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

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9 Roles of Regional Health Care Coalitions in Planning and Response Key Points Made by Individual Speakers x Among other joint functions, health care coalitions pool and share re- sources in order to receive and care for mass casualties, establish re- dundant communications, share situational awareness and scarce resources, and provide palliative care for victims not expected to sur- vive. x Regional health care coalitions could extend beyond the traditional partners to include long-term care facilities, community health centers, behavioral health care, and many others. This would considerably en- hance surge capacity as long as health care staff is properly trained. x Nascent health care coalitions now exist throughout the United States, but work needs to be done to help them mature and to interconnect them, especially across state lines. Regional coalitions should form a web of interconnected coalitions to further augment their capabilities and network. x The Radiation Injury Treatment Network (RITN) has the capacity to ac- cept and care for 30,000 radiation-injured patients; however, it is not yet integrated with existing health care coalitions. RITN is eager to become more involved with health care coalitions, whether through local public health, hospitals, or nontraditional care settings. The utter reality of an improvised nuclear device (IND) event, in any city, is that all hospital and health care offices in close proximity will be overwhelmed. However, through collaborations of hospitals, long-term care facilities, community health centers, and other alternatives, multiple jurisdictions and regions can alleviate the burden of patient load from close-proximity hospitals and redirect patients, resources, and staff to other locations and institutions that are more capable or less stressed. 81 

82 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK This can dramatically increase the surge capacity of a region if done cor- rectly, but the collaboration cannot be formed overnight. Many health care coalitions have existed and evolved for years, but they still have room for important growth and adaptation that could assist affected communities and entire regions after an IND attack. IMPROVING HOSPITAL PREPAREDNESS With casualties running into the tens of thousands or hundreds of thousands, responding to an IND attack would be a monumental task that could not be effectively handled by any single hospital or health care organization working in isolation. David Marcozzi of the Office of the Assistant Secretary for Preparedness and Response spoke of the office’s desire to develop a comprehensive national preparedness and response health care system that is coordinated to meet local, state, and national needs during public health emergencies. The system he envisions has dual uses, is financially sustainable, and is undergirded by a population- based health care delivery model. However, he admits that his goal can- not be achieved at a time when all trends point to hospitals contracting and striving to eliminate surge capacity. His goal also cannot be achieved through his agency’s hospital preparedness program budget, which dis- penses only $347 million in grants and cooperative agreements to a health care system that is much larger—roughly $2.5 trillion in annual health expenditures. But Marcozzi said that his goal of hospital prepar- edness is achievable through building regional health care coalitions composed of traditional and nontraditional care providers that combine their surge capacity. More surge capacity can also be gained by reducing hospitals’ current patient load through re-triaging or normal attrition. Health care coalitions are formal collaborations—among hospitals, public health departments, emergency management agencies, and many other health care entities in a given region—that are organized to respond to mass casualty and catastrophic health events. The coalitions extend beyond the traditional partners to include long-term care facilities, com- munity health centers, and many others (see Box 9-1). By fostering the creation of multifaceted health care coalitions, Marcozzi’s hospital pre- paredness program strives to better align health care and public health. 

ROLES OF REGIONAL HEALTH CARE COALITIONS 83 BOX 9-1 Potential Partners in Health Care Coalitions from David Marcozzi’s Presentation x Hospitals x Long-term care facilities x Urgent care facilities x Alternative care sites x Behavioral health care x Community-based organizations x Community health centers x Dialysis facilities x Emergency medical services x Emergency management x National Disaster Medical System x Primary care providers x Public health x Private insurance x Home health agencies x State medical societies x Volunteers Immediate Bed Availability One way to obtain more surge capacity is for hospitals to re-triage (i.e., reverse triage) their existing patients by safely discharging them to coalition partners or home. Evidence shows that this is achievable. In an influential study, Kelen and collaborators (2006) developed a disposition classification system that categorized inpatients according to their suita- bility for immediate discharge. Through a tabletop exercise, the system succeeded at increasing hospital capacity while minimizing the risk of adverse effects. Furthermore, reverse triage succeeded during a real-life public health emergency in Sydney, Australia, in 2012 (Satterthwaite and Atkinson, 2012). Another way to increase surge capacity is by normal attrition. Because the average length of stay in hospitals is 5 days, ac- cording to the Centers for Disease Control and Prevention, hospitals are every day discharging approximately 20 percent of their bed volume, Marcozzi said. Marcozzi’s goal is for 20 percent of hospital bed capacity to be available for a health emergency within 4 hours. If there were 100 coali- tions across the nation, each with 1,000 beds, creating a 20 percent surge capacity would provide 200 beds per coalition, for a total of 20,000 beds 

84 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK becoming available. Altogether the experience shows that medical surge, whether through re-triaging or attrition, is evidence-based, operationally tenable, and ethical. It is also economically sustainable because the sys- tems being put in place increase the efficiency of overall operations and increase referrals from coalition partners, thereby increasing hospital revenues, regardless of whether there is a true public health emergency. NATIONAL CAPITAL REGION HEALTH CARE COALITIONS Dan Hanfling of Inova Health System in Virginia spoke about his white paper (see Appendix I) on the functions of the National Capital Region (NCR), a regional health care coalition forged from three previ- ously separate coalitions serving the Washington, DC, metropolitan area. The coalition partners are x Northern Virginia Hospital Alliance, consisting of 14 hospitals and 6 freestanding emergency departments; x D.C. Emergency Healthcare Coalition, consisting of 7 acute-care hospitals and 40 skilled nursing facilities and community health centers; and x Maryland Institute for Emergency Medical Services System Re- gion V, consisting of 13 hospitals and 1 freestanding emergency department. The NCR coalition was activated for the presidential inauguration of 2013, during which coalition partners worked together to plan for and coordinate emergency response as well as developing incident action plans and other documents. Following an IND attack, the NCR coalition expects to perform numerous functions: receive mass casualties through medical surge capacity; establish communications resistant to the ac- companying electromagnetic pulse; stockpile resources needed for an emergency (e.g., radiation detection equipment, respirators, and decon- tamination supplies); share situational awareness; contribute various are- as of expertise (e.g., burn care and pediatric care); provide palliative care for victims not expected to survive; share scarce resources; and manage mass fatalities in the first few days before additional help arrives from DMORT (the Disaster Mortuary Operational Response Team, organized by ASPR). 

ROLES OF REGIONAL HEALTH CARE COALITIONS 85 The partners in the coalition are to be notified under the following criteria: judgment by health care leadership that notification of the other NCR partners is warranted; a single mass casualty event that involves 40 or more patients who require transportation to specialty hospitals (pediat- rics, trauma) throughout the NCR; a single hazardous materials event involving 30 or more patients that may require decontamination; or an event involving a suspected or confirmed biological agent. Notification would also be required when a fire or emergency medical services agen- cy has activated a mass casualty unit, task force, or the equivalent, or an agency or health care facility has accessed or requested a CHEMPACK (containing antidotes to toxic nerve agents)1 or MMRS (Metropolitan Medical Response System)2 pharmaceutical cache. Just as the NCR was forged among three formerly separate coali- tions, the NCR itself needs to evolve and become part of other regional coalitions. This kind of flexibility would make the NCR health care coa- lition “network centric.” A network-centric community is continuously evolving and interconnected by communications, which improves mis- sion effectiveness and optimizes resource management (see Appendix I). Being network centric is essential for an IND scenario in which one part- ner, such as the District of Columbia, is destroyed by the blast and the fallout patterns heavily disrupt another coalition partner. The remaining partner will need to become part of another regional coalition to handle the resulting mass casualties. ROLES FOR OUTLYING COMMUNITIES Eric Toner of the UPMC Center for Health Security painted a stark picture of the post–IND attack mayhem that would ensue in outlying hospitals in the absence of a health care coalition. Staff would be in short supply and unprepared to deal with radiation-related injuries, supplies would run short, surge capacity would be exhausted, and hospital func- tioning would near gridlock. Alternative care sites would be ill-equipped to receive patients or to receive volunteer medical staff because of the lack of credentialing. 1 See http://www.chemm.nlm.nih.gov/chempack.htm (accessed May 1, 2013). 2 See http://www.bt.cdc.gov/planning/CoopAgreementAward/presentations/mmrs-oep10 minbriefing-jim11.pdf (accessed April 5, 2013). 

86 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK Toner then outlined the essential features of a health care coalition: x Includes most acute-care hospitals in the region x Includes or is connected to public health and emergency medical services x Has a formal structure and meets regularly x Collaborates around planning, exercises, purchasing, and response x Distributes patient load x Shares staff, equipment, and supplies x Coordinates the use of volunteers and other health care facilities x Shares clinical expertise, such as trauma care, burn care, or radiation Toner and colleagues conducted a survey of almost 5,000 hospitals nationwide, asking them about their participation in health care coalitions (Rambhia et al., 2012). Although only 10 percent of hospitals responded, they constituted a random sample. The authors found that the 477 re- spondents were members of 314 unique coalitions. Ninety-five percent of the responding hospitals participated in a coalition. Equal numbers of the coalitions were headed by public health agencies and by individual hos- pitals. Most of the coalitions were in a nascent stage. The participants in coalitions were, as expected, from public health, emergency manage- ment, emergency medical services, and hospital associations. Relatively few coalitions included primary care doctors, home health agencies, phy- sicians’ practices, state medical societies, and health care clinics, which could indicate an opportunity for growth and inclusion for those coali- tions missing these areas. Almost all coalitions reported joint planning, joint training and drills, regular meetings, formal links, joint purchasing, and joint response to mass casualty events. Somewhat fewer reported sharing bed availability and surge capacity, participating in a local emer- gency operations center, coordinating alternative care facilities, and co- ordinating use of volunteers. Fewer than 25 percent reported contributing money or in-kind resources. In the event of an IND detonation in a major city, Toner said there will be a need not only for one health care coalition, but also for inter- connected networks of health care coalitions, making them network cen- tric. Toner envisions a cascade of patient movement as each member hospital or facility within a coalition becomes full. The spillover from the first hospital is sent to a second hospital or health facility in the coalition, which, in turn, fills up and sends away or discharges patients to a third site, which is in another coalition, and so on. Coalitions are central to 

ROLES OF REGIONAL HEALTH CARE COALITIONS 87 federal health care preparedness policy. Nascent coalitions now exist in most U.S. locations, but in Toner’s opinion work needs to be done to help them mature and become interconnected, especially across state lines. Integration of the Radiation Injury Treatment Network (RITN) into Local, Regional, and National Response As previously discussed in Chapter 7, RITN is a network of 51 aca- demic medical centers, 6 blood donor centers, and 7 umbilical cord blood banks. It has published treatment guidelines for acute radiation syndrome as well as guidelines for determining eligibility for and conducting a stem cell transplant, according to speaker and RITN medical advisor David Weinstock of the Dana-Farber Cancer Institute. As part of its pre-event planning and training, RITN has developed standard operating procedures at each of its centers, site readiness assessments, annual tabletop exercises, and an annual training and educational requirement, under which more than 5,000 of its affiliated staff have received basic to intensive radiation training. RITN has the capacity to accept and care for 30,000 patients; how- ever, it is not yet integrated with existing health care coalitions at a local and regional level to ensure that these organizations can tap more readily into RITN’s network, Weinstock said. RITN is eager to become more involved with health care coalitions, whether through local public health agencies, hospitals, or nontraditional care settings. Besides accepting patients after an IND attack, RITN physicians could consult through tel- emedicine or other vehicles to provide just-in-time training to treatment providers close to the site of detonation. RITN is also interested in shar- ing supplies, staff, and space. It is building up its stock of granulocyte colony stimulating factor (GCSF), a cytokine, through a user-managed inventory, which is like a stockpile but avoids the problem of replacing unused but expired medications (see Chapter 8). RITN’s goal is to have ready access to 20,000 doses of GCSF. Weinstock noted that his organi- zation hopes to partner with academic medical centers that are not cur- rently participating in RITN. 

88 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK EXERCISING AN IND INCIDENT AS A REGIONAL COALITION Jenny Atas, the medical director of Region 2 South Healthcare Coali- tion, described her experience with the coalition’s first-ever full-scale IND exercise. Her state of Michigan is already divided into eight emer- gency management regions, each of which functions essentially as a health care coalition and has an active advisory board. Atas said that her coalition decided to conduct the IND exercise because none of the coali- tions in the state had a coordinated regional plan for responding to an IND. Much of the civil defense planning is based on the Cold War stra- tegic thermonuclear detonation scenarios that are no longer applicable. For example, the concept of a fallout shelter worked well with the advanced warning of incoming missiles, but its applicability is less clear for an attack that occurs without any notice, which is far more likely in current times. Atas described the planning of Operation Shared Burden, which had two phases, with Phase 1 devoted to a tabletop exercise preceded by an education seminar. The education seminar was conducted by a subject area expert from the U.S. Department of Energy Center for Radiologi- cal/Nuclear Training. The seminar also featured the state’s Burn Surge Plan, operated by the University of Michigan, which had taken 5 years to develop, as well as distribution of a library of IND reference materials. The tabletop exercise used the same scenario as the full-scale exercise. Its purpose was to identify the level of preparedness and planning needed for a real IND detonation. Participants during the exercise discussed their organizations’ roles and responsibilities, policies, plans, and procedures. The second phase, which was scheduled several months after phase 1, was the full-scale exercise, held on October 4, 2012. The scenario was for a ground burst of a 10-kiloton IND detonated at 1:00 p.m. on a work- day in the center of Detroit. The scenario assumed 14,000 fatalities, 30,000 seriously injured victims in the severe damage zone and moderate damage zone, and 10,000 minor injuries. It also assumed a loss of elec- trical equipment from the electromagnetic pulse (EMP), three EMP- and blast-related airline crashes, the impassability of roads and expressways, the loss of utilities, the closing of the Canadian border, and severe dam- age to rail lines. While it assumed the preservation of cellular telephone service, a severe overloading of circuits was assumed. Thirty-seven hos- pitals participated, as did 12,000 participants, who included 10,700 per- sonnel (including federal, state, regional, county, and city employees), 

ROLES OF REGIONAL HEALTH CARE COALITIONS 89 BOX 9-2 Objectives of the Full-Scale Exercise—Michigan Region 2 South Regionwide Objectives x Test and evaluate primary and secondary communication tools x Test and evaluate regional casualty transport system x Test and evaluate patient tracking system x Test and evaluate decontamination capabilities Objectives for Individual Hospitals x Test and evaluate hospital external disaster plans x Test and evaluate hospital evacuation/shelter-in-place plans x Test and evaluate hospital emergency operations centers x Test and evaluate decontamination capability x Test and evaluate primary and secondary communication systems 1,100 actors playing patients, 134 evaluators, and 58 controllers. The objectives of exercise are listed in Box 9-2. Lessons Identified According to the after-action report (Operation Shared Burden, 2012), the participants were highly positive about the experience. The report found good participation and problem solving, good learning ex- perience, strong teamwork, and effective working relationships within and between organizations and facilities. The report noted that organiza- tions showed great adaptability and flexibility under the difficult condi- tions created by the scenario, good internal and external communications using all systems, strong supplementary help through RACES3 operators, proactive public information, good patient tracking through the EMTRAC system,4 and well-prepared participants who were knowledgeable about their roles and responsibilities. 3 RACES is the Radio Amateur Civil Emergency Service manned by volunteer opera- tors who are licensed and certified by Federal Emergency Management Agency and the Federal Communications Commission. The purpose of RACES is to ensure communica- tion during drills, exercises, and emergencies. 4 See http://www.emtracsystems.com (accessed July 1, 2013). 

90 NATIONWIDE RESPONSE ISSUES AFTER AN IND ATTACK The areas for improvement and follow-up activities included the following: x Identify communication systems and pathways x Assign priority of message flow because participants noted that they received multiple copies of the same message x Establish plans and procedures for a virtual joint information center because it can be quickly activated x Review state burn surge plans, procedures, supplies, and training because many participants were unfamiliar with them and sup- plies were insufficient x Develop staffing patterns for extended operations for the region- al medical coordination center (RMCC) to ensure that multiple shifts are staffed round the clock x Review plans to coordinate RMCC with city and county emer- gency operations centers SUMMARY Responding to an IND attack is such an enormous task that it could not be effectively handled by any single hospital or health care organiza- tion working in isolation. Many speakers have supported the concept that true regional planning would be necessary to adequately and effectively respond to such a large incident. Health care coalitions have the potential to serve as convening bodies for much of this regional planning to take place. Newly developing health care coalitions have more opportunity to respond to an IND because they can pool and share their resources more easily up front. Robust health care coalitions, if sufficiently large, have the capacity to receive mass casualties; establish communications re- sistant to the EMP; share situational awareness and scarce resources; provide palliative care for victims not expected to survive; and manage mass fatalities, among other joint functions. Even more surge capacity can come with the inclusion of coalition partners outside of the tradition- al medical setting, such as long-term care centers, nursing homes, and others, making it important to have a strong convening body for collabo- ration. By failing to consider nontraditional partners, many coalitions have limited their scope and missed an excellent opportunity for increas- ing resources and surge capacity by broadening the coalition body. 

ROLES OF REGIONAL HEALTH CARE COALITIONS 91 Reverse triaging hospital patients can also increase surge capacity, by effectively discharging healthier patients who do not need acute care to make way for IND casualties. One large health care coalition example is RITN, which focuses on the special needs of irradiated patients and consists of more than 50 medical centers nationwide. If needed, these centers could accept approximately 30,000 patients around the country after a disaster. RITN is eager to partner with regional and local health care coalitions to augment the national response capability in an IND event.