the financial realities of disaster preparedness and response. National health care expenditures grew 4

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