Total Quality Management, Journey to Excellence, Continuous Quality/Process Improvement, and Ethical Issues

Topic 3 DQ 2Urinary tract infections (UTIs) are more susceptible in patients that have an indwelling catheter for longer periods of time, versus patients with short-time use (Letica-Kriegel et al., 2019). For this reason, the Center for Medicare and Medicaid Services (CMS) added Catheter-Associated Urinary Tract Infection (CAUTI) to their list of health care-acquired conditions (HACs), and so that hospitals create risk management strategies to prevent this from happening in patients (CMS, 2021).Henry Ford Allegiance Health has implemented a policy titled, “Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) to ensure that indwelling urinary catheters are only left in place as long as medically necessary, strict maintenance of the catheter is followed, and indwelling catheterization should be avoided if other means are available and appropriate (HFAH, 2021). This policy is to be used by physicians and nursing staff, as well as families and patients that are educated in the insertion of or in the care of catheter use (HFAH, 2021). It covers the different kinds of catheterization available and indications for catheter use, as well as maintenance of and urine collection of urinary catheters and can be accessed via the policy portal on the OneHenry website. If a patient were to be diagnosed with a UTI while having a urinary catheter, this would be reported using the RL reporting process and looked into to understand what/where/when/why this was caused and how it could have been prevented. Overtime, this information can be used to amend the policies as necessary to improve prevention.In my experience, I utilize this policy any time that we have a patient on the unit that utilizes any form of urinary catheterization. On our mental health unit, we can go weeks or months without coming across any form of urinary catheter, so when we do… it is important to refer to the policy to avoid CAUTI in our patients.The Center for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never events” from happening within their health care facilities? Support your response with a minimum two peer-reviewed articles.Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years. There should be a mix between research and your reflections. Add critical thinking in the posts along with research. Apply the material in a substantial way.

Multicultural Patient Education, Illiteracy, and Effective Communication

Topic 3 DQ 1Culture is the characteristics and shared ideas of attitudes, values, beliefs, and behaviors by a group of people (Nielsen-Bohlman et al., 2004). Patients’ belief could affect their health care decision (Falvo, 2011). Cultural misunderstanding between patients and providers contributes to patient dissatisfaction and poor quality of care. Cultural competence is the ability to understand and interact with patients from different cultures. To provide patient education regarding cultural competence, the nurses should understand patients’ culture including language, family, beliefs, and cultural differences.Language includes low health literacy and limited English proficiency. The nurses should offer an interpreter to break any communication barriers and provide education material at a sixth-grade or lower reading level. Family members play vital roles in patient education including contribution to decision-making, following treatment recommendations, and quality of care. The health care professionals should be aware of the patient’s family members who could affect patient care. The nurses should include family members during patient education. So that, family members could understand patients’ conditions and cooperate with the treatment regimen.Overall, health care professionals should separate their own cultural beliefs so they could tailor with patients’ cultures. It could make them to better understand patients’ culture in order to provide high-quality health careDiscuss a patient of another culture. How can the health care professional communicate in presenting patient education? Consider language, family, cultural differences, and method of communication.Using 200-300 words APA format with at least two references. Sources must be published within the last 5 years

External Influences on Consumer Choice

Advantages and disadvantages of different health care insurance plans.

Shifts in the U.S. Health Care System

1 current event or shift in the health care system

Response 1 by 11/11/2021

Response #1: If this were about Cystic Fibrosis, how would the responses be different to the questions in the Initial Post? Give a detailed explanation supporting your response.

Healthcare Emergency Management

Healthcare Emergency Management

Health Care at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Joint Commission on Accreditation of Healthcare Organizations © C

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opyright 2003 by the Joint Commission on Accreditation of Healthcare Organizations. All rights reserved. No part of this book may be reproduced in any form or by any means without written permission from the publisher. Request for permission to reprint: 630-792-5631. Health Care at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Joint Commission on Accreditation of Healthcare Organizations Joint Commission Public Policy Initiative This white paper is the second work product of the Joint Commission’s new Public Policy Initiative. Launched in 2001, this initiative seeks to address broad issues that have the potential to seriously undermine the provision of safe, high-quality health care and, indeed, the health of the American people. These are issues which demand the attention and engagement of multiple publics if successful resolution is to be achieved. For each of the identified public policy issues, the Joint Commission already has state-of-the-art standards in place. However, simple application of these standards, and other unidimensional efforts, will leave this country far short of its health care goals and objectives. Thus, this paper does not describe new Joint Commission requirements for health care organizations, nor even suggest that new requirements will be forthcoming in the future. Rather, the Joint Commission has devised a public policy action plan that involves the gathering of information and multiple perspectives on the issue; formulation of comprehensive solutions; and assignment of accountabilities for these solutions. The execution of this plan includes the convening of roundtable discussions and national symposia, the issuance of this white paper, and active pursuit of the suggested recommendations. This paper is a call to action for those who influence, develop or carry out policies that will lead the way to resolution of the issue. This is specifically in furtherance of the Joint Commission’s stated mission to improve the safety and quality of health care provided to the public. Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Table of Contents Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Part I. Enlist the Community in Preparing the Local Response . . . . . . . . . . . . . . . . . . . . . . 10 Enlisting the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Forging New Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 An Exemplary Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Getting There . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Part II. Focus on the Key Aspects of the Preparedness System that Will Preserve the Ability of Community Health Care Organizations to Care for Patients, Protect Staff and Serve the Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Define Surge Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Preserve the Organization – Protect the Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Ensure Care for the “Other” Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Manage the Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Consider the Threat to Mind, as well as Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Enlist the Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Identify Communication and Information Needs and Meet Them . . . . . . . . . . . . . . 31 Test, Learn, Improve and Be Ready . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 37 A Question of Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Sustainable Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Guiding the Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Knowing What Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 End Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Preamble But now, in the face of an atrophied public health infrastructure and lack of leadership and coordination among other emergency preparedness constituencies, hospitals and other health care organizations are being asked to step up their level of emergency preparedness involvement. This unfortunately is occurring at a time when many of those entities face severe resource constraints and may not always be able to manage current day-to-day patient care demands. It does not take long for complacency to settle in. Eighteen months after the September 11, 2001 attacks and the subsequent, insidious, selected and deliberate dispersion of anthrax spores, there are clear signs that the focus of American attention has long since moved on. The sense of urgency to prepare has now become a wait-and-see sense. Vigilance eventually gives way to ambiguity. Indeed, the two occasions during the past six months in which the national terrorism level has been raised to Orange (high threat) have generally provoked public mysticism as to what individuals should do to prepare. This confused state of non-readiness is what terrorists lay in wait for. And, the world in which we carry out our daily lives can change in an instant. At a recent national symposium on emergency preparedness, Jerome Hauer, acting assistant secretary of the Office of Public Health Emergency Preparedness of the Department of Health and Human Services (DHHS), remarking on the strong likelihood of another terrorist attack in the near future, said,“At the end of the day, it is medical care that will be needed.” But if medical care capacity is already in variable and sometimes scarce supply, planning for unexpected surges in demand becomes all the more critical. So, too, does funding and federal leadership for these efforts. This is not our world as we once knew it. It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday. Such systems make effective responses to emergencies possible, and they also serve as deterrents to actual attacks. And, they are needed – whatever the level of our sense of security – to facilitate the management of crises that seem to be becoming everyday occurrences. The purpose of this report is to frame the issues that must be addressed in developing community-wide preparedness and to delineate federal and state responsibilities for eliminating barriers, and for facilitating and sustaining — through leadership, funding and other resource deployment – community-based emergency preparedness across the United States. The concept of community-wide preparedness systems is new to most health care organizations. While most have long prepared and tested disaster plans, health care organizations have operated in isolation, and their disaster plans reflect this mindset. 4 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Introduction apparent, priority brought into sharp relief fundamental new needs for emergency preparedness that would call for leadership and coordination at the community level, which did not then, and largely does not now, exist. On the day that America experienced its worst violation at the hands of terrorists, the many “first responders” involved in rescuing, treating and protecting the thousands of people who were victimized, or had the potential to be, valiantly performed their jobs. But for many, their efforts were futile in the face of such enormous destruction. Emergency medical personnel and health care workers from nearby and far away were drawn to these scenes of destruction to lend their support and expertise. Hospitals in the vicinity of the World Trade Center, despite being overwhelmed by power outages, disabled telecommunications, and the rush of the injured and those fleeing the smoke-choked streets for shelter, were nevertheless able to summon a response. This does not gainsay the continuing extraordinary efforts of the three public safety agencies that this country has long relied on – law enforcement, fire and rescue, and emergency medical services. Nor does it ignore the sometimes heroic efforts of underfunded public health agencies and health care provider organizations in managing extremely challenging situations. But in most communities there is no team, nor teamwork, among all of these players and other municipal and county leaders. And, there is no community emergency preparedness plan, nor program, nor system. And then, while the country was still reeling from the September 11 attack, a different kind of attack, this time with a biological agent, anthrax, unfolded in Florida, New York, New Jersey,Washington D.C. and Connecticut.These disasters, wrought by terrorism, rapidly focused the nation’s attention on national security – the need to protect American ideals and resources, and most fundamentally, the very safety and health of the American people. Both for America’s leaders and for this nation’s communities, this compelling new, or newly While the cast of emergency preparedness players in a given community can lengthen rapidly, there is no denying the central role that hospitals can and must play in these efforts. However, these are difficult and occasionally overwhelming times for hospitals, even without this expanded responsibility. In fact, many hospitals are struggling to meet the daily demands for their health care services. It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday. 5 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Add to this brewing cataclysm the need for “surge capacity” – the ability to care for perhaps hundreds to thousands more patients at a given time – in hospitals already full, already stressed, and already searching for more resources to provide care, and the challenge of preparedness becomes even more daunting. As a matter of public policy, this country has purposefully shrunk the installed capacity of its health care delivery system over the past two decades. This has translated into the closure of many hospitals and even more emergency departments, despite the escalating demands for services. In addition, many hospitals now are experiencing severe shortages of nurses and other essential health care personnel. This is further reducing the capacity of these hospitals to deliver care, including emergency care. Today’s hard reality is that hospital emergency departments across the country are overcrowded and, even absent any external disaster, likely to be diverting patients on any given day. Since the Fall 2001 terrorism attacks, there has been a flurry of activity focused on the preparation of emergency preparedness plans.The emphasis on plans substantially understates what are really needed – emergency preparedness programs. According to a recent report,“Preparedness at home plays a critical role in combating terrorism by reducing its appeal as an effective means of warfare.”4 However, this level of preparedness implies a tightly knit system among the key emergency preparedness participants that simply does not exist in most communities today. “All emergencies are local” is a truism that conveys the responsibility of the community to plan, prepare and respond to an emergency. But as this paper points out, that truism is today far more a call to action than a reality. This paper is a call to action for federal and state governments as well, for weaving the tightly knit system of preparedness also takes resources, leadership and guidance. Adding to these problems are sky-high liability insurance premiums for physicians that are limiting the availability of critical specialists in certain jurisdictions. Further, most states in the country, with strapped budgets, are reducing the numbers of people on their Medicaid rolls.1 Medicare too is threatening more cuts in hospital reimbursement2 and the numbers of uninsured are on the rise.3 All of these factors promise to further undermine the ability of hospitals to meet the routine, let alone the extraordinary, needs of their communities. 6 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems none yet that present evidence-based models which are likely to be adaptable to the varied urban, suburban and sparsely populated communities that make up the United States. Since the events of September 11 and the subsequent anthrax attacks, the federal government has stepped forward to fund the rehabilitation of the public health system, and to a significantly lesser extent, the preparedness efforts of the nation’s hospitals. However, although the federal plan enlisted state governments to allocate federal funds to their hospitals well over a year ago, the money has not yet reached hospitals and some local public health agencies. There unfortunately is an oft-repeated refrain of money not making it from Washington to the trenches where it is needed.5 The money may eventually make it, but the funds are a small sum in comparison to what is actually needed.6 Given the urgency for community-based emergency preparedness and the obvious barriers to achieving this goal across the country, the Joint Commission convened an expert Public Policy Roundtable to discuss emergency preparedness issues and to frame specific recommendations, fulfillment of which would permit achievement of a level of preparedness that could truly offer protection and assurances to the American public. Among the specific issues addressed by the Roundtable were the resources and requirements for community-based response systems; the need for collaboration between the medical care and public health establishments, as well as other new partnerships that must be forged; issues of accountability and mechanisms for validating readiness; and the appropriate roles of federal and state governments. In addition to the disputes and confusion over meeting what remains today for many hospitals, an unfunded mandate, hospitals and their communities are struggling to know how to get started. There is a fundamental need for templates or scalable models of community-wide preparedness to guide planning before, and actions taken during and after, an emergency. Several nascent templates are emerging; however, there are In addition to the disputes and confusion over meeting what remains today for many hospitals, an unfunded mandate, hospitals and their communities are struggling to know how to get started. 7 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Based on those discussions, the following recommendations are proposed: II. Focus on the key aspects of the preparedness system that will preserve the ability of community health care resources to care for patients, protect staff and serve the public. • Prospectively define point-in-time and longitudinal surge capacity at the community level. • Establish mutual aid agreements among community hospitals and other health care organizations. • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. • Support the provision of decontamination capabilities in each hospital. • Maintain the ability to provide routine care. • Make provision for the graceful degradation of care. • Provide for waiver of regulatory requirements under conditions of extreme emergency. I. Enlist the community in preparing the local response • Initiate and facilitate the development of community-based emergency preparedness programs across the country. • Constitute community organizations that comprise all of the key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. • Encourage the transition of community health care resources from an organization-focused approach to emergency preparedness to one that encompasses the community. • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. 8 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities and fluidity of authority. • Make provisions for accommodating and managing the substantial acute mental health needs of the community. • Directly address the fear created by terrorist acts through targeted education, application of risk reduction strategies and the teaching of coping skills. • Provide public education about emergency preparedness. • Actively engage the public in emergency preparedness planning. • Anticipate the information needs of the community. • Create redundant, interoperable communications capabilities. • Develop a centralized community-wide patient locator system. • Engage the mass media in the emergency preparedness planning process. • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills. • Assure the inclusion of all community emergency preparedness program participants in the plan tests. III.Establish accountabilities, oversight, leadership and sustainment of community preparedness systems • Develop and implement objective evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans. • Provide funding at the local level for emergency preparedness planning. • Explore alternative options for providing sustained funding for hospital emergency preparedness activities. • Initiate and fund public-private sector partnerships that are charged to conduct research on and develop relevant, scalable templates for emergency preparedness plans that will meet local community needs. • Disseminate information about existing best practices and lessons learned respecting existing emergency preparedness initiatives. • Clarify the applications of EMTALA, HIPAA, EPA and other regulatory requirements in emergency situations. • Coordinate domestic and international emergency preparedness efforts. This paper provides supporting documentation for its conclusions, describes specific recommendations, and assigns accountabilities for carrying out these recommendations. 9 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems I. Enlist the Community in Preparing the Local Response preparedness to one that encompasses the entire community and its resources. The planning process is expected to systematically address the full range of potential disasters – including terrorism — identified through a “hazard vulnerability assessment,” that is conducted in collaboration with the organization’s community. The standards also require that organizations define an internal command structure that links with the community command structure. A final new requirement, stemming from the 2001 Houston flood experience and the September 11 experience, requires the health care organizations in the community to work cooperatively to create a mutual aid context for planning and response efforts. A New Context for Disaster Planning The Joint Commission has long required accredited organizations to create disaster plans and to test them at least twice a year. For many organizations, these requirements have often seemed like “make-work.” Only in those communities where actual disasters have struck has all of the actual preparation appeared to have been worth it. But the events of September 11, 2001 have created a new world for America’s communities and a new context for disaster preparedness for health care organizations. Almost propitiously, the Joint Commission had — during 2000 — been working to upgrade and reframe its traditional disaster preparedness standards into an expanded community-based emergency management framework. These new requirements were introduced in January 2001. The urgency to move these new requirements forward had resulted from a series of conversations with senior military and health care officials. Underlying the new Joint Commission standards is the fact that, in an emergency situation, health care provider organizations must work with each other and with other public safety and support entities to manage the casualties that have occurred and to minimize the risk of additional casualties. Managing a mass casualty or bioterrorism situation is no job for a single provider organization. The expanded framework of expectations now in place seeks to transition hospitals and other health care organizations from an organization-focused mindset of disaster Managing a mass casualty or bioterrorism situation is no job for a single provider organization. This is, in fact, the responsibility of “the community” – an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations. 10 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems disease prevention activities, management of disease outbreaks, and intervention in community-wide emergency department overcrowding situations. This is, in fact, the responsibility of “the community” – an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations. Emergency planning must be local – that is, based in the community – because almost all disasters and mass casualty situations are local. The sobering reality is that many communities will be on their own for the first 24-72 hours after such an event. Community-wide emergency preparedness programs do exist, and some are quite elaborate. However, they are few in number, and almost all exist is large metropolitan areas. By contrast, most of America’s communities are “waiting for someone to call the meeting.” Creating a detailed emergency preparedness plan, or program, particularly in the face of uncertain resource support is – to be sure – a daunting challenge. Indeed, planning templates that might serve as reference points for inexperienced project leaders are virtually non-existent. And the challenge is heightened still further by the fact that the core participants are in many ways strangers to each other, and each, by virtue of their unique responsibilities, is used to being “in control.” Enlisting the Community There thus exists a fundamental need to formalize an organization of community resources. That organization should comprise those authorities, agencies, providers, industries and other vital community elements that are critical to mounting an effective emergency response and protecting the community. This new “community organization” must then have the authority, and with this, both the necessary funding and accountability for planning, assessing and maintaining community-wide emergency preparedness — in effect, making the plan a program. Further, the program that is brought to life must have an ongoing reality, one in which the participants become familiar with their respective roles and a capabilities because they are working and interacting with each other on a regular basis. Such operational preparedness programs need not be theoretical. Among the obvious opportunities for ongoing collaborative efforts are community-wide health promotion and Yet, the planning process – the building of the relationships that will become the program – is a fundamental exercise in give-and-take. This is indeed a process in which primacy and control are relinquished to create a greater good.The new give-andtake relationships also set the stage for the management of actual disasters. Such management is almost always situational. That is, the nature of the situation dictates the command structure and who will be “in control.” 11 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Community-wide preparedness also has its pragmatic virtues, particularly in optimizing the deployment of available resources. For example, communication and collaboration among local hospitals make it much less likely that multiple hospitals will be depending on the same community resources for their own emergency planning purposes. One focuses on the care of the individual, the other on the health of the population. Their funding sources reflect these differing orientations – medical care is dependent on private funding; public health on public funding. But these old divisions must be bridged in order to ensure an integrated emergency response – in order to create a tightly woven preparedness system. Some of the ways in which the medical care and public health sectors can and should begin to collaborate are in developing health surveillance systems, in facilitating inter-organizational communication systems, and in the training of care providers to recognize signs and symptoms of exposure to chemical, biological or radiological agents. The potential response capability may in fact be called upon to expand in relation to the reach of the devastation brought by a catastrophic event. Such an event may cross multiple jurisdictions, necessitating a broader coordinated response among communitybased emergency preparedness programs. However, the effectiveness of a broad response cannot be fully realized unless the basic community programs are first put in place. There have also been frictions, of varying degree, between fire and police, between emergency management agencies and public health agencies, between emergency medical services and hospitals, and between city and county government authorities, among others. But these frictions can and must be overtaken by a new partnership mentality, and additional partners need to become engaged. Forging New Partnerships Some of the partnerships that must be forged face long-standing historical obstacles. There, for example, exists a long-standing gulf between medical care and public health. These two health care sectors have never had an effective working relationship.7 Accountability Tactics municipalities emergency management agencies hospitals public health agencies • Initiate and facilitate the development of community-based emergency preparedness programs across the country. 12 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems across responding organizations and agencies. The Council has also facilitated the implementation of syndromic surveillance systems at both the state and local levels. In addition, the Council has aided the New York State Department of Health in the development of a Web-based capacity-monitoring system to gauge bed and supply availability, and staffing levels at area hospitals. The Web-based system also collects patient information to serve as a patient locator system in the event of a mass casualty event. There are now encouraging indications that this is beginning to happen. For example, since September 11, the military have been involved in training civilian health care personnel and in participating in hospital emergency drills.8 And, in New York City, city and state public health agencies, hospitals, emergency medical services, city emergency management officials, and others have established new working relationships that undergird a state-of-the-art preparedness system. An Exemplary Effort In the aftermath of the terrorism attacks in New York City, the Greater New York Hospital Association (GNYHA) has taken a leadership role in forging a cross-disciplinary, cross-jurisdictional partnership among responding authorities, agencies and providers. In creating the Emergency Preparedness Coordinating Council, the GNYHA has helped its member organizations — and local, state and federal public health and emergency management agencies — to become better prepared, and able to offer an integrated response to a disaster.9 According to the GNYHA, many of the initiatives that the Emergency Preparedness Coordinating Council has spearheaded have focused on the collection of data — before, during and after an emergency – that are critical to waging an effective response and recovery. Among these initiatives, the Council has developed an emergency contacts directory to improve communications among key personnel Taking the lessons learned from the World Trade Center disaster and the subsequent anthrax attacks, the GNYHA and its Emergency Preparedness Coordinating Council have focused on helping local health care organizations and public safety agencies to improve upon those response elements that went wrong. For instance, telecommunications capabilities in the vicinity of Ground Zero were lost. To ensure effective communications in the event of another disaster, the Council has worked with the Office of Emergency Management (OEM) to purchase and distribute 800 Megahertz radios, and has established a dedicated channel for health care organizations to communicate with one another and with OEM. The Council has also taken a prominent role in informing and educating health care personnel in the detection of and response to biological, chemical and nuclear events. 13 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Letters mailed in October of 2001 that contained highly virulent, weaponized anthrax constituted the first bioterrorism attack in this country to which the Centers for Disease Control and Prevention (CDC) had to respond.10 A total of 22 confirmed or suspected cases of anthrax infection –11 inhalational, which led to five deaths, and 11 cutaneous cases – resulted from the anthrax attack.11 While the investigation into the perpetrator of the “anthrax letters” remains open, the public health response and medical care for those affected are now a case history of lessons learned. Lessons Learned The events of September 11 were instantly recognizable as disasters, and each prompted immediate action by all first-responders. In New York, calls went out across the city, the state, and surrounding states for hospitals to ready for victims. But some emergencies are not readily apparent. Rather, they unfold over days or weeks. The anthrax attack in the fall of 2001 was just such an emergency, and it raised important issues of cross-disciplinary and cross-jurisdictional coordination and authority as the impact of the attack unfolded. Tactics Accountability • Constitute a community organization that comprises local government officials, emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medical services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. community organization participants • Encourage the transition of community health care institutions from an organization-focused approach to emergency preparedness to one that encompasses the community. community organization • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. federal and state government agencies 14 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems both postal workers from the Brentwood postal facility in Washington, D.C., who sought medical attention for their severe flu-like symptoms.15 The first challenge in responding to the anthrax attack was in making the initial diagnosis. Few clinicians have presence-ofmind awareness of the signs and symptoms of bioterrorism agents, such as anthrax, smallpox, and plague. In fact, in a recent study of preparedness among family physicians for bioterrorism, only one-quarter of those surveyed felt prepared, and still fewer, 17 percent, reported that their local medical communities could respond effectively.12 However, prior training in bioterrorism was a significant positive factor in the responses of physicians who perceived themselves to be ready to respond to an attack.13 In addition to the fatal delays in diagnosis, there were significant breakdowns in communications across health care disciplines and public health authorities in the anthrax attack response. In particular, the ability or willingness of the public health system to communicate and work with the medical care system arose as an issue.When the first case of inhalational anthrax in a Brentwood postal worker was preliminarily diagnosed at a D.C.-area hospital and reported to public health officials, these officials, doubting the diagnosis16, did not immediately act to notify other area hospitals. At an early evening news conference the following day, officials “played down” the patient’s condition, saying it was “unconfirmed.”17 Potentially important opportunities for screening emergency department visitors were lost across the D.C. area. The first diagnosis of anthrax in the 2001 attack was made by an astute physician who suspected the disease; the confirmation was subsequently made by a laboratory worker who had undergone bioterrorism preparedness training. But the general unfamiliarity of medical professionals with bio-agents contributed to the misdiagnosis and delayed treatment for two other infected patients, Emergency preparedness is already a way of life in some countries; it needs to be woven into the fabric of American life to a much greater extent than it is today. 15 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Aside from local grass roots efforts, there was no infrastructure in affected areas that would have made it possible for vital clinical information to be shared in an emergency situation across the medical care community, or between public health authorities and practicing clinicians. Stories were told about physicians, even in prominent teaching hospitals, having to get their medical information from CNN during the height of the crisis.18 The Hart Senate Office Building was closed, as were other Senate office buildings, and, even briefly, the House of Representatives, until the risk of anthrax exposure had been clarified. Until credible, standardized bioterrorism response protocols are established and widely disseminated, the risk of promulgation of conflicting information and diversity in responses will continue to exist. This fundamental missing link could eventually undermine the public trust in the limited infrastructure now in place. The communications failure between and among public health officials and the medical community, and the limited base of expert information among those providing critical advice, had a tragic impact on postal workers in Washington D.C.’s Brentwood postal facility who were repeatedly reassured that no risk of anthrax contamination was posed to them.19 Two eventually died from inhalational anthrax. Getting There Americans, their families, and their community institutions increasingly tend to lead insular existences, but insularity is the antithesis of what will be needed to create emergency preparedness programs across America’s communities. Emergency preparedness is already a way of life in some countries; it needs to be woven into the fabric of American life to a much greater extent than it is today. In New Jersey, the health commissioner decided to ignore CDC recommendations and administer prophylaxis to all postal workers at two Trenton-area postal facilities.20 Accountability Tactics • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. health care and public health membership organizations federal government agencies • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. federal and state government agencies 16 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems few of these dollars are making their way down to the local community level. The funding allocated to public health is highly appropriate, but at the planned funding levels will only restore most public health departments to a baseline functional state. Meanwhile, most hospitals, which are required by the Joint Commission to be engaged in emergency planning and preparedness activities, have yet to see their first nickel of federal terrorism preparedness funds. Over time, the emergency preparedness engine simply cannot run without fuel. What needs to be done? First, someone does need to call the first meeting, to bring the parties together. The participants will vary by community, but the logical conveners are relatively few: the local emergency management agency, the local public health agency, and/or the local hospital(s). In small, sparsely populated communities, the hospital may be the only logical convener. Second, community planning templates need to be developed and disseminated. The disaster-based experience that is needed to develop meaningful templates is, fortunately, limited in this country, but available knowledge from experiences in the United States and elsewhere needs to be harvested and translated into scalable models that lend themselves to ready adaptation by communities of various types. Emergency preparedness plans that are created out of whole cloth are unlikely to offer comprehensive protection for a community. One might well ask whether such an extensive community-preparedness effort, and the funding and other resources required to support such an effort, are really necessary or justified. Today, the perceived terrorism vulnerabilities are clearly focused on the country’s major metropolitan areas. Nevertheless, it is well to remember that the primary objective of terrorism is to create fear. Little imagination is required to understand the potential psychological impacts on the populace of even a few selected terrorism attacks on typical small towns across America. Third, emergency preparedness at the community level takes resources, especially money. Despite the ballyhooed billions of federal dollars being poured into terrorism prevention and preparedness efforts, very 17 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Recommendations Accountability Tactics municipalities emergency management agencies hospitals public health agencies • Initiate and facilitate the development of community-based emergency preparedness programs across the country. • Constitute a community organization that comprises local government officials, emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medical services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. community organization participants • Encourage the transition of community health care institutions from an organization-focused approach to emergency preparedness to one that encompasses the community. community organization • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. federal and state government agencies • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. health care and public health membership organizations federal government agencies • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. federal and state government agencies 18 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems II. Focus on the key aspects of the preparedness system that will preserve the ability of community health care organizations to care for patients, protect staff and serve the public. time-limited period to accommodate the needs emanating from an acute disaster will eventually be needed by patients having more “routine” care requirements such as surgical procedures, cancer chemotherapy, or the delivery of a child. Thus, the capacity needed to manage longer-term disasters, e.g., a biological attack, may eventually be in direct competition with the ongoing care needed by the people in the community. Preparedness Priorities Developing a community-based preparedness program requires forethought of a wide variety of issues that could determine the outcome of a response. These include education of first responders, provider organization staff, and the public; creation of redundant, reliable communication systems; definition of roles and responsibilities among responders; definition of available human, equipment and supply resources; and incident management and coordination, among others. Among these are a series of truly critical elements of the preparedness system that are integral to the ability of a community to successfully mount an effective response. These are elaborated upon below. It is important that surge capacity – both in its point-in-time and longitudinal dimensions – be prospectively determined as part of the emergency planning process. There is also a basic need to define an agreed-upon set of units, or measures, of surge capacity at the federal level or, at the very least, at the state level. Such definition is essential to the communication of needs within and across communities. 1. Define Surge Capacity Surge capacity – the ability to expand care capabilities in response to sudden or more prolonged demand – is perhaps the most fundamental component of an emergency preparedness program. Surge capacity encompasses potential patient beds; available space in which patients may be triaged, managed, vaccinated, decontaminated, or simply located; available personnel of all types; necessary medications, supplies and equipment; and even the legal capacity to deliver health care under situations which exceed authorized capacity. Surge capacity has both point-in-time and longitudinal dimensions, and these differ from each other. That is, capacity that can be mobilized for a Current Capacity The American Hospital Association (AHA) reports that there are 900 fewer hospitals today than there were in 1980.21 Through the 1980s and 1990s, the expansion of managed care and increasingly stringent federal reimbursement policies progressively leveraged hospitals to close and consolidate, and to reduce overall capacity in an effort to create greater efficiencies in the delivery system. Today, with the aging of society and the corresponding increase in patient acuity, many hospitals are now challenged to meet a typical day’s demand for their services. 19 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems surge capacity exists in these communities. The underlying causes of this problem are well known — inadequate numbers of hospital beds, limited access to primary care, unavailability of physician specialists, and major shortages of other key clinical personnel, especially nurses. As a reflection of this challenge, hospital emergency departments in many cities are frequently overcrowded and likely to be diverting ambulances on any given day. According to a recent AHA survey, 62 percent of all hospitals and 79 percent of urban hospitals are at or over emergency department (ED) capacity.22 More than half of urban hospitals report that they have been on “diversion” – diverting ambulances – for a portion of time.23 In many communities, accurate, standardized measurement of bed capacity has become an immediate need. Available hospital bed capacity is typically determined through a daily midnight census of occupied inpatient beds. Measuring bed capacity in this way fails to account for the inflow and outflow Overcrowded emergency departments are a clear and visible symptom of a destabilized health care environment, and raise clear and compelling questions as to whether any real Accountability Tactics Surge Capacity • Determine standardized, universal measures of surge capacity. federal and state government agencies community organization • Prospectively define point-in-time and longitudinal surge capacity at the community level. community organization • Identify latent space and human resources capacities. community organization • Establish mutual aid agreements among community hospitals and other health care organizations. health care organizations community organization • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. health care organizations community organization • Standardize equipment, supplies and medication doses to facilitate the provision of safe, efficient care. health care organizations pharmaceutical companies community organization federal government • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. 20 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems also the Nursing Reserve Corps. – a roster of volunteer nurses who may be deployed to a disaster site or mass vaccination clinic if and when such needs arise. However, the actual availability of these nurses during a disaster remains uncertain. Depending on the extent of the disaster or the occurrence of concurrent disasters, many of these nurses may be needed in their own communities. Even absent a local disaster, provider organizations in a given community may not be able to release volunteer nurses from their staffs without compromising their own care capabilities. occurring throughout the hospital all day long and almost certainly overestimates available capacity. The Agency for Healthcare Research and Quality has embarked on a study to determine useful, relevant measures that can predict the imminent onset of emergency department overcrowding. Overcrowding in most or all of a community’s emergency departments which results in widespread ambulance diversions is, one could argue, itself a community disaster which should cause activation of the community’s emergency preparedness plan. Too Few Caregivers A severe shortage of nurses is already compromising access to health care services today,24 and a potential shortage of more than 400,000 nurses is projected by 2020.25 Given this reality, it is unclear how additional nursing services can be made available in the face of a natural or terrorist disaster. In addition to the shortage of nurses, there are acute shortages of pharmacists, laboratory technicians, respiratory therapists, and, increasingly, physicians. A planned source of surge capacity in the event of a disaster is the National Disaster Medical System (NDMS). NDMS is administered by the Office of Emergency Response (OER), which will transition from DHHS to the Department of Homeland Security in March 2003. NDMS teams include nearly 8,000 volunteer health care professionals from around the country who have been organized into general and specialty teams to help local communities respond to a disaster. Several major initiatives are underway to attract potential nurses into health care. Most notable among these is the recently enacted, but only modestly funded thus far, Nursing Reinvestment Act. This Act contemplates support both for nursing school faculty and for aspiring students, and provides for nurse recruitment campaigns. However, the long-term impacts of these initiatives are difficult to gauge. DHHS Secretary Tommy Thompson recently called for more robust funding for the Nurse Reinvestment Act, and In many communities, accurate, standardized measurement of bed capacity has become an immediate need. 21 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems was no existing mechanism to document their knowledge, skills, and experience – i.e., their credentials. Nor was there any way to objectively catalogue the special competencies that were then on-site and those that were still needed. There are currently 27 primary care teams who can, under ideal circumstances, respond to an emergency call within 12 to 24 hours. Four teams specialize in responding to an incident caused by a chemical or bioterrorism attack. There are also burn teams, mental health teams and disaster mortuary teams that can assist in a mass casualty event. But for the same reasons that a threshold number of nurses may not be available to travel to a disaster, neither may the health care workers who comprise the NDMS teams. The subsequently enacted Public Health Security Act includes a provision for the creation of a national emergency volunteer system for health care professionals. However, DHHS has not yet funded this initiative. The events of September 11 dramatize the urgency for moving this project forward. A national credentialing system built upon a common technology platform and using consensus credentialing standards would also provide rapid access to information on volunteer clinicians – both in the planning process and during an actual event. Truly adding to the capacity of available personnel in a disaster or emergency response may necessitate drawing upon medical, nursing and allied health students. DHHS is also encouraging health care organizations to consider retired physicians and nurses in their personnel surge capacity planning.26 Finally, there is also a clear role for the lay public in caring for themselves or family members in the face of a disaster. Even today, 70-90 percent of routine care is being provided by family members or other non-professional caregivers.27 While the lay caregiver role certainly has its limitations, an educated public is an important potential resource. Space and Supplies Space is a further critical consideration in defining and developing surge capacity. Space needs are defined in large measure by the uses for which the space might be deployed. Such uses include a wide range of potential activities which should be catalogued and addressed in the emergency preparedness plan. Among the diverse potential needs for space are triage, decontamination, mass vaccination, temporary mortuary, counseling, and patient care. In some instances, temporary expansion of hospital capacity will be most appropriate, e.g., through converting single patient rooms to doubles, and use of cafeteria, meeting room and office space. In other cases, nursing homes, clinics, At the same time, a disaster must not become a disorganized free-for-all for well-intended, would-be caregivers. In the immediate aftermath of the September 11 events, physicians and nurses came to the disaster sites and nearby hospitals from near and far to offer their services. But nobody knew who they were. Had their services been needed, there 22 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems patients for the first 48 hours of an emergency. Distribution of the SNS supplies also requires that there be local capacity to quickly unload, transport and administer the drugs across the affected region. rehabilitation centers, and surgery centers will be appropriate to the needs. And in still other instances, hotels, closed hospitals, armories, auditoriums and similar facilities can be utilized. Finally, caring for people in their own homes is an important source of surge capacity, and may be a particularly attractive alternative in the event of a biological attack with an infectious agent. Fully cataloging space options is also particularly important in light of the distinct possibility that hospitals and other organized settings of care may themselves become disaster casualties. There is finally an important need to standardize equipment and supplies to the extent possible. With the potential for enlisting volunteer medical personnel or borrowing staff from other hospitals in the region, such standardization will reduce the likelihood of errors and untoward events and facilitate the provision of care. Examples include standardizing switches, dials and gauges on oxygen equipment, and standardizing packaged doses of pharmaceuticals. As important as the need for identifying space options, is the need to assure the availability of adequate reserves of medications, equipment and other supplies. While immediate outside support may be forthcoming, a given community may be on its own for hours to days following a disaster. 2. Preserve the Organization — Protect the Staff “When I had a chance to look outside the command center, I saw all the doctors and nurses watching and waiting,” said Mary Thompson, the incident commander and chief operating officer at Bellevue Hospital in Manhattan, following the September 11 attack on the World Trade Center.28 “I realized if there was a biological component to this attack, they would all be contaminated. If that had been the case, I would have had to call all new surgeons.”29 By way of example, although a “push pack” is promised within 12 hours of request, pharmaceutical supplies from the Strategic National Stockpile (SNS) may take up to 48 hours to reach the locations in which they are needed. DHHS suggests that hospitals maintain enough antibiotics on hand to supply hospital staff, first responders and Despite their eagerness to respond, health care workers face real risks in doing so. Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response – to themselves and to the organization. 23 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems 500,000 first responders and health care workers. A growing number of hospitals have abstained from the pre-event vaccination program, citing the unnecessary risk to health care workers and others from the vaccine in absence of a clear smallpox threat.30 There are important lessons to be gained from this potential scenario. Sadly, one of those lessons is that there is no “face value” to terrorism. Every event must be regarded with great caution and suspicion – a bomb may be a “dirty bomb,” an explosion could be accompanied by a release of a biological agent. The responsibilities of hospitals and other health care organizations to their employees extend beyond physical protection. An emergency response can be as emotionally anguishing as it is physically punishing. The care and support for organization staff must encompass their mental health needs as well. Hence, there is a particular need for sensitivity to personal concerns and obligations when workers, for instance, may be separated from their families and loved ones for long hours and even days. Communications support, attention to child-care needs, provision of transportation alternatives, and even direct on-site personal support can all help to alleviate worker stress. In fact, health care organizations may be well served by gathering information about staff concerns and obligations before an event occurs. For example, sixty-two percent of St.Vincent’s Catholic Medical Center’s emergency department nurses are spouses or partners of first responders in the New York City region.31 On September 11, they were asked to perform their duties on a day that must have been both professionally and personally anguishing. Despite their eagerness to respond, health care workers face real risks in doing so. Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response – to themselves and to the organization. These staff must also have the highest priority for prophylactic antibiotics, chemical antidotes, and other practical therapeutic measures. Each hospital should have a decontamination capability in place to manage workers and patients and to preserve the ability of the organization to provide care. Although there has been some debate as to the need for such a broad-based capability, the practical reality is that the determination of contamination will often not occur until the patient has undergone a screening examination and initial stabilization. Reducing the risk to caregivers and preserving the capability of the organization to treat patients also underlies current planning regarding smallpox vaccinations.The President has authorized a pre-event vaccination program beginning with the voluntary vaccination of approximately 24 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems “federal zone,” prohibiting entry by unauthorized individuals and vehicles. New York University Downtown Hospital became the home care provider of only choice for the residents of an apartment building across the street when home care agency nurses could not breach the federal zone.32 Fortunately for these home care patients, a hospital was located across the street. In addition to receiving communications support in reaching family and loved ones, frontline workers need real-time, current information about an event that is in progress. Keeping staff apprised of “what’s going on” within the organization and across responding organizations helps them anticipate downstream needs and gain a sense of control over their own environment. In addition, maintaining contact with the “outside world” through the Internet and broadcast media can help staff avoid feelings of detachment. In order to gain capacity to care for more victims in the wake of an emergency, hospitals may cancel scheduled surgeries and defer other planned diagnostic, therapeutic and rehabilitative activities. This may buy time, but it will not buy long-term capacity. Scheduled surgeries have been scheduled for sound reasons and cannot be delayed indefinitely. 3. Ensure Care for the “Other” Patients In a massive disaster, there is the potential that many chronically and acutely ill patients could lose access to their physicians or settings where they usually receive care or obtain medications. This happened in New York City on September 11 when the affected portion of the city was declared a Accountability Tactics Direct Caregiver Protection • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. health care organizations community organization • Provide direct caregiver support to meet mental health and other personal needs. health care organization • Support the provision of decontamination capabilities in each hospital. federal and state government hospitals community organization • Assure direct caregiver access to current information about the emergency on a continuing basis. health care organizations community organization 25 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Their privacy will be compromised, but their wounds will still be treated. Care and access to caregivers may even become rationed. The goal of graceful degradation is to avoid having the health system become a victim of the assault – from becoming incapacitated and unable to deliver care of any kind. The hospital, in essence, must engineer its failures – those that it can allow – while maintaining its ability to provide care. Delivering mothers will still need access to hospital obstetric and neonatal units, cancer patients to radiotherapy units, stroke patients to rehabilitative services, and so on. In the face of the requirement for a sustained response to an emergency, and once every option has been exercised for the transfer and treatment of patients in various settings and at various levels of care, something less than the usual standard of care in the affected community must become acceptable. At the same time that graceful degradation of health care services is occurring, the care providers and health care organizations must be exempted from the day-to-day rules of operation and regulations that otherwise would prohibit them from caring for patients in such fashions. Indeed, they must be legally protected from reciprocal actions that may occur, for instance, for violations of privacy or delivery of sub-standard care once a state of emergency has been declared. Graceful Degradation Like the electrical utility that plans for “brown-outs” in order to avoid “black-outs,”33 hospitals and other provider organizations – when stretched beyond their limits, must begin to plan to engineer their failures. The goal of such efforts is to achieve “graceful degradation” of the health care system’s care capabilities as opposed to catastrophic failure of its services. Under such scenarios, patients may need to be treated and boarded in hallways. Accountability Tactics Meeting the Care Needs of All Patients • Maintain the ability to provide routine care. health care professionals health care organizations community organization • Make provisions for the graceful degradation of care in all emergency preparedness plans. health care organizations community organization • Provide for waiver of regulatory requirements and other standards expectations under conditions of extreme emergency. federal and state government agencies accrediting bodies 26 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems sharing vital information, and managing the logistics of an integrated response. The incident management system should also establish the common terminology that community participants in the emergency management program are expected to use, in order to reduce the risk of miscommunications. 4. Manage the Incident Often referred to as “command-and-control” or incident command systems, the established authorities that have taken on responsibilities for managing emergency responses have often taken on an unnecessarily militaristic tone.34 Command and control may, indeed, be necessary, but so too are effective coordination and communication. The basic need is for an integrated response that is managed through either an incident command system or, when circumstances warrant, a unified management approach. Although definitive studies have not been conducted to establish the evidence base for the incident command system approach, it proved to be an integral element of the generally effective responses to the earthquake and fire disasters that have historically beset California, and in the September 11 attacks in New York City and Washington D.C. The variability of emergencies and the evolution of responses to them over time necessitate that the incident management system provide for fluidity of authority to adjust to changing needs. These characteristics of emergency management may also require that there be multiple, but unified authorities managing the response. Application of such an incident management system does not preclude others from having authority and responsibility within their domains of expertise or experience. Rather, it assures that there is an emergency management structure in place that is responsible for coordinating resource deployment, The importance of such systems is also emphasized by their absence. During the 2001 anthrax attacks, there was no incident management system of any kind. Nor was there any coordinated response among various authorities within localities or across multiple jurisdictions. So disjointed was the response that differing information was provided by various responsible public health offices as to how to recognize and treat anthrax infections. Accountability Tactics Incident Management community organization • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities, and fluidity of authority as a function of the scale and nature of the emergency situation. 27 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems that individuals need not be in the vicinity of a catastrophic event to experience substantial event-related stress.39 With eyes glued to the graphic television coverage across the nation, 90 percent of adults surveyed reported having some symptoms of stress.40 While 60 percent of those in close proximity to the sites of attack reported high degrees of stress, 36 percent of respondents living more than 1,000 miles away from the World Trade Center also reported substantial stress.41 Recognizing the need for a functional conduit of accurate information, the District of Columbia Hospital Association worked with emergency physicians across the National Capital Region to organize daily conference calls that created interfaces among the health care providers, local public health representatives, the D.C. Department of Health, and the CDC.35 5. Consider the Threat to Mind, as well as Body Significant consideration must be given to the psychological effects of a disaster. It is estimated that for every one physical casualty caused by a terrorism incident, there are four to 20 psychological victims.36 The September 11 attack has been described as a “mental health catastrophe.”37 In just one of the hospitals proximate to the attack in New York City — St.Vincent’s Catholic Medical Center — staff in the psychiatric department provided counseling and support to more than 7,000 people and received more than 10,000 calls to their help line during the first two weeks following the disaster.38 Though initially traumatized, the vast majority, through their own resiliency, will suffer no significant residua;42 however, some will manifest symptoms of post-traumatic stress disorder (PTSD). Even then, most PTSD sufferers typically recover rapidly.43 However, in the rare event that PTSD persists, it requires evaluation and treatment.44 Other trauma-related disorders are more common.45 These include unexplained physical symptoms, sleep disturbances, increased use of alcohol and cigarettes, and increased family conflict and violence.46 But, because these symptoms are often associated with the stresses of daily living, they may easily be overlooked and not associated with the traumatic event.47 Results of a survey conducted by the RAND Corporation three to five days after the September 11 attack clearly demonstrated Accountability Tactics Mental Health Management mental health professionals health care organizations community organization • Make provisions for accommodating and managing the substantial acute mental health needs of the community when a natural or terrorist event occurs. 28 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Psychological victims often also include those involved in treating the physical casualties. In fact, disaster responders, including medical personnel, are a high-risk group for developing trauma-related disorders. In addition to assuring access to personal protective equipment (PPE), vaccination and prophylactic treatments for first responders and frontline health care workers, health care organizations need to direct attention to mitigating the stress-related psychological effects of disaster response on these individuals. sense of security. A recent incident in which 250 people were exposed to radioactive material in Goiannia, Brazil illustrates the psychological impact of a terrorizing event. Five thousand of the first 60,000 people who sought medical care after awareness of the incident spread, though unexposed, developed the physical symptoms (rash and nausea) that mimicked those of radiation exposure. All told, 125,000 people sought medical screening for radiological contamination – a 500-to-1 ratio of patients screened to patients exposed.51 Throughout the duration of the response, responders should be given – even if it must be mandated for some – rest periods. Over-dedication is a risk factor for developing PTSD.48 Further, care providers should be encouraged to “naturally debrief” – that is to talk with their colleagues, friends and families about their experiences.49 First responders and other high-risk groups should also be evaluated over time following the disaster to monitor their recovery and detect any signs of an “abnormal response.”50 Fear, though, can be assuaged through targeted education, application of risk-reduction strategies, and the teaching of coping skills.52 6. Enlist the Public While the fear bred by a disaster or terrorist incident may far exceed the deleterious effects of the occurrence itself, it would be unfair to characterize that fear as unreasonable. In the face of real threats to safety and the absence of credible and helpful information, public fear may indeed be reasonable.53 But, contrary to common perception, widespread panic is rare in response to disasters.54 The preparedness program should also anticipate and address the “fear factor” inherent in terrorism. The goal of terrorism is, after all, to instill fear and erode society’s Significant consideration must be given to the psychological effects of a disaster. 29 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems The public may indeed assume even more basic life-saving roles in emergency situations. In a mass casualty event, rescuers and emergency medical services may quickly become overwhelmed. When this has occurred, members of the public have, in fact, saved the majority of victims in the search and rescue phase of a disaster response.58 Lay individuals may, and often do, become active caregivers when medical resources become thin – visiting the ill in their homes, distributing antibiotics, even conducting epidemiological investigations and outbreak reporting.59 Nevertheless, prospective, and later concurrent, education and information sharing is an essential element of strategies to ensure calm and promote constructive behaviors, particularly in the event of an unprecedented attack.55 A recent report issued by the National Academy of Sciences emphasizes that, in the event of a terrorist incident, it is essential that trusted spokespersons inform the public immediately and with expert authority, to both educate the public and assuage public concerns.56 Ideally, the public should be enlisted as a capable, active partner in the preparedness system.57 An educated public plays a potentially vital role in infectious disease containment and bioterrorism surveillance. When individuals are aware of the signs and symptoms of a suspected biological agent, they are more likely to seek medical attention when it is warranted, and not otherwise unwittingly overwhelm the health system and hinder its ability to care for those most in need. They are also then able to engage in risk reduction activities to help contain an infectious outbreak. It almost goes without saying that the mass media can and should play a central role in conveying information that will permit the general public to optimize their contributions to the emergency response. Civic organizations, professional networks and social groups are also potential conduits for information, as well as resources that can be enlisted to aid in a response effort.60 Accountability Tactics Public Engagement • Provide public education about emergency preparedness. federal and state governments community organization • Actively engage the public in emergency preparedness planning. community organization 30 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Immediately following the World Trade Center attack, telephone lines were down, and cell networks became jammed. New York-area hospitals were deluged by calls from families and friends of the missing who, without a centralized patient locator system, were virtually impossible to find on a real-time basis. 7. Identify Communication and Information Needs and Meet Them Information management — the ability to communicate, what to communicate, to whom and when – lies at the heart of the emergency response. For health care organizations, the information needs of its constituents – the general public, patients and their families, the staff and their families, first responders, the media, community officials, and public health agencies, among others – should be anticipated. This experience dramatized the need for redundant communications capabilities in emergency situations. Various options for backing up telephone communications exist. These include two-way radios and dedicated channels, wireless personal digital assistants (PDAs), cell phones, satellite phones, pagers, and Internet connectivity and designated Web sites. The experiences of September 11 and the subsequent anthrax attacks underscored the criticality of communications in mounting an effective emergency response. In this situation, vulnerabilities in the communications infrastructure quickly surfaced. Accountability Tactics Information Management • Anticipate the information needs of community organization participants and the public. community organization • Create redundant, interoperable communications capabilities. federal and state governments community organization • Develop a centralized community-wide patient locator system. community organization • Prospectively identify trusted spokespersons to communicate with the public in the event of a natural or intentional disaster. community organization • Engage the mass media in the emergency preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions. community organization • Develop an “information stockpile” to support communications activities. community organization 31 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems with the medical community, is a key aspect of effective communications and underlies the ability to elicit the desired responses. Sources of scientific and relevant expertise should be prospectively identified to ensure the authenticity of the information being imparted. Protocols for using various communications modalities should be pre-determined and consistent across the preparedness system, and all should be inter-operable. A centralized patient locator system, such as that being developed under the leadership of the Greater New York Hospital Association in New York, is another vital communications infrastructure asset. The news media can be a critical partner in the dissemination of information, and are logical additional participants in the development of community-based emergency preparedness plans. In any event, it is essential to involve media representatives early in communication and information-sharing processes. Media understanding of the information and the underlying issues offers the greatest prospect for accurate, sensitive, and constructive reporting to the public. The media may also – by default – become the principal initial conduit of clinical information for medical care providers. In this regard, an “information stockpile”68 of credible information that is available in various formats – public service announcements, brochures, fact sheets,Web communications – should also be developed to support outreach efforts. A critical issue in the analysis of the 2001 anthrax response is the way in which information was – and was not — managed and communicated. This resulted in a crisis in confidence in the public health system.61,62,63 Information was not being coordinated among public health agencies involved in the response, nor between public health agencies and the medical community charged with evaluating and treating potential anthrax victims.64,65,66 Attempts by the authorities managing the response to “spin” the information to reduce perceptions of risk, and perhaps to gloss over errors or a lack of expertise, served to erode public trust.67 The identification and use of credible, expert spokespersons to take the lead in communicating with the public, as well as The news media can be a critical partner in the dissemination of information, and are logical additional participants in the development of community-based emergency preparedness plans. 32 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Further, the more realistic the drill is, the better the learning and improvement opportunities will be. Indeed, some have suggested that if a drill is not planned to truly inconvenience the participants and the community – as a real emergency would – then its value is already compromised.69 At the same time, it bears recognition that mini-emergencies – often occasioned by emergency department overcrowding across communities – are everyday realities in many parts of the country and certainly provide ample justification for activation of basic elements of a community’s emergency preparedness plan. Such activation can both help to address temporary clinical care crises and also permit continuing refinement of preparedness plans. 8. Test, Learn, Improve and Be Ready The Joint Commission emergency management standards require each accredited health care organization to conduct drills of its emergency management plan at least twice yearly. While such drills are sometimes viewed as “make-work,” they are in fact a critical element of the emergency preparedness process. And as the complexity of the planning process escalates from an individual organization basis to a community base, the need for carefully crafted, full-scale drills in which all of the participants are involved becomes even greater. Further, the drill is more than just an exercise; it is a special opportunity to learn how the preparedness plan and response can be improved. In that regard, it is essential that appropriate metrics for drill evaluation be prospectively identified. Accountability Tactics Emergency Preparedness Program Testing • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan. community organization • Prospectively establish appropriate metrics for objectively assessing the effectiveness of the plan. community organization • Assure the inclusion of all community emergency preparedness program participants in plan tests. community organization • Activate the preparedness plan in response to real-world health care crises, e.g. community-wide emergency department overcrowding. community organization 33 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems The University of Maryland Medical System recently conducted a full-scale drill, dubbed “Free State Response,” in partnership with the U.S.Air Force and the Maryland Emergency Management Authority. All told, the drill cost between $200,000 and $300,000, but in the view of the medical system, that money bought “profound knowledge.”70 In addition to revealing where existing vulnerabilities lay, the drill inculcated the emergency management plan into the minds of the medical system’s staff – where it could more easily be retrieved during an actual disaster.71 Of the two drills the Joint Commission requires each year, one is expected to be a community-wide drill. Such drills can be costly. As a means to cost-share or defray the costs, accredited health care organizations are encouraged to seek partners in the community who will also benefit from the drill. Local government, public health authorities, emergency medical services, fire and police – all of the key participants in the local preparedness system — should be involved in and share in the accountability for community-wide drills. Recommendations Accountability Tactics Surge Capacity • Determine standardized, universal measures of surge capacity. federal and state government agencies community organization • Prospectively define point-in-time and longitudinal surge capacity at the community level. community organization • Identify latent space and human resources capacities. community organization • Establish mutual aid agreements among community hospitals and other health care organizations. health care organizations community organization • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. health care organizations community organization • Standardize equipment, supplies and medication doses to facilitate the provision of safe, efficient care. health care organizations pharmaceutical companies community organization • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. federal government 34 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Accountability Tactics Direct Caregiver Protection • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. health care organizations community organization • Provide direct caregiver support to meet mental health and other personal needs. health care organization • Support the provision of decontamination capabilities in each hospital. federal and state government hospitals community organization • Assure direct caregiver access to current information about the emergency on a continuing basis. health care organizations community organization Meeting the Care Needs of All Patients • Maintain the ability to provide routine care. health care professionals health care organizations community organization • Make provisions for the graceful degradation of care in all emergency preparedness plans. health care organizations community organization • Provide for waiver of regulatory requirements and other standards expectations under conditions of extreme emergency. federal and state government agencies accrediting bodies Incident Management community organization • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities and fluidity of authority as a function of the scale and nature of the emergency situation. Mental Health Management mental health professionals health care organizations community organization • Make provisions for accommodating and managing the substantial acute mental health needs of the community when a natural or terrorist event occurs. 35 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Accountability Tactics Public Engagement • Provide public education about emergency preparedness. federal and state governments community organization • Actively engage the public in emergency preparedness planning. community organization Information Management • Anticipate the information needs of community organization participants and the public. community organization • Create redundant, interoperable communications capabilities. federal and state governments community organization • Develop a centralized community-wide patient locator system. community organization • Prospectively identify trusted spokespersons to communicate with the public in the event of a natural or intentional disaster. community organization • Engage the mass media in the emergency preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions. community organization • Develop an “information stockpile” to support communications activities. community organization Emergency Preparedness Program Testing • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan. community organization • Prospectively establish appropriate metrics for objectively assessing the effectiveness of the plan. community organization • Assure the inclusion of all community emergency preparedness program participants in plan tests. community organization • Activate the preparedness plan in response to real-world health care crises, e.g. community-wide emergency department overcrowding. community organization 36 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems agencies, both as recipients of significant funding and as critical participants in the development of community preparedness initiatives, also lack the objectivity necessary to thoroughly assess the functionality of community preparedness programs in their states. A Question of Accountability With the current heavy focus on emergency preparedness planning, little attention is being paid to mechanisms for assessing the actual readiness of communities for emergencies. Indeed, states have been required to submit “plans for planning” for emergency preparedness as the principal condition for receipt of federal funding. However, actual readiness will not be defined simply by the creation of a plan or even by its periodic testing. Readiness must eventually be assessed by objective parties against prospectively established standards. Such standards must include expectations for evidence of maintenance of readiness over time. The appropriate time to establish an effective, objective oversight mechanism for evaluating community emergency preparedness programs and assuring that they are meeting reasonable standards expectations is not after this country has experienced multiple plan failures. There are already sufficient lessons from the past to underscore the importance of preventive measures in this area as well. The issues of accountability and oversight currently hover in the background. Governors have been defined as being accountable for submitting their state emergency preparedness work plans to DHHS. This at least creates presumptive accountability on the part of individual governors for state-wide emergency preparedness. At the same time, it very much leaves open the issue as to how the individual governors will simultaneously and objectively determine the effectiveness of that preparedness. State public health Sustainable Funding Following the 2001 terrorism attacks, Congress appropriated $40 billion to be expended through 2002 on terrorism preparedness efforts; $135 million of these funds were earmarked for hospitals. Most hospitals are still awaiting receipt of those funds, which, owing to the manner in which states allocate such funds, are currently unaccounted for or are hung-up in state budget hearings.72 Accountability Tactics federal government • Develop and implement objective evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans and the actual readiness of community organizations to manage disasters and terrorist events. 37 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems term, there is clearly a need for a sustainable funding mechanism to support their emergency preparedness efforts. As the most critical care delivery component of a tightly woven preparedness system, hospitals will require funding for development, as well as for maintenance and fortification of their preparedness programs. In the absence of adequate federal funding, and with hospitals’ inability to rely on private funding to bolster their preparedness efforts, some have suggested exploration of creative “taxation” approaches, such as a hospital surcharge on patient visits, to provide a sustained funding stream that will permit hospitals to meet public expectations of their emergency preparedness capabilities. Indeed, if “at the end of the day, it is medical care that will be needed,”77 hospitals and other organizations in the care continuum are going to require the means to provide it. In the President’s 2003 budget, $535 million is earmarked for hospital preparedness.73 The budget also includes $3.5 billion in terrorism preparedness funds for first responders to acquire new technologies, equipment and communications systems, and to conduct drills among first responder agencies. Unfortunately for hospitals, the President’s budget limits the definition of first responders to firefighters, local law enforcement, rescue squads, ambulances and emergency medical personnel.73 All FY2003 terrorism preparedness funding, though, remains “on the table” in anticipation of budget allocation hearings. Many expect that with a potential war with Iraq and the stumbling U.S. economy, the level of funding for preparedness activities will likely be reduced.76 While it remains to be seen what actual funding hospitals will receive in the near Accountability Tactics • Provide funding at the local level for emergency preparedness planning, specifically including adequate funding for hospitals, and assure that the funds actually reach the local level. federal and state governments • Explore alternative options for providing sustained funding for hospital emergency preparedness activities. hospitals federal and state governments • Initiate and fund public-private sector partnerships that are charged to conduct research on and develop relevant, scalable templates for emergency preparedness plans that will meet local community needs in a variety of urban, suburban, and sparsely populated settings. federal and state governments academic health centers established community organizations accrediting bodies 38 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems executive director of the State Bioterrorism Preparedness and Response Program; establishment of an advisory committee that includes representatives from state and local health departments, other appropriate government agencies, emergency medical services, police and fire departments, hospitals, community health centers, and other health care providers, among others; and the preparation of a timeline for development of both state and regional plans for responding to incidents of bioterrorism, other infectious diseases, and other public health threats and emergencies. Each state is also to establish a hospital planning committee, designate a coordinator for hospital bioterrorism planning, and develop a plan for a potential epidemic involving at least 500 patients. While these macro state plans are necessary, they are far from sufficient to meet local community planning needs. Once again, most disasters and terrorist events will be local, and the effectiveness of the response will be determined at the local level. Guiding the Effort There is – as already noted – also the need for credible guidance, in the form of templates or models, to jumpstart and facilitate community preparedness program development. Many involved in developing community-wide preparedness programs have little idea as to what constitutes an acceptable, let alone, ideal model. And the fact is that response capabilities and basic needs and structure vary substantially among urban, suburban, and rural communities and even within those communities. A nascent national template for emergency management has now emerged through the enactment of the “Public Health Security and Bioterrorism Preparedness and Response Act.” Preceding the enactment of the bioterrorism legislation, all states were required to submit their bioterrorism preparedness work plans to DHHS as a prerequisite for allocation of state funding. Among the 17 critical benchmarks DHHS required in the state plans were the designation of a senior public health official within the state to serve as the Accountability Tactics • Disseminate information about existing best practices and lessons learned respecting existing emergency preparedness initiatives to community organizations, hospitals and other health care organizations. federal and state governments 39 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems features of an all risks ready emergency facility — one built specifically for scalability, threat mitigation, and management of the medical consequences of terrorism. E.R. One will utilize new information, building, materials and engineering technologies, and will embed concepts of modularity and flexibility so as to be configurable to any threat. Leading Project E.R. One is the Washington Hospital Center, which is the largest hospital in Washington D.C. The hospital is located less than two miles from the U.S. Capitol and so is the likely hospital to receive large numbers of victims from an attack on this country’s seat of government. Another template developed by federal authorities is the model plan recently released by the Centers for Disease Control and Prevention (CDC) for vaccinating the U.S. population following a smallpox outbreak. The model plan was sent to all 50 states to aid in the rapid creation of voluntary smallpox vaccination clinics that would permit the vaccination of one million people within 10 days. The plan provides information on the supplies and resources that will be provided by the federal government; security considerations; suggested clinic organization and logistics; estimated personnel needs; clinical issues and considerations; sample consent forms and public education materials; and a template for delivery of mass patient care should that become necessary.78 The model plan does not, however, provide direction as to the acquisition of resources – either financial or human – to create and operate mass vaccination clinics. This too is a necessary template but one which is targeted to a specific potential problem. Other preparedness models are being developed in the private sector.79 However, public-private sector partnerships offer the best overall prospect for research on and development of relevant, scalable models that will meet local community needs in a variety of urban, suburban, and sparsely populated settings. There is considerable urgency to move this work forward. The federal government is also investing in the creation of a model facility for emergency preparedness. “Project E.R. One” is a federal initiative to develop the design Indeed, if “at the end of the day, it is medical care that will be needed,” hospitals and other organizations in the care continuum are going to require the means to provide it. 40 Health Care at the Crossroads: Strategies for Creating and Sustaining Comm…
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Healthcare Emergency Management

Healthcare Emergency Management

Health Care at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Joint Commission on Accreditation of Healthcare Organizations © Copyright 2003 by the Joint Commission on Accreditation of Healthcare Organizations. All rights reserved. No part of this book may be reproduced in any form or by any means without written permission from the publisher. Request for permission to reprint: 630-792-5631. Health Care at the Crossroads Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Joint Commission on Accreditation of Healthcare Organizations Joint Commission Public Policy Initiative This white paper is the second work product of the Joint Commission’s new Public Policy Initiative. Launched in 2001, this initiative seeks to address broad issues that have the potential to seriously undermine the provision of safe, high-quality health care and, indeed, the health of the American people. These are issues which demand the attention and

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engagement of multiple publics if successful resolution is to be achieved. For each of the identified public policy issues, the Joint Commission already has state-of-the-art standards in place. However, simple application of these standards, and other unidimensional efforts, will leave this country far short of its health care goals and objectives. Thus, this paper does not describe new Joint Commission requirements for health care organizations, nor even suggest that new requirements will be forthcoming in the future. Rather, the Joint Commission has devised a public policy action plan that involves the gathering of information and multiple perspectives on the issue; formulation of comprehensive solutions; and assignment of accountabilities for these solutions. The execution of this plan includes the convening of roundtable discussions and national symposia, the issuance of this white paper, and active pursuit of the suggested recommendations. This paper is a call to action for those who influence, develop or carry out policies that will lead the way to resolution of the issue. This is specifically in furtherance of the Joint Commission’s stated mission to improve the safety and quality of health care provided to the public. Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Table of Contents Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Part I. Enlist the Community in Preparing the Local Response . . . . . . . . . . . . . . . . . . . . . . 10 Enlisting the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Forging New Partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 An Exemplary Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Lessons Learned . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Getting There . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Part II. Focus on the Key Aspects of the Preparedness System that Will Preserve the Ability of Community Health Care Organizations to Care for Patients, Protect Staff and Serve the Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Define Surge Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Preserve the Organization – Protect the Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Ensure Care for the “Other” Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Manage the Incident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Consider the Threat to Mind, as well as Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Enlist the Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Identify Communication and Information Needs and Meet Them . . . . . . . . . . . . . . 31 Test, Learn, Improve and Be Ready . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems . . . . . . . . . . . . . . . . . . . . . . . . . . 37 A Question of Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Sustainable Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Guiding the Effort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Knowing What Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 End Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Preamble But now, in the face of an atrophied public health infrastructure and lack of leadership and coordination among other emergency preparedness constituencies, hospitals and other health care organizations are being asked to step up their level of emergency preparedness involvement. This unfortunately is occurring at a time when many of those entities face severe resource constraints and may not always be able to manage current day-to-day patient care demands. It does not take long for complacency to settle in. Eighteen months after the September 11, 2001 attacks and the subsequent, insidious, selected and deliberate dispersion of anthrax spores, there are clear signs that the focus of American attention has long since moved on. The sense of urgency to prepare has now become a wait-and-see sense. Vigilance eventually gives way to ambiguity. Indeed, the two occasions during the past six months in which the national terrorism level has been raised to Orange (high threat) have generally provoked public mysticism as to what individuals should do to prepare. This confused state of non-readiness is what terrorists lay in wait for. And, the world in which we carry out our daily lives can change in an instant. At a recent national symposium on emergency preparedness, Jerome Hauer, acting assistant secretary of the Office of Public Health Emergency Preparedness of the Department of Health and Human Services (DHHS), remarking on the strong likelihood of another terrorist attack in the near future, said,“At the end of the day, it is medical care that will be needed.” But if medical care capacity is already in variable and sometimes scarce supply, planning for unexpected surges in demand becomes all the more critical. So, too, does funding and federal leadership for these efforts. This is not our world as we once knew it. It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday. Such systems make effective responses to emergencies possible, and they also serve as deterrents to actual attacks. And, they are needed – whatever the level of our sense of security – to facilitate the management of crises that seem to be becoming everyday occurrences. The purpose of this report is to frame the issues that must be addressed in developing community-wide preparedness and to delineate federal and state responsibilities for eliminating barriers, and for facilitating and sustaining — through leadership, funding and other resource deployment – community-based emergency preparedness across the United States. The concept of community-wide preparedness systems is new to most health care organizations. While most have long prepared and tested disaster plans, health care organizations have operated in isolation, and their disaster plans reflect this mindset. 4 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Introduction apparent, priority brought into sharp relief fundamental new needs for emergency preparedness that would call for leadership and coordination at the community level, which did not then, and largely does not now, exist. On the day that America experienced its worst violation at the hands of terrorists, the many “first responders” involved in rescuing, treating and protecting the thousands of people who were victimized, or had the potential to be, valiantly performed their jobs. But for many, their efforts were futile in the face of such enormous destruction. Emergency medical personnel and health care workers from nearby and far away were drawn to these scenes of destruction to lend their support and expertise. Hospitals in the vicinity of the World Trade Center, despite being overwhelmed by power outages, disabled telecommunications, and the rush of the injured and those fleeing the smoke-choked streets for shelter, were nevertheless able to summon a response. This does not gainsay the continuing extraordinary efforts of the three public safety agencies that this country has long relied on – law enforcement, fire and rescue, and emergency medical services. Nor does it ignore the sometimes heroic efforts of underfunded public health agencies and health care provider organizations in managing extremely challenging situations. But in most communities there is no team, nor teamwork, among all of these players and other municipal and county leaders. And, there is no community emergency preparedness plan, nor program, nor system. And then, while the country was still reeling from the September 11 attack, a different kind of attack, this time with a biological agent, anthrax, unfolded in Florida, New York, New Jersey,Washington D.C. and Connecticut.These disasters, wrought by terrorism, rapidly focused the nation’s attention on national security – the need to protect American ideals and resources, and most fundamentally, the very safety and health of the American people. Both for America’s leaders and for this nation’s communities, this compelling new, or newly While the cast of emergency preparedness players in a given community can lengthen rapidly, there is no denying the central role that hospitals can and must play in these efforts. However, these are difficult and occasionally overwhelming times for hospitals, even without this expanded responsibility. In fact, many hospitals are struggling to meet the daily demands for their health care services. It is no longer sufficient to develop disaster plans and dust them off if a threat appears imminent. Rather, a system of preparedness across communities must be in place everyday. 5 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Add to this brewing cataclysm the need for “surge capacity” – the ability to care for perhaps hundreds to thousands more patients at a given time – in hospitals already full, already stressed, and already searching for more resources to provide care, and the challenge of preparedness becomes even more daunting. As a matter of public policy, this country has purposefully shrunk the installed capacity of its health care delivery system over the past two decades. This has translated into the closure of many hospitals and even more emergency departments, despite the escalating demands for services. In addition, many hospitals now are experiencing severe shortages of nurses and other essential health care personnel. This is further reducing the capacity of these hospitals to deliver care, including emergency care. Today’s hard reality is that hospital emergency departments across the country are overcrowded and, even absent any external disaster, likely to be diverting patients on any given day. Since the Fall 2001 terrorism attacks, there has been a flurry of activity focused on the preparation of emergency preparedness plans.The emphasis on plans substantially understates what are really needed – emergency preparedness programs. According to a recent report,“Preparedness at home plays a critical role in combating terrorism by reducing its appeal as an effective means of warfare.”4 However, this level of preparedness implies a tightly knit system among the key emergency preparedness participants that simply does not exist in most communities today. “All emergencies are local” is a truism that conveys the responsibility of the community to plan, prepare and respond to an emergency. But as this paper points out, that truism is today far more a call to action than a reality. This paper is a call to action for federal and state governments as well, for weaving the tightly knit system of preparedness also takes resources, leadership and guidance. Adding to these problems are sky-high liability insurance premiums for physicians that are limiting the availability of critical specialists in certain jurisdictions. Further, most states in the country, with strapped budgets, are reducing the numbers of people on their Medicaid rolls.1 Medicare too is threatening more cuts in hospital reimbursement2 and the numbers of uninsured are on the rise.3 All of these factors promise to further undermine the ability of hospitals to meet the routine, let alone the extraordinary, needs of their communities. 6 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems none yet that present evidence-based models which are likely to be adaptable to the varied urban, suburban and sparsely populated communities that make up the United States. Since the events of September 11 and the subsequent anthrax attacks, the federal government has stepped forward to fund the rehabilitation of the public health system, and to a significantly lesser extent, the preparedness efforts of the nation’s hospitals. However, although the federal plan enlisted state governments to allocate federal funds to their hospitals well over a year ago, the money has not yet reached hospitals and some local public health agencies. There unfortunately is an oft-repeated refrain of money not making it from Washington to the trenches where it is needed.5 The money may eventually make it, but the funds are a small sum in comparison to what is actually needed.6 Given the urgency for community-based emergency preparedness and the obvious barriers to achieving this goal across the country, the Joint Commission convened an expert Public Policy Roundtable to discuss emergency preparedness issues and to frame specific recommendations, fulfillment of which would permit achievement of a level of preparedness that could truly offer protection and assurances to the American public. Among the specific issues addressed by the Roundtable were the resources and requirements for community-based response systems; the need for collaboration between the medical care and public health establishments, as well as other new partnerships that must be forged; issues of accountability and mechanisms for validating readiness; and the appropriate roles of federal and state governments. In addition to the disputes and confusion over meeting what remains today for many hospitals, an unfunded mandate, hospitals and their communities are struggling to know how to get started. There is a fundamental need for templates or scalable models of community-wide preparedness to guide planning before, and actions taken during and after, an emergency. Several nascent templates are emerging; however, there are In addition to the disputes and confusion over meeting what remains today for many hospitals, an unfunded mandate, hospitals and their communities are struggling to know how to get started. 7 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Based on those discussions, the following recommendations are proposed: II. Focus on the key aspects of the preparedness system that will preserve the ability of community health care resources to care for patients, protect staff and serve the public. • Prospectively define point-in-time and longitudinal surge capacity at the community level. • Establish mutual aid agreements among community hospitals and other health care organizations. • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. • Support the provision of decontamination capabilities in each hospital. • Maintain the ability to provide routine care. • Make provision for the graceful degradation of care. • Provide for waiver of regulatory requirements under conditions of extreme emergency. I. Enlist the community in preparing the local response • Initiate and facilitate the development of community-based emergency preparedness programs across the country. • Constitute community organizations that comprise all of the key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. • Encourage the transition of community health care resources from an organization-focused approach to emergency preparedness to one that encompasses the community. • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. 8 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities and fluidity of authority. • Make provisions for accommodating and managing the substantial acute mental health needs of the community. • Directly address the fear created by terrorist acts through targeted education, application of risk reduction strategies and the teaching of coping skills. • Provide public education about emergency preparedness. • Actively engage the public in emergency preparedness planning. • Anticipate the information needs of the community. • Create redundant, interoperable communications capabilities. • Develop a centralized community-wide patient locator system. • Engage the mass media in the emergency preparedness planning process. • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills. • Assure the inclusion of all community emergency preparedness program participants in the plan tests. III.Establish accountabilities, oversight, leadership and sustainment of community preparedness systems • Develop and implement objective evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans. • Provide funding at the local level for emergency preparedness planning. • Explore alternative options for providing sustained funding for hospital emergency preparedness activities. • Initiate and fund public-private sector partnerships that are charged to conduct research on and develop relevant, scalable templates for emergency preparedness plans that will meet local community needs. • Disseminate information about existing best practices and lessons learned respecting existing emergency preparedness initiatives. • Clarify the applications of EMTALA, HIPAA, EPA and other regulatory requirements in emergency situations. • Coordinate domestic and international emergency preparedness efforts. This paper provides supporting documentation for its conclusions, describes specific recommendations, and assigns accountabilities for carrying out these recommendations. 9 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems I. Enlist the Community in Preparing the Local Response preparedness to one that encompasses the entire community and its resources. The planning process is expected to systematically address the full range of potential disasters – including terrorism — identified through a “hazard vulnerability assessment,” that is conducted in collaboration with the organization’s community. The standards also require that organizations define an internal command structure that links with the community command structure. A final new requirement, stemming from the 2001 Houston flood experience and the September 11 experience, requires the health care organizations in the community to work cooperatively to create a mutual aid context for planning and response efforts. A New Context for Disaster Planning The Joint Commission has long required accredited organizations to create disaster plans and to test them at least twice a year. For many organizations, these requirements have often seemed like “make-work.” Only in those communities where actual disasters have struck has all of the actual preparation appeared to have been worth it. But the events of September 11, 2001 have created a new world for America’s communities and a new context for disaster preparedness for health care organizations. Almost propitiously, the Joint Commission had — during 2000 — been working to upgrade and reframe its traditional disaster preparedness standards into an expanded community-based emergency management framework. These new requirements were introduced in January 2001. The urgency to move these new requirements forward had resulted from a series of conversations with senior military and health care officials. Underlying the new Joint Commission standards is the fact that, in an emergency situation, health care provider organizations must work with each other and with other public safety and support entities to manage the casualties that have occurred and to minimize the risk of additional casualties. Managing a mass casualty or bioterrorism situation is no job for a single provider organization. The expanded framework of expectations now in place seeks to transition hospitals and other health care organizations from an organization-focused mindset of disaster Managing a mass casualty or bioterrorism situation is no job for a single provider organization. This is, in fact, the responsibility of “the community” – an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations. 10 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems disease prevention activities, management of disease outbreaks, and intervention in community-wide emergency department overcrowding situations. This is, in fact, the responsibility of “the community” – an as yet ill-defined composite that, at a minimum, includes emergency medical services, fire, police, the public health system, local municipalities and government authorities, and local hospitals and other health care organizations. Emergency planning must be local – that is, based in the community – because almost all disasters and mass casualty situations are local. The sobering reality is that many communities will be on their own for the first 24-72 hours after such an event. Community-wide emergency preparedness programs do exist, and some are quite elaborate. However, they are few in number, and almost all exist is large metropolitan areas. By contrast, most of America’s communities are “waiting for someone to call the meeting.” Creating a detailed emergency preparedness plan, or program, particularly in the face of uncertain resource support is – to be sure – a daunting challenge. Indeed, planning templates that might serve as reference points for inexperienced project leaders are virtually non-existent. And the challenge is heightened still further by the fact that the core participants are in many ways strangers to each other, and each, by virtue of their unique responsibilities, is used to being “in control.” Enlisting the Community There thus exists a fundamental need to formalize an organization of community resources. That organization should comprise those authorities, agencies, providers, industries and other vital community elements that are critical to mounting an effective emergency response and protecting the community. This new “community organization” must then have the authority, and with this, both the necessary funding and accountability for planning, assessing and maintaining community-wide emergency preparedness — in effect, making the plan a program. Further, the program that is brought to life must have an ongoing reality, one in which the participants become familiar with their respective roles and a capabilities because they are working and interacting with each other on a regular basis. Such operational preparedness programs need not be theoretical. Among the obvious opportunities for ongoing collaborative efforts are community-wide health promotion and Yet, the planning process – the building of the relationships that will become the program – is a fundamental exercise in give-and-take. This is indeed a process in which primacy and control are relinquished to create a greater good.The new give-andtake relationships also set the stage for the management of actual disasters. Such management is almost always situational. That is, the nature of the situation dictates the command structure and who will be “in control.” 11 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Community-wide preparedness also has its pragmatic virtues, particularly in optimizing the deployment of available resources. For example, communication and collaboration among local hospitals make it much less likely that multiple hospitals will be depending on the same community resources for their own emergency planning purposes. One focuses on the care of the individual, the other on the health of the population. Their funding sources reflect these differing orientations – medical care is dependent on private funding; public health on public funding. But these old divisions must be bridged in order to ensure an integrated emergency response – in order to create a tightly woven preparedness system. Some of the ways in which the medical care and public health sectors can and should begin to collaborate are in developing health surveillance systems, in facilitating inter-organizational communication systems, and in the training of care providers to recognize signs and symptoms of exposure to chemical, biological or radiological agents. The potential response capability may in fact be called upon to expand in relation to the reach of the devastation brought by a catastrophic event. Such an event may cross multiple jurisdictions, necessitating a broader coordinated response among communitybased emergency preparedness programs. However, the effectiveness of a broad response cannot be fully realized unless the basic community programs are first put in place. There have also been frictions, of varying degree, between fire and police, between emergency management agencies and public health agencies, between emergency medical services and hospitals, and between city and county government authorities, among others. But these frictions can and must be overtaken by a new partnership mentality, and additional partners need to become engaged. Forging New Partnerships Some of the partnerships that must be forged face long-standing historical obstacles. There, for example, exists a long-standing gulf between medical care and public health. These two health care sectors have never had an effective working relationship.7 Accountability Tactics municipalities emergency management agencies hospitals public health agencies • Initiate and facilitate the development of community-based emergency preparedness programs across the country. 12 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems across responding organizations and agencies. The Council has also facilitated the implementation of syndromic surveillance systems at both the state and local levels. In addition, the Council has aided the New York State Department of Health in the development of a Web-based capacity-monitoring system to gauge bed and supply availability, and staffing levels at area hospitals. The Web-based system also collects patient information to serve as a patient locator system in the event of a mass casualty event. There are now encouraging indications that this is beginning to happen. For example, since September 11, the military have been involved in training civilian health care personnel and in participating in hospital emergency drills.8 And, in New York City, city and state public health agencies, hospitals, emergency medical services, city emergency management officials, and others have established new working relationships that undergird a state-of-the-art preparedness system. An Exemplary Effort In the aftermath of the terrorism attacks in New York City, the Greater New York Hospital Association (GNYHA) has taken a leadership role in forging a cross-disciplinary, cross-jurisdictional partnership among responding authorities, agencies and providers. In creating the Emergency Preparedness Coordinating Council, the GNYHA has helped its member organizations — and local, state and federal public health and emergency management agencies — to become better prepared, and able to offer an integrated response to a disaster.9 According to the GNYHA, many of the initiatives that the Emergency Preparedness Coordinating Council has spearheaded have focused on the collection of data — before, during and after an emergency – that are critical to waging an effective response and recovery. Among these initiatives, the Council has developed an emergency contacts directory to improve communications among key personnel Taking the lessons learned from the World Trade Center disaster and the subsequent anthrax attacks, the GNYHA and its Emergency Preparedness Coordinating Council have focused on helping local health care organizations and public safety agencies to improve upon those response elements that went wrong. For instance, telecommunications capabilities in the vicinity of Ground Zero were lost. To ensure effective communications in the event of another disaster, the Council has worked with the Office of Emergency Management (OEM) to purchase and distribute 800 Megahertz radios, and has established a dedicated channel for health care organizations to communicate with one another and with OEM. The Council has also taken a prominent role in informing and educating health care personnel in the detection of and response to biological, chemical and nuclear events. 13 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Letters mailed in October of 2001 that contained highly virulent, weaponized anthrax constituted the first bioterrorism attack in this country to which the Centers for Disease Control and Prevention (CDC) had to respond.10 A total of 22 confirmed or suspected cases of anthrax infection –11 inhalational, which led to five deaths, and 11 cutaneous cases – resulted from the anthrax attack.11 While the investigation into the perpetrator of the “anthrax letters” remains open, the public health response and medical care for those affected are now a case history of lessons learned. Lessons Learned The events of September 11 were instantly recognizable as disasters, and each prompted immediate action by all first-responders. In New York, calls went out across the city, the state, and surrounding states for hospitals to ready for victims. But some emergencies are not readily apparent. Rather, they unfold over days or weeks. The anthrax attack in the fall of 2001 was just such an emergency, and it raised important issues of cross-disciplinary and cross-jurisdictional coordination and authority as the impact of the attack unfolded. Tactics Accountability • Constitute a community organization that comprises local government officials, emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medical services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. community organization participants • Encourage the transition of community health care institutions from an organization-focused approach to emergency preparedness to one that encompasses the community. community organization • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. federal and state government agencies 14 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems both postal workers from the Brentwood postal facility in Washington, D.C., who sought medical attention for their severe flu-like symptoms.15 The first challenge in responding to the anthrax attack was in making the initial diagnosis. Few clinicians have presence-ofmind awareness of the signs and symptoms of bioterrorism agents, such as anthrax, smallpox, and plague. In fact, in a recent study of preparedness among family physicians for bioterrorism, only one-quarter of those surveyed felt prepared, and still fewer, 17 percent, reported that their local medical communities could respond effectively.12 However, prior training in bioterrorism was a significant positive factor in the responses of physicians who perceived themselves to be ready to respond to an attack.13 In addition to the fatal delays in diagnosis, there were significant breakdowns in communications across health care disciplines and public health authorities in the anthrax attack response. In particular, the ability or willingness of the public health system to communicate and work with the medical care system arose as an issue.When the first case of inhalational anthrax in a Brentwood postal worker was preliminarily diagnosed at a D.C.-area hospital and reported to public health officials, these officials, doubting the diagnosis16, did not immediately act to notify other area hospitals. At an early evening news conference the following day, officials “played down” the patient’s condition, saying it was “unconfirmed.”17 Potentially important opportunities for screening emergency department visitors were lost across the D.C. area. The first diagnosis of anthrax in the 2001 attack was made by an astute physician who suspected the disease; the confirmation was subsequently made by a laboratory worker who had undergone bioterrorism preparedness training. But the general unfamiliarity of medical professionals with bio-agents contributed to the misdiagnosis and delayed treatment for two other infected patients, Emergency preparedness is already a way of life in some countries; it needs to be woven into the fabric of American life to a much greater extent than it is today. 15 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Aside from local grass roots efforts, there was no infrastructure in affected areas that would have made it possible for vital clinical information to be shared in an emergency situation across the medical care community, or between public health authorities and practicing clinicians. Stories were told about physicians, even in prominent teaching hospitals, having to get their medical information from CNN during the height of the crisis.18 The Hart Senate Office Building was closed, as were other Senate office buildings, and, even briefly, the House of Representatives, until the risk of anthrax exposure had been clarified. Until credible, standardized bioterrorism response protocols are established and widely disseminated, the risk of promulgation of conflicting information and diversity in responses will continue to exist. This fundamental missing link could eventually undermine the public trust in the limited infrastructure now in place. The communications failure between and among public health officials and the medical community, and the limited base of expert information among those providing critical advice, had a tragic impact on postal workers in Washington D.C.’s Brentwood postal facility who were repeatedly reassured that no risk of anthrax contamination was posed to them.19 Two eventually died from inhalational anthrax. Getting There Americans, their families, and their community institutions increasingly tend to lead insular existences, but insularity is the antithesis of what will be needed to create emergency preparedness programs across America’s communities. Emergency preparedness is already a way of life in some countries; it needs to be woven into the fabric of American life to a much greater extent than it is today. In New Jersey, the health commissioner decided to ignore CDC recommendations and administer prophylaxis to all postal workers at two Trenton-area postal facilities.20 Accountability Tactics • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. health care and public health membership organizations federal government agencies • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. federal and state government agencies 16 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems few of these dollars are making their way down to the local community level. The funding allocated to public health is highly appropriate, but at the planned funding levels will only restore most public health departments to a baseline functional state. Meanwhile, most hospitals, which are required by the Joint Commission to be engaged in emergency planning and preparedness activities, have yet to see their first nickel of federal terrorism preparedness funds. Over time, the emergency preparedness engine simply cannot run without fuel. What needs to be done? First, someone does need to call the first meeting, to bring the parties together. The participants will vary by community, but the logical conveners are relatively few: the local emergency management agency, the local public health agency, and/or the local hospital(s). In small, sparsely populated communities, the hospital may be the only logical convener. Second, community planning templates need to be developed and disseminated. The disaster-based experience that is needed to develop meaningful templates is, fortunately, limited in this country, but available knowledge from experiences in the United States and elsewhere needs to be harvested and translated into scalable models that lend themselves to ready adaptation by communities of various types. Emergency preparedness plans that are created out of whole cloth are unlikely to offer comprehensive protection for a community. One might well ask whether such an extensive community-preparedness effort, and the funding and other resources required to support such an effort, are really necessary or justified. Today, the perceived terrorism vulnerabilities are clearly focused on the country’s major metropolitan areas. Nevertheless, it is well to remember that the primary objective of terrorism is to create fear. Little imagination is required to understand the potential psychological impacts on the populace of even a few selected terrorism attacks on typical small towns across America. Third, emergency preparedness at the community level takes resources, especially money. Despite the ballyhooed billions of federal dollars being poured into terrorism prevention and preparedness efforts, very 17 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Recommendations Accountability Tactics municipalities emergency management agencies hospitals public health agencies • Initiate and facilitate the development of community-based emergency preparedness programs across the country. • Constitute a community organization that comprises local government officials, emergency management officials, public health authorities, health care organizations, police, fire, public works (e.g. water, electricity), emergency medical services, local industry leaders, and other key participants – as appropriate to the community – to develop the community-wide emergency preparedness program. community organization participants • Encourage the transition of community health care institutions from an organization-focused approach to emergency preparedness to one that encompasses the community. community organization • Provide the community organization with necessary funding and other resources and hold it accountable for overseeing the planning, assessment and maintenance of the preparedness program. federal and state government agencies • Encourage the pursuit of substantive collaborative activities that will also serve to bridge the gap between the medical care and public health systems. health care and public health membership organizations federal government agencies • Develop and distribute emergency planning and preparedness templates for potential adaptation by various types of communities. federal and state government agencies 18 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems II. Focus on the key aspects of the preparedness system that will preserve the ability of community health care organizations to care for patients, protect staff and serve the public. time-limited period to accommodate the needs emanating from an acute disaster will eventually be needed by patients having more “routine” care requirements such as surgical procedures, cancer chemotherapy, or the delivery of a child. Thus, the capacity needed to manage longer-term disasters, e.g., a biological attack, may eventually be in direct competition with the ongoing care needed by the people in the community. Preparedness Priorities Developing a community-based preparedness program requires forethought of a wide variety of issues that could determine the outcome of a response. These include education of first responders, provider organization staff, and the public; creation of redundant, reliable communication systems; definition of roles and responsibilities among responders; definition of available human, equipment and supply resources; and incident management and coordination, among others. Among these are a series of truly critical elements of the preparedness system that are integral to the ability of a community to successfully mount an effective response. These are elaborated upon below. It is important that surge capacity – both in its point-in-time and longitudinal dimensions – be prospectively determined as part of the emergency planning process. There is also a basic need to define an agreed-upon set of units, or measures, of surge capacity at the federal level or, at the very least, at the state level. Such definition is essential to the communication of needs within and across communities. 1. Define Surge Capacity Surge capacity – the ability to expand care capabilities in response to sudden or more prolonged demand – is perhaps the most fundamental component of an emergency preparedness program. Surge capacity encompasses potential patient beds; available space in which patients may be triaged, managed, vaccinated, decontaminated, or simply located; available personnel of all types; necessary medications, supplies and equipment; and even the legal capacity to deliver health care under situations which exceed authorized capacity. Surge capacity has both point-in-time and longitudinal dimensions, and these differ from each other. That is, capacity that can be mobilized for a Current Capacity The American Hospital Association (AHA) reports that there are 900 fewer hospitals today than there were in 1980.21 Through the 1980s and 1990s, the expansion of managed care and increasingly stringent federal reimbursement policies progressively leveraged hospitals to close and consolidate, and to reduce overall capacity in an effort to create greater efficiencies in the delivery system. Today, with the aging of society and the corresponding increase in patient acuity, many hospitals are now challenged to meet a typical day’s demand for their services. 19 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems surge capacity exists in these communities. The underlying causes of this problem are well known — inadequate numbers of hospital beds, limited access to primary care, unavailability of physician specialists, and major shortages of other key clinical personnel, especially nurses. As a reflection of this challenge, hospital emergency departments in many cities are frequently overcrowded and likely to be diverting ambulances on any given day. According to a recent AHA survey, 62 percent of all hospitals and 79 percent of urban hospitals are at or over emergency department (ED) capacity.22 More than half of urban hospitals report that they have been on “diversion” – diverting ambulances – for a portion of time.23 In many communities, accurate, standardized measurement of bed capacity has become an immediate need. Available hospital bed capacity is typically determined through a daily midnight census of occupied inpatient beds. Measuring bed capacity in this way fails to account for the inflow and outflow Overcrowded emergency departments are a clear and visible symptom of a destabilized health care environment, and raise clear and compelling questions as to whether any real Accountability Tactics Surge Capacity • Determine standardized, universal measures of surge capacity. federal and state government agencies community organization • Prospectively define point-in-time and longitudinal surge capacity at the community level. community organization • Identify latent space and human resources capacities. community organization • Establish mutual aid agreements among community hospitals and other health care organizations. health care organizations community organization • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. health care organizations community organization • Standardize equipment, supplies and medication doses to facilitate the provision of safe, efficient care. health care organizations pharmaceutical companies community organization federal government • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. 20 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems also the Nursing Reserve Corps. – a roster of volunteer nurses who may be deployed to a disaster site or mass vaccination clinic if and when such needs arise. However, the actual availability of these nurses during a disaster remains uncertain. Depending on the extent of the disaster or the occurrence of concurrent disasters, many of these nurses may be needed in their own communities. Even absent a local disaster, provider organizations in a given community may not be able to release volunteer nurses from their staffs without compromising their own care capabilities. occurring throughout the hospital all day long and almost certainly overestimates available capacity. The Agency for Healthcare Research and Quality has embarked on a study to determine useful, relevant measures that can predict the imminent onset of emergency department overcrowding. Overcrowding in most or all of a community’s emergency departments which results in widespread ambulance diversions is, one could argue, itself a community disaster which should cause activation of the community’s emergency preparedness plan. Too Few Caregivers A severe shortage of nurses is already compromising access to health care services today,24 and a potential shortage of more than 400,000 nurses is projected by 2020.25 Given this reality, it is unclear how additional nursing services can be made available in the face of a natural or terrorist disaster. In addition to the shortage of nurses, there are acute shortages of pharmacists, laboratory technicians, respiratory therapists, and, increasingly, physicians. A planned source of surge capacity in the event of a disaster is the National Disaster Medical System (NDMS). NDMS is administered by the Office of Emergency Response (OER), which will transition from DHHS to the Department of Homeland Security in March 2003. NDMS teams include nearly 8,000 volunteer health care professionals from around the country who have been organized into general and specialty teams to help local communities respond to a disaster. Several major initiatives are underway to attract potential nurses into health care. Most notable among these is the recently enacted, but only modestly funded thus far, Nursing Reinvestment Act. This Act contemplates support both for nursing school faculty and for aspiring students, and provides for nurse recruitment campaigns. However, the long-term impacts of these initiatives are difficult to gauge. DHHS Secretary Tommy Thompson recently called for more robust funding for the Nurse Reinvestment Act, and In many communities, accurate, standardized measurement of bed capacity has become an immediate need. 21 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems was no existing mechanism to document their knowledge, skills, and experience – i.e., their credentials. Nor was there any way to objectively catalogue the special competencies that were then on-site and those that were still needed. There are currently 27 primary care teams who can, under ideal circumstances, respond to an emergency call within 12 to 24 hours. Four teams specialize in responding to an incident caused by a chemical or bioterrorism attack. There are also burn teams, mental health teams and disaster mortuary teams that can assist in a mass casualty event. But for the same reasons that a threshold number of nurses may not be available to travel to a disaster, neither may the health care workers who comprise the NDMS teams. The subsequently enacted Public Health Security Act includes a provision for the creation of a national emergency volunteer system for health care professionals. However, DHHS has not yet funded this initiative. The events of September 11 dramatize the urgency for moving this project forward. A national credentialing system built upon a common technology platform and using consensus credentialing standards would also provide rapid access to information on volunteer clinicians – both in the planning process and during an actual event. Truly adding to the capacity of available personnel in a disaster or emergency response may necessitate drawing upon medical, nursing and allied health students. DHHS is also encouraging health care organizations to consider retired physicians and nurses in their personnel surge capacity planning.26 Finally, there is also a clear role for the lay public in caring for themselves or family members in the face of a disaster. Even today, 70-90 percent of routine care is being provided by family members or other non-professional caregivers.27 While the lay caregiver role certainly has its limitations, an educated public is an important potential resource. Space and Supplies Space is a further critical consideration in defining and developing surge capacity. Space needs are defined in large measure by the uses for which the space might be deployed. Such uses include a wide range of potential activities which should be catalogued and addressed in the emergency preparedness plan. Among the diverse potential needs for space are triage, decontamination, mass vaccination, temporary mortuary, counseling, and patient care. In some instances, temporary expansion of hospital capacity will be most appropriate, e.g., through converting single patient rooms to doubles, and use of cafeteria, meeting room and office space. In other cases, nursing homes, clinics, At the same time, a disaster must not become a disorganized free-for-all for well-intended, would-be caregivers. In the immediate aftermath of the September 11 events, physicians and nurses came to the disaster sites and nearby hospitals from near and far to offer their services. But nobody knew who they were. Had their services been needed, there 22 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems patients for the first 48 hours of an emergency. Distribution of the SNS supplies also requires that there be local capacity to quickly unload, transport and administer the drugs across the affected region. rehabilitation centers, and surgery centers will be appropriate to the needs. And in still other instances, hotels, closed hospitals, armories, auditoriums and similar facilities can be utilized. Finally, caring for people in their own homes is an important source of surge capacity, and may be a particularly attractive alternative in the event of a biological attack with an infectious agent. Fully cataloging space options is also particularly important in light of the distinct possibility that hospitals and other organized settings of care may themselves become disaster casualties. There is finally an important need to standardize equipment and supplies to the extent possible. With the potential for enlisting volunteer medical personnel or borrowing staff from other hospitals in the region, such standardization will reduce the likelihood of errors and untoward events and facilitate the provision of care. Examples include standardizing switches, dials and gauges on oxygen equipment, and standardizing packaged doses of pharmaceuticals. As important as the need for identifying space options, is the need to assure the availability of adequate reserves of medications, equipment and other supplies. While immediate outside support may be forthcoming, a given community may be on its own for hours to days following a disaster. 2. Preserve the Organization — Protect the Staff “When I had a chance to look outside the command center, I saw all the doctors and nurses watching and waiting,” said Mary Thompson, the incident commander and chief operating officer at Bellevue Hospital in Manhattan, following the September 11 attack on the World Trade Center.28 “I realized if there was a biological component to this attack, they would all be contaminated. If that had been the case, I would have had to call all new surgeons.”29 By way of example, although a “push pack” is promised within 12 hours of request, pharmaceutical supplies from the Strategic National Stockpile (SNS) may take up to 48 hours to reach the locations in which they are needed. DHHS suggests that hospitals maintain enough antibiotics on hand to supply hospital staff, first responders and Despite their eagerness to respond, health care workers face real risks in doing so. Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response – to themselves and to the organization. 23 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems 500,000 first responders and health care workers. A growing number of hospitals have abstained from the pre-event vaccination program, citing the unnecessary risk to health care workers and others from the vaccine in absence of a clear smallpox threat.30 There are important lessons to be gained from this potential scenario. Sadly, one of those lessons is that there is no “face value” to terrorism. Every event must be regarded with great caution and suspicion – a bomb may be a “dirty bomb,” an explosion could be accompanied by a release of a biological agent. The responsibilities of hospitals and other health care organizations to their employees extend beyond physical protection. An emergency response can be as emotionally anguishing as it is physically punishing. The care and support for organization staff must encompass their mental health needs as well. Hence, there is a particular need for sensitivity to personal concerns and obligations when workers, for instance, may be separated from their families and loved ones for long hours and even days. Communications support, attention to child-care needs, provision of transportation alternatives, and even direct on-site personal support can all help to alleviate worker stress. In fact, health care organizations may be well served by gathering information about staff concerns and obligations before an event occurs. For example, sixty-two percent of St.Vincent’s Catholic Medical Center’s emergency department nurses are spouses or partners of first responders in the New York City region.31 On September 11, they were asked to perform their duties on a day that must have been both professionally and personally anguishing. Despite their eagerness to respond, health care workers face real risks in doing so. Staff members need to be trained and be provided proper equipment to reduce the risk of an unsafe response – to themselves and to the organization. These staff must also have the highest priority for prophylactic antibiotics, chemical antidotes, and other practical therapeutic measures. Each hospital should have a decontamination capability in place to manage workers and patients and to preserve the ability of the organization to provide care. Although there has been some debate as to the need for such a broad-based capability, the practical reality is that the determination of contamination will often not occur until the patient has undergone a screening examination and initial stabilization. Reducing the risk to caregivers and preserving the capability of the organization to treat patients also underlies current planning regarding smallpox vaccinations.The President has authorized a pre-event vaccination program beginning with the voluntary vaccination of approximately 24 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems “federal zone,” prohibiting entry by unauthorized individuals and vehicles. New York University Downtown Hospital became the home care provider of only choice for the residents of an apartment building across the street when home care agency nurses could not breach the federal zone.32 Fortunately for these home care patients, a hospital was located across the street. In addition to receiving communications support in reaching family and loved ones, frontline workers need real-time, current information about an event that is in progress. Keeping staff apprised of “what’s going on” within the organization and across responding organizations helps them anticipate downstream needs and gain a sense of control over their own environment. In addition, maintaining contact with the “outside world” through the Internet and broadcast media can help staff avoid feelings of detachment. In order to gain capacity to care for more victims in the wake of an emergency, hospitals may cancel scheduled surgeries and defer other planned diagnostic, therapeutic and rehabilitative activities. This may buy time, but it will not buy long-term capacity. Scheduled surgeries have been scheduled for sound reasons and cannot be delayed indefinitely. 3. Ensure Care for the “Other” Patients In a massive disaster, there is the potential that many chronically and acutely ill patients could lose access to their physicians or settings where they usually receive care or obtain medications. This happened in New York City on September 11 when the affected portion of the city was declared a Accountability Tactics Direct Caregiver Protection • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. health care organizations community organization • Provide direct caregiver support to meet mental health and other personal needs. health care organization • Support the provision of decontamination capabilities in each hospital. federal and state government hospitals community organization • Assure direct caregiver access to current information about the emergency on a continuing basis. health care organizations community organization 25 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Their privacy will be compromised, but their wounds will still be treated. Care and access to caregivers may even become rationed. The goal of graceful degradation is to avoid having the health system become a victim of the assault – from becoming incapacitated and unable to deliver care of any kind. The hospital, in essence, must engineer its failures – those that it can allow – while maintaining its ability to provide care. Delivering mothers will still need access to hospital obstetric and neonatal units, cancer patients to radiotherapy units, stroke patients to rehabilitative services, and so on. In the face of the requirement for a sustained response to an emergency, and once every option has been exercised for the transfer and treatment of patients in various settings and at various levels of care, something less than the usual standard of care in the affected community must become acceptable. At the same time that graceful degradation of health care services is occurring, the care providers and health care organizations must be exempted from the day-to-day rules of operation and regulations that otherwise would prohibit them from caring for patients in such fashions. Indeed, they must be legally protected from reciprocal actions that may occur, for instance, for violations of privacy or delivery of sub-standard care once a state of emergency has been declared. Graceful Degradation Like the electrical utility that plans for “brown-outs” in order to avoid “black-outs,”33 hospitals and other provider organizations – when stretched beyond their limits, must begin to plan to engineer their failures. The goal of such efforts is to achieve “graceful degradation” of the health care system’s care capabilities as opposed to catastrophic failure of its services. Under such scenarios, patients may need to be treated and boarded in hallways. Accountability Tactics Meeting the Care Needs of All Patients • Maintain the ability to provide routine care. health care professionals health care organizations community organization • Make provisions for the graceful degradation of care in all emergency preparedness plans. health care organizations community organization • Provide for waiver of regulatory requirements and other standards expectations under conditions of extreme emergency. federal and state government agencies accrediting bodies 26 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems sharing vital information, and managing the logistics of an integrated response. The incident management system should also establish the common terminology that community participants in the emergency management program are expected to use, in order to reduce the risk of miscommunications. 4. Manage the Incident Often referred to as “command-and-control” or incident command systems, the established authorities that have taken on responsibilities for managing emergency responses have often taken on an unnecessarily militaristic tone.34 Command and control may, indeed, be necessary, but so too are effective coordination and communication. The basic need is for an integrated response that is managed through either an incident command system or, when circumstances warrant, a unified management approach. Although definitive studies have not been conducted to establish the evidence base for the incident command system approach, it proved to be an integral element of the generally effective responses to the earthquake and fire disasters that have historically beset California, and in the September 11 attacks in New York City and Washington D.C. The variability of emergencies and the evolution of responses to them over time necessitate that the incident management system provide for fluidity of authority to adjust to changing needs. These characteristics of emergency management may also require that there be multiple, but unified authorities managing the response. Application of such an incident management system does not preclude others from having authority and responsibility within their domains of expertise or experience. Rather, it assures that there is an emergency management structure in place that is responsible for coordinating resource deployment, The importance of such systems is also emphasized by their absence. During the 2001 anthrax attacks, there was no incident management system of any kind. Nor was there any coordinated response among various authorities within localities or across multiple jurisdictions. So disjointed was the response that differing information was provided by various responsible public health offices as to how to recognize and treat anthrax infections. Accountability Tactics Incident Management community organization • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities, and fluidity of authority as a function of the scale and nature of the emergency situation. 27 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems that individuals need not be in the vicinity of a catastrophic event to experience substantial event-related stress.39 With eyes glued to the graphic television coverage across the nation, 90 percent of adults surveyed reported having some symptoms of stress.40 While 60 percent of those in close proximity to the sites of attack reported high degrees of stress, 36 percent of respondents living more than 1,000 miles away from the World Trade Center also reported substantial stress.41 Recognizing the need for a functional conduit of accurate information, the District of Columbia Hospital Association worked with emergency physicians across the National Capital Region to organize daily conference calls that created interfaces among the health care providers, local public health representatives, the D.C. Department of Health, and the CDC.35 5. Consider the Threat to Mind, as well as Body Significant consideration must be given to the psychological effects of a disaster. It is estimated that for every one physical casualty caused by a terrorism incident, there are four to 20 psychological victims.36 The September 11 attack has been described as a “mental health catastrophe.”37 In just one of the hospitals proximate to the attack in New York City — St.Vincent’s Catholic Medical Center — staff in the psychiatric department provided counseling and support to more than 7,000 people and received more than 10,000 calls to their help line during the first two weeks following the disaster.38 Though initially traumatized, the vast majority, through their own resiliency, will suffer no significant residua;42 however, some will manifest symptoms of post-traumatic stress disorder (PTSD). Even then, most PTSD sufferers typically recover rapidly.43 However, in the rare event that PTSD persists, it requires evaluation and treatment.44 Other trauma-related disorders are more common.45 These include unexplained physical symptoms, sleep disturbances, increased use of alcohol and cigarettes, and increased family conflict and violence.46 But, because these symptoms are often associated with the stresses of daily living, they may easily be overlooked and not associated with the traumatic event.47 Results of a survey conducted by the RAND Corporation three to five days after the September 11 attack clearly demonstrated Accountability Tactics Mental Health Management mental health professionals health care organizations community organization • Make provisions for accommodating and managing the substantial acute mental health needs of the community when a natural or terrorist event occurs. 28 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Psychological victims often also include those involved in treating the physical casualties. In fact, disaster responders, including medical personnel, are a high-risk group for developing trauma-related disorders. In addition to assuring access to personal protective equipment (PPE), vaccination and prophylactic treatments for first responders and frontline health care workers, health care organizations need to direct attention to mitigating the stress-related psychological effects of disaster response on these individuals. sense of security. A recent incident in which 250 people were exposed to radioactive material in Goiannia, Brazil illustrates the psychological impact of a terrorizing event. Five thousand of the first 60,000 people who sought medical care after awareness of the incident spread, though unexposed, developed the physical symptoms (rash and nausea) that mimicked those of radiation exposure. All told, 125,000 people sought medical screening for radiological contamination – a 500-to-1 ratio of patients screened to patients exposed.51 Throughout the duration of the response, responders should be given – even if it must be mandated for some – rest periods. Over-dedication is a risk factor for developing PTSD.48 Further, care providers should be encouraged to “naturally debrief” – that is to talk with their colleagues, friends and families about their experiences.49 First responders and other high-risk groups should also be evaluated over time following the disaster to monitor their recovery and detect any signs of an “abnormal response.”50 Fear, though, can be assuaged through targeted education, application of risk-reduction strategies, and the teaching of coping skills.52 6. Enlist the Public While the fear bred by a disaster or terrorist incident may far exceed the deleterious effects of the occurrence itself, it would be unfair to characterize that fear as unreasonable. In the face of real threats to safety and the absence of credible and helpful information, public fear may indeed be reasonable.53 But, contrary to common perception, widespread panic is rare in response to disasters.54 The preparedness program should also anticipate and address the “fear factor” inherent in terrorism. The goal of terrorism is, after all, to instill fear and erode society’s Significant consideration must be given to the psychological effects of a disaster. 29 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems The public may indeed assume even more basic life-saving roles in emergency situations. In a mass casualty event, rescuers and emergency medical services may quickly become overwhelmed. When this has occurred, members of the public have, in fact, saved the majority of victims in the search and rescue phase of a disaster response.58 Lay individuals may, and often do, become active caregivers when medical resources become thin – visiting the ill in their homes, distributing antibiotics, even conducting epidemiological investigations and outbreak reporting.59 Nevertheless, prospective, and later concurrent, education and information sharing is an essential element of strategies to ensure calm and promote constructive behaviors, particularly in the event of an unprecedented attack.55 A recent report issued by the National Academy of Sciences emphasizes that, in the event of a terrorist incident, it is essential that trusted spokespersons inform the public immediately and with expert authority, to both educate the public and assuage public concerns.56 Ideally, the public should be enlisted as a capable, active partner in the preparedness system.57 An educated public plays a potentially vital role in infectious disease containment and bioterrorism surveillance. When individuals are aware of the signs and symptoms of a suspected biological agent, they are more likely to seek medical attention when it is warranted, and not otherwise unwittingly overwhelm the health system and hinder its ability to care for those most in need. They are also then able to engage in risk reduction activities to help contain an infectious outbreak. It almost goes without saying that the mass media can and should play a central role in conveying information that will permit the general public to optimize their contributions to the emergency response. Civic organizations, professional networks and social groups are also potential conduits for information, as well as resources that can be enlisted to aid in a response effort.60 Accountability Tactics Public Engagement • Provide public education about emergency preparedness. federal and state governments community organization • Actively engage the public in emergency preparedness planning. community organization 30 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Immediately following the World Trade Center attack, telephone lines were down, and cell networks became jammed. New York-area hospitals were deluged by calls from families and friends of the missing who, without a centralized patient locator system, were virtually impossible to find on a real-time basis. 7. Identify Communication and Information Needs and Meet Them Information management — the ability to communicate, what to communicate, to whom and when – lies at the heart of the emergency response. For health care organizations, the information needs of its constituents – the general public, patients and their families, the staff and their families, first responders, the media, community officials, and public health agencies, among others – should be anticipated. This experience dramatized the need for redundant communications capabilities in emergency situations. Various options for backing up telephone communications exist. These include two-way radios and dedicated channels, wireless personal digital assistants (PDAs), cell phones, satellite phones, pagers, and Internet connectivity and designated Web sites. The experiences of September 11 and the subsequent anthrax attacks underscored the criticality of communications in mounting an effective emergency response. In this situation, vulnerabilities in the communications infrastructure quickly surfaced. Accountability Tactics Information Management • Anticipate the information needs of community organization participants and the public. community organization • Create redundant, interoperable communications capabilities. federal and state governments community organization • Develop a centralized community-wide patient locator system. community organization • Prospectively identify trusted spokespersons to communicate with the public in the event of a natural or intentional disaster. community organization • Engage the mass media in the emergency preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions. community organization • Develop an “information stockpile” to support communications activities. community organization 31 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems with the medical community, is a key aspect of effective communications and underlies the ability to elicit the desired responses. Sources of scientific and relevant expertise should be prospectively identified to ensure the authenticity of the information being imparted. Protocols for using various communications modalities should be pre-determined and consistent across the preparedness system, and all should be inter-operable. A centralized patient locator system, such as that being developed under the leadership of the Greater New York Hospital Association in New York, is another vital communications infrastructure asset. The news media can be a critical partner in the dissemination of information, and are logical additional participants in the development of community-based emergency preparedness plans. In any event, it is essential to involve media representatives early in communication and information-sharing processes. Media understanding of the information and the underlying issues offers the greatest prospect for accurate, sensitive, and constructive reporting to the public. The media may also – by default – become the principal initial conduit of clinical information for medical care providers. In this regard, an “information stockpile”68 of credible information that is available in various formats – public service announcements, brochures, fact sheets,Web communications – should also be developed to support outreach efforts. A critical issue in the analysis of the 2001 anthrax response is the way in which information was – and was not — managed and communicated. This resulted in a crisis in confidence in the public health system.61,62,63 Information was not being coordinated among public health agencies involved in the response, nor between public health agencies and the medical community charged with evaluating and treating potential anthrax victims.64,65,66 Attempts by the authorities managing the response to “spin” the information to reduce perceptions of risk, and perhaps to gloss over errors or a lack of expertise, served to erode public trust.67 The identification and use of credible, expert spokespersons to take the lead in communicating with the public, as well as The news media can be a critical partner in the dissemination of information, and are logical additional participants in the development of community-based emergency preparedness plans. 32 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Further, the more realistic the drill is, the better the learning and improvement opportunities will be. Indeed, some have suggested that if a drill is not planned to truly inconvenience the participants and the community – as a real emergency would – then its value is already compromised.69 At the same time, it bears recognition that mini-emergencies – often occasioned by emergency department overcrowding across communities – are everyday realities in many parts of the country and certainly provide ample justification for activation of basic elements of a community’s emergency preparedness plan. Such activation can both help to address temporary clinical care crises and also permit continuing refinement of preparedness plans. 8. Test, Learn, Improve and Be Ready The Joint Commission emergency management standards require each accredited health care organization to conduct drills of its emergency management plan at least twice yearly. While such drills are sometimes viewed as “make-work,” they are in fact a critical element of the emergency preparedness process. And as the complexity of the planning process escalates from an individual organization basis to a community base, the need for carefully crafted, full-scale drills in which all of the participants are involved becomes even greater. Further, the drill is more than just an exercise; it is a special opportunity to learn how the preparedness plan and response can be improved. In that regard, it is essential that appropriate metrics for drill evaluation be prospectively identified. Accountability Tactics Emergency Preparedness Program Testing • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan. community organization • Prospectively establish appropriate metrics for objectively assessing the effectiveness of the plan. community organization • Assure the inclusion of all community emergency preparedness program participants in plan tests. community organization • Activate the preparedness plan in response to real-world health care crises, e.g. community-wide emergency department overcrowding. community organization 33 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems The University of Maryland Medical System recently conducted a full-scale drill, dubbed “Free State Response,” in partnership with the U.S.Air Force and the Maryland Emergency Management Authority. All told, the drill cost between $200,000 and $300,000, but in the view of the medical system, that money bought “profound knowledge.”70 In addition to revealing where existing vulnerabilities lay, the drill inculcated the emergency management plan into the minds of the medical system’s staff – where it could more easily be retrieved during an actual disaster.71 Of the two drills the Joint Commission requires each year, one is expected to be a community-wide drill. Such drills can be costly. As a means to cost-share or defray the costs, accredited health care organizations are encouraged to seek partners in the community who will also benefit from the drill. Local government, public health authorities, emergency medical services, fire and police – all of the key participants in the local preparedness system — should be involved in and share in the accountability for community-wide drills. Recommendations Accountability Tactics Surge Capacity • Determine standardized, universal measures of surge capacity. federal and state government agencies community organization • Prospectively define point-in-time and longitudinal surge capacity at the community level. community organization • Identify latent space and human resources capacities. community organization • Establish mutual aid agreements among community hospitals and other health care organizations. health care organizations community organization • Ensure a 48-72 hour stand-alone capability through the appropriate stockpiling of necessary medications and supplies. health care organizations community organization • Standardize equipment, supplies and medication doses to facilitate the provision of safe, efficient care. health care organizations pharmaceutical companies community organization • Fund and facilitate the creation of a credentialing database to support a national emergency volunteer system for health care professionals. federal government 34 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Accountability Tactics Direct Caregiver Protection • Make direct caregivers the highest priority for training and for receipt of protective equipment, vaccinations, prophylactic antibiotics, chemical antidotes, and other protective measures. health care organizations community organization • Provide direct caregiver support to meet mental health and other personal needs. health care organization • Support the provision of decontamination capabilities in each hospital. federal and state government hospitals community organization • Assure direct caregiver access to current information about the emergency on a continuing basis. health care organizations community organization Meeting the Care Needs of All Patients • Maintain the ability to provide routine care. health care professionals health care organizations community organization • Make provisions for the graceful degradation of care in all emergency preparedness plans. health care organizations community organization • Provide for waiver of regulatory requirements and other standards expectations under conditions of extreme emergency. federal and state government agencies accrediting bodies Incident Management community organization • Adopt incident management approaches that provide for simultaneous management involvement by multiple authorities and fluidity of authority as a function of the scale and nature of the emergency situation. Mental Health Management mental health professionals health care organizations community organization • Make provisions for accommodating and managing the substantial acute mental health needs of the community when a natural or terrorist event occurs. 35 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Accountability Tactics Public Engagement • Provide public education about emergency preparedness. federal and state governments community organization • Actively engage the public in emergency preparedness planning. community organization Information Management • Anticipate the information needs of community organization participants and the public. community organization • Create redundant, interoperable communications capabilities. federal and state governments community organization • Develop a centralized community-wide patient locator system. community organization • Prospectively identify trusted spokespersons to communicate with the public in the event of a natural or intentional disaster. community organization • Engage the mass media in the emergency preparedness planning process and, in the event of an emergency situation, utilize the media to communicate accurate information and helpful instructions. community organization • Develop an “information stockpile” to support communications activities. community organization Emergency Preparedness Program Testing • Regularly test, at least yearly, community emergency preparedness plans through reality-based drills for the purpose of identifying opportunities for improving and refining the plan. community organization • Prospectively establish appropriate metrics for objectively assessing the effectiveness of the plan. community organization • Assure the inclusion of all community emergency preparedness program participants in plan tests. community organization • Activate the preparedness plan in response to real-world health care crises, e.g. community-wide emergency department overcrowding. community organization 36 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems Part III. Establish Accountabilities, Oversight, Leadership and Sustainment of Community Preparedness Systems agencies, both as recipients of significant funding and as critical participants in the development of community preparedness initiatives, also lack the objectivity necessary to thoroughly assess the functionality of community preparedness programs in their states. A Question of Accountability With the current heavy focus on emergency preparedness planning, little attention is being paid to mechanisms for assessing the actual readiness of communities for emergencies. Indeed, states have been required to submit “plans for planning” for emergency preparedness as the principal condition for receipt of federal funding. However, actual readiness will not be defined simply by the creation of a plan or even by its periodic testing. Readiness must eventually be assessed by objective parties against prospectively established standards. Such standards must include expectations for evidence of maintenance of readiness over time. The appropriate time to establish an effective, objective oversight mechanism for evaluating community emergency preparedness programs and assuring that they are meeting reasonable standards expectations is not after this country has experienced multiple plan failures. There are already sufficient lessons from the past to underscore the importance of preventive measures in this area as well. The issues of accountability and oversight currently hover in the background. Governors have been defined as being accountable for submitting their state emergency preparedness work plans to DHHS. This at least creates presumptive accountability on the part of individual governors for state-wide emergency preparedness. At the same time, it very much leaves open the issue as to how the individual governors will simultaneously and objectively determine the effectiveness of that preparedness. State public health Sustainable Funding Following the 2001 terrorism attacks, Congress appropriated $40 billion to be expended through 2002 on terrorism preparedness efforts; $135 million of these funds were earmarked for hospitals. Most hospitals are still awaiting receipt of those funds, which, owing to the manner in which states allocate such funds, are currently unaccounted for or are hung-up in state budget hearings.72 Accountability Tactics federal government • Develop and implement objective evaluation methods for assessing the substance and effectiveness of local emergency preparedness plans and the actual readiness of community organizations to manage disasters and terrorist events. 37 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems term, there is clearly a need for a sustainable funding mechanism to support their emergency preparedness efforts. As the most critical care delivery component of a tightly woven preparedness system, hospitals will require funding for development, as well as for maintenance and fortification of their preparedness programs. In the absence of adequate federal funding, and with hospitals’ inability to rely on private funding to bolster their preparedness efforts, some have suggested exploration of creative “taxation” approaches, such as a hospital surcharge on patient visits, to provide a sustained funding stream that will permit hospitals to meet public expectations of their emergency preparedness capabilities. Indeed, if “at the end of the day, it is medical care that will be needed,”77 hospitals and other organizations in the care continuum are going to require the means to provide it. In the President’s 2003 budget, $535 million is earmarked for hospital preparedness.73 The budget also includes $3.5 billion in terrorism preparedness funds for first responders to acquire new technologies, equipment and communications systems, and to conduct drills among first responder agencies. Unfortunately for hospitals, the President’s budget limits the definition of first responders to firefighters, local law enforcement, rescue squads, ambulances and emergency medical personnel.73 All FY2003 terrorism preparedness funding, though, remains “on the table” in anticipation of budget allocation hearings. Many expect that with a potential war with Iraq and the stumbling U.S. economy, the level of funding for preparedness activities will likely be reduced.76 While it remains to be seen what actual funding hospitals will receive in the near Accountability Tactics • Provide funding at the local level for emergency preparedness planning, specifically including adequate funding for hospitals, and assure that the funds actually reach the local level. federal and state governments • Explore alternative options for providing sustained funding for hospital emergency preparedness activities. hospitals federal and state governments • Initiate and fund public-private sector partnerships that are charged to conduct research on and develop relevant, scalable templates for emergency preparedness plans that will meet local community needs in a variety of urban, suburban, and sparsely populated settings. federal and state governments academic health centers established community organizations accrediting bodies 38 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems executive director of the State Bioterrorism Preparedness and Response Program; establishment of an advisory committee that includes representatives from state and local health departments, other appropriate government agencies, emergency medical services, police and fire departments, hospitals, community health centers, and other health care providers, among others; and the preparation of a timeline for development of both state and regional plans for responding to incidents of bioterrorism, other infectious diseases, and other public health threats and emergencies. Each state is also to establish a hospital planning committee, designate a coordinator for hospital bioterrorism planning, and develop a plan for a potential epidemic involving at least 500 patients. While these macro state plans are necessary, they are far from sufficient to meet local community planning needs. Once again, most disasters and terrorist events will be local, and the effectiveness of the response will be determined at the local level. Guiding the Effort There is – as already noted – also the need for credible guidance, in the form of templates or models, to jumpstart and facilitate community preparedness program development. Many involved in developing community-wide preparedness programs have little idea as to what constitutes an acceptable, let alone, ideal model. And the fact is that response capabilities and basic needs and structure vary substantially among urban, suburban, and rural communities and even within those communities. A nascent national template for emergency management has now emerged through the enactment of the “Public Health Security and Bioterrorism Preparedness and Response Act.” Preceding the enactment of the bioterrorism legislation, all states were required to submit their bioterrorism preparedness work plans to DHHS as a prerequisite for allocation of state funding. Among the 17 critical benchmarks DHHS required in the state plans were the designation of a senior public health official within the state to serve as the Accountability Tactics • Disseminate information about existing best practices and lessons learned respecting existing emergency preparedness initiatives to community organizations, hospitals and other health care organizations. federal and state governments 39 Health Care at the Crossroads: Strategies for Creating and Sustaining Community-wide Emergency Preparedness Systems features of an all risks ready emergency facility — one built specifically for scalability, threat mitigation, and management of the medical consequences of terrorism. E.R. One will utilize new information, building, materials and engineering technologies, and will embed concepts of modularity and flexibility so as to be configurable to any threat. Leading Project E.R. One is the Washington Hospital Center, which is the largest hospital in Washington D.C. The hospital is located less than two miles from the U.S. Capitol and so is the likely hospital to receive large numbers of victims from an attack on this country’s seat of government. Another template developed by federal authorities is the model plan recently released by the Centers for Disease Control and Prevention (CDC) for vaccinating the U.S. population following a smallpox outbreak. The model plan was sent to all 50 states to aid in the rapid creation of voluntary smallpox vaccination clinics that would permit the vaccination of one million people within 10 days. The plan provides information on the supplies and resources that will be provided by the federal government; security considerations; suggested clinic organization and logistics; estimated personnel needs; clinical issues and considerations; sample consent forms and public education materials; and a template for delivery of mass patient care should that become necessary.78 The model plan does not, however, provide direction as to the acquisition of resources – either financial or human – to create and operate mass vaccination clinics. This too is a necessary template but one which is targeted to a specific potential problem. Other preparedness models are being developed in the private sector.79 However, public-private sector partnerships offer the best overall prospect for research on and development of relevant, scalable models that will meet local community needs in a variety of urban, suburban, and sparsely populated settings. There is considerable urgency to move this work forward. The federal government is also investing in the creation of a model facility for emergency preparedness. “Project E.R. One” is a federal initiative to develop the design Indeed, if “at the end of the day, it is medical care that will be needed,” hospitals and other organizations in the care continuum are going to require the means to provide it. 40 Health Care at the Crossroads: Strategies for Creating and Sustaining Comm…
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Joint Commission Critical Aspects

Joint Commission Critical Aspects

Add and comment to these posts with reference

Each reply with 200 words

Post One:

Pick 2 of the six Joint Commission’s six critical aspects of emergency response. Describe them and provide supporting documentation on why they are defined as critical by the Joint Commission.

Communication (EM.02.02.01)

In this aspect, we will be looking at two vital functions that will make the response succeed or fail. First, Interorganizational communication is the type of communication necessary to perform the plans set up by the organization’s leaders. In the case of a health care emergency management, the CEO and the emergency management team will write down their plans for emergency events, but to execute these plans and getting everyone involved and informed of their role in the response, communication means must be planned and made available at all times. Additionally, documenting all the information and updates that’ll come up when communicating is crucial to the viability of the response as well as to dodge any legal issues in the future. Moreover, transferring patients between hospitals during a crisis will require communication units to be well prepared in all the participating facilities, that’s why it is important to have a backup communication plan. Second, the communication unit in a health care facility must have a valid procedure on how to communicate to the public important messages during a calamity. Either through the Healthcare incident Command System or by disseminating information directly from the hospital staff. A useful suggestion would be to have a prewritten public service announcement ready to be broadcasted in times of disasters.

Utility Management (EM.02.02.09)

Keeping the facility’s systems up and running at all times is essential for all operation especially those that take place during a disaster. The communication aspect success depends on successful utilization of the institution’s resources. That’s why FEMA has provided a very comprehensive and detailed plan that must be rewritten and applied to every institution where people study or work etc., to keep your operation flowing and working smoothly, planning must take into consideration managing the utilities within the health care facility. A small problem like no electricity in one suite inside one of the hospitals building will disturb the whole hospital and might have an effect on operations throughout the whole hospital.

References:

Medford-Davis, L. N., & Kapur, G. B. (2014). Preparing for effective communications during disasters: lessons from a World Health Organization quality improvement project. International journal of emergency medicine, 7(1), 15.

Future of Emergency Care in the United States Health System Staff, Board on Health Care Services Staff, Institute of Medicine Staff, National Academy of Sciences, Board on Health Care Services, Committee on the Future of Emergency Care in the United States Health System, . . . Institute of Medicine. (2007). Hospital-based emergency care: At the breaking point. Washington, D.C: National Academies Press.

What is Continuity of Operations? Elements of a Viable … (n.d.). Retrieved from https://www.fema.gov/pdf/about/org/ncp/coop_brochu…

Post Two:

According to McNew (2018), it is essential to integrate the six critical aspects of emergency response into the phases of emergency management in healthcare, and these vital aspects include communication, utility management, safety and security, patient clinical and support activities, staff responsibilities and resources and assets. The element known as patient clinical and support activities refers to the hospital’s requirement to ensure that patient safety is maintained when an emergency or disaster strikes by ens

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uring that a plan is in place to track patients on the site. They need to ensure that patients’ needs are addressed during the emergency period, including during extreme conditions, and then creating plans to get them transferred and ensure that life is protected and preserved, and disability prevented. The next critical aspect to discuss is resources and assets.

Following the resources and assets aspect, they are required to ensure that provisions like food, sleeping materials and vendor and community services among others are available in order to take care of the patients. The two aspects discussed are considered critical because they provide a glimpse into the specific manner that hospitals are expected to manage emergency situations. Hospitals are then allowed to have a perspective on what to prioritize and how to navigate seemingly impossible situations in an adaptive way.

References

McNew. (2018). Emergency Department Compliance Manual, 2018 Edition. Alphen aan den Rijn, Netherlands: Wolters Kluwer Law & Business.

HIM445 Wk3 Ashford university Customer service and critical pathways

HIM445 Wk3 Ashford university Customer service and critical pathways

Critical Pathway

Using the Gantt chart and timeline developed in Week Three for your clinic, determine the critical pathway. What are the factors that contribute to the critical pathway? Identify tasks that could be done simultaneously and if so redo the Gantt chart in preparation for the Final Project. If you cannot identify any tasks that could be done simultaneously, explain why.

Part 1 Assignment

Customer Service

By Day 1 of Week One, your instructor will assign each student an option. Assume you are working on a project to improve customer service. Create a Pareto chart based on the information in the assigned option. Use the Pareto chart template (available in the online classroom) or use Excel to produce a Pareto chart that looks like the Pareto chart in Chapter 8 of the course textbook. Include three detailed actions to take to address the customer complaints.

Option 1:

Customer Complaint Frequency/Week
Customer is on hold too long 41
An appointment is not available within 48 hours 35
Wait time in the exam room exceeds 20 minutes 98
Co-pay amount is incorrectly calculated by staff 75

Option 2:

Customer Complaint Frequency/Week
Signage is difficult to follow within the facility 120
Hallway service is difficult to walk on between facility sections 89
Walls and baseboards are dented, scraped or otherwise marred 57
Soap and/or paper towels not available in bathroom 15

Option 3:

Customer Complaint Frequency/Week
Customer is on hold too long 95
Customer gets transferred to the wrong area or cut off 25
Service rep cannot answer customer’s question 125
Service rep does not follow through as promised 45

Option 4:

Customer Complaint Frequency/Week
Room temperature is too cold 70
Room temperature is too hot 45
Room is not clean 35
Sheets are stained/have holes 95

Part 2 of assignment

  • Includes the Pareto chart with title, X and Y-axis labels, and the line chart to show cumulative percentage. A sample Pareto chart you may use is available in the online classroom.
  • Includes three detailed actions to take to address the customer complaints and includes the rationale for the priority of the actions.

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  • Must be two double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.)Links to an external site..
  • Must include a separate title page with the following:
    • Title of paper
    • Student’s name
    • Course name and number
    • Instructor’s name
    • Date submitted
  • Must document all sources in APA style as outlined in the Ashford Writing Center.
  • Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.

Disaster Managing Efforts Discussion Board Question

Disaster Managing Efforts Discussion Board Question

Image source: www.ucdenver.edu Emergency Management Update Team 2016- 1 © Copyright, The Joint Commission Emergency Management Debrief Lessons Learned Planning & Le

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adership Emergency Program Emergency Management Update Team 2016- 2 © Copyright, The Joint Commission EMERGENCY MANAGEMENT CHAPTER OUTLINE  Foundation for the Emergency Operations Plan [EM.01.01.01]  The Emergency Operations Plan (EOP) General Requirements [EM.02.01.01]  Specific Requirements  Six Critical Areas [EM.02.02.01-EM.02.02.11]  Disaster Volunteers [EM.02.02.13-EM.02.02.15]  Evaluation Evaluating the planning activities [EM.03.01.01]  Evaluating the Emergency Operations Plan through exercises [EM.03.03.03]  Emergency Management Update Team 2016- 3 © Copyright, The Joint Commission  1. Communication [EM.02.02.01] 2. Resources & Assets [EM.02.02.03] 3. Safety & Security [EM.02.02.05] 4. Staff responsibilities [EM.02.02.07] 5. Utilities Management [EM.02.02.09] 6. Patient, clinical & support activities [EM.02.02.11] Emergency Management Update Team 2016- 4 © Copyright, The Joint Commission SIX CRITICAL AREAS 2016 Emergency Management Update Team The Joint Commission © Copyright, The Joint Commission WHAT HAS THE JOINT COMMISSION BEEN UP TO? EMERGENCY MANAGEMENT TEAM  Cross-divisional team  Review of large-scale events  Improvement  Field and surveyor education  Survey process and standards Emergency Management Update Team 2016- 6 © Copyright, The Joint Commission  Debriefs  Lessons learned  Education and process improvement DEBRIEFS WITH HEALTH CARE ORGANIZATIONS  Hurricane Sandy  West Texas Fertilizer Explosion  West Virginia Water Contamination  Boston Marathon Bombing  Ebola Outbreak  Baltimore Civil Unrest  San Bernardino Terrorist Event  Ferguson Civil Unrest Emergency Management Update Team 2016- 7 © Copyright, The Joint Commission  South Carolina Flooding LESSONS LEARNED – PLANNING/PREPAREDNESS  Establish relationships w/law enforcement & back-up security agencies  Joint education, drills, etc.  Activate ICS early in incident to support situational awareness  Plan / drill for escalating events  Mass shooting plus bomb threat. Emergency Management Update Team 2016- 8 © Copyright, The Joint Commission  Communication. LESSONS LEARNED – PLANNING/PREPAREDNESS  Identify & reach out to staff living in hot  e.g., laundry service  Know actual usage of utilities on ‘normal’ day, in evening, on weekends. Emergency Management Update Team 2016- 9 © Copyright, The Joint Commission zones during unrest to identify support needs in advance.  Consider supply chain and alternate service providers during water contamination. LESSONS LEARNED – PLANNING/PREPAREDNESS  Plan for most emerging infectious diseases rather than new ‘outbreak of the week’ plan.  IC plan, surge plan, all hazards plan, decon plan, pan-flu plan  Don’t overlook common risks that could go on the HVA in community or region  CBRNE: Fertilizer storage facilities throughout the region that could pose risk of combustion/explosion. Emergency Management Update Team 2016- 10 © Copyright, The Joint Commission  Risks LESSONS LEARNED – PLANNING/PREPAREDNESS  Planning for civil unrest focused primarily on:  Communications (with staff, patients, community incident command, the public/media)  Security  Transit (to the facility for patients and staff) Emergency Management Update Team 2016- 11 © Copyright, The Joint Commission  Reviewing EOP annually  Policies addressing utility disruption, including approach to clinical interventions  Water LESSONS LEARNED – PLANNING/PREPAREDNESS  Don’t overlook home care, outpatient services and other ancillary providers home care providers were held back from entering certain communities where there were clients with chronic conditions – care arrangements can be addressed proactively. Emergency Management Update Team 2016- 12 © Copyright, The Joint Commission  During unrest LESSONS LEARNED – GENERAL RESPONSE hospital & campus to identify flood issues early.  Divert spontaneous volunteers (even clinical) from ED to avoid congestion during trauma response.  Community-based & mobile services (e.g., addiction services) need to choose their locations during unrest to preserve safety of staff/patients. Emergency Management Update Team 2016- 13 © Copyright, The Joint Commission  Conduct frequent tours (every 2 hours) of LESSONS LEARNED – COMMUNICATIONS command/control, staff, patients/families, media & the public.  Don’t presume that all staff have smart phones or use social media; use redundant methods of staff communication.  Manage staff stress and access to misinformation via proactive staff communication strategy. Emergency Management Update Team 2016- 14 © Copyright, The Joint Commission  Have separate lines of communication for LESSONS LEARNED – COMMUNICATIONS with cell phone during response and recovery.  Proactive media/social media outreach plan mitigates intrusions from reporters that consume leaders’ time during response.  Regular joint calls with local providers, city & state support situational awareness during unrest. Emergency Management Update Team 2016- 15 © Copyright, The Joint Commission  Carry extra batteries and/or chargers along  During unrest:  Monitor social media used/sponsored by protest groups to anticipate crowd movement and potential impact on transit or emergency/urgent care.  Reinforce with staff – verbally and in written messaging/scripts used as needed in patient/family interactions – values of diversity and role to care for all people to help mitigate safety concerns or racial tension impacting community. Emergency Management Update Team 2016- 16 © Copyright, The Joint Commission LESSONS LEARNED – COMMUNICATIONS LESSONS LEARNED – SECURITY  Definition of ‘lock-down’ with response partners  Security forces have one meaning, hospitals may vary  Civil unrest response from small community hospital & secured it’s perimeter – closed all off-site locations  Security to central site  Moved vehicles  Removed from public access items that could be removed/damaged Emergency Management Update Team 2016- 17 © Copyright, The Joint Commission  Reduced LESSONS LEARNED – SECURITY  Reinforced with staff use of de-escalation techniques during civil unrest.  Train/exercise with local law enforcement  During terrorist shooting over 40 officers were onsite in minutes Conducted bomb search and provided essential support. No need to arm hospital security.  Separate ED waiting area for injured police officers & their families during unrest Emergency Management Update Team 2016- 18 © Copyright, The Joint Commission  LESSONS LEARNED – STAFF  Senior leadership  Prioritize time and resources for staff training Emergency Management Update Team 2016- 19 © Copyright, The Joint Commission  Weather/natural disasters  Prepare for staff rotations & shift relief  Designated sleeping areas, adequate meals  Shuttle system to/from homes LESSONS LEARNED – STAFF  Monitor local/county/state agencies  Road closures, curfews, etc. that impact staff movement to & from work community conditions change  Place Critical Incident Stress management staff in EOC  Provide real-time support & guidance to chain of command during unrest Emergency Management Update Team 2016- 20 © Copyright, The Joint Commission  Adjust shifts, allow sheltering in place as LESSONS LEARNED – PATIENT CARE  Flooding  Review IC plan to assess patient risk for HAI. Emergency Management Update Team 2016- 21 © Copyright, The Joint Commission  Water contamination  Home health & DME partners proactively monitor at-risk patients  Facilitate patient education on O2 concentrators, CPAP machines, & water sourcing. LESSONS LEARNED – EXERCISES  Stress & test system, staff, leaders with escalating complications & patients with different functional needs.  Train & practice staff in active shooter response with in-house security & law enforcement. Emergency Management Update Team 2016- 22 © Copyright, The Joint Commission  Joint exercise LESSONS LEARNED – LEADERSHIP  Leaders met frequent w/staff to discuss quality of care and safety during flood response/recovery.  Leaders facilitated visible presence of security in and around building during unrest  Increased sense of security. managerial assistance; identified & addressed staff morale/support needs in process after terrorist attack. Emergency Management Update Team 2016- 23 © Copyright, The Joint Commission  Leaders rounded & provided hands-on LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING  Reinforced w/staff & community role of hospital as safe zone for all injured. Emergency Management Update Team 2016- 24 © Copyright, The Joint Commission  Civil unrest/recovery  Town hall meetings for information & support and to dispel myths/rumors  Made available EAP & pastoral care  Routed routine monthly prayer walk through vulnerable community.  During unrest response & recovery  Invited staff discussion (individual or small group) on racial tension  Sense of safety at home in impacted community  Need for safety tips or security/transit support (alter work hours, shelter at hospital, etc.). Emergency Management Update Team 2016- 25 © Copyright, The Joint Commission LESSONS LEARNED – PSYCHOSOCIAL SUPPORT/COPING LESSONS LEARNED – INFECTIOUS DISEASE  Plan, train, & exercise for infectious disease emergencies:  initial screening of PPE, including don and dof  safe patient flow (entry point to isolation)  iterative training of care teams  dedicated equipment  safe transfer of patients  disposal & transport of waste Emergency Management Update Team 2016- 26 © Copyright, The Joint Commission  use LESSONS LEARNED – UTILITIES  Water  Processes for cleaning water systems after loss of water  Supply for systems management  Potable vs. non-potable • Equipment use, i.e. sterile processing • Human consumption Emergency Management Update Team 2016- 27 © Copyright, The Joint Commission  Fuel  Increase run time through load-shedding LESSONS LEARNED – HEALTH CARE PARTNERS  Water contamination:  Ambulatory dialysis company deployed water tanker truck to supply hospital  Dialysis biochemist supported hospital in sampling & testing water Emergency Management Update Team 2016- 28 © Copyright, The Joint Commission  Nursing home destroyed in industrial blast:  Other homes contacted hospital to offer beds  Hospital worked with case manager, behavioral health staff and home care to place patients 2 weeks post-disaster LESSONS LEARNED – HEALTH CARE PARTNERS  Maintain access to care  Chronic care patients  Medications from pharmacies outside of impacted area of emergency • Civil unrest, weather emergencies, etc. Emergency Management Update Team 2016- 29 © Copyright, The Joint Commission  Reinforce IC preparedness  Affiliated clinics and physician offices where at-risk patients may be seen.  Screening, use of PPE and other precautions LESSONS LEARNED – EVACUATION  Practice evacuation drills using evacuation equipment: equipment is required?  Where will equipment be deployed (which units, floors, etc.)?  Who needs to be trained in its use? Emergency Management Update Team 2016- 30 © Copyright, The Joint Commission  How much LESSONS LEARNED – RECOVERY  Recovery  Ancillary / offsite / support departments that were impacted by event or that contribute to resiliency.  Business continuity  Timely engagement with FEMA and insurers Emergency Management Update Team 2016- 31 © Copyright, The Joint Commission  Leadership engagement  Avoid fatigue and silos  Accountability Link: http://www.jointcommission.org/emergency_management.aspx Emergency Management Update Team 2016- 32 © Copyright, The Joint Commission EMERGENCY MANAGEMENT PORTAL 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page i HEALTH CARE EMERGENCY MANAGEMENT PRINCIPLES AND PRACTICE Editors Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor, Public Health Practice New York Medical College School of Health Science and Practice Valhalla, New York and David Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l World Headquarters Jones & Bartlett Learning 40 Tall Pine Drive Sudbury, MA 01776 978-443-5000 info@jblearning.com www.jblearning.com 5/21/10 1:36 AM Page ii Jones & Bartlett Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada Jones & Bartlett Learning International Barb House, Barb Mews London W6 7PA United Kingdom Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to specialsales@jblearning.com. Copyright © 2011 by Jones & Bartlett Learning, LLC All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Publisher: Michael Brown Editorial Assistant: Catie Heverling Editorial Assistant: Teresa Reilly Production Manager: Tracey Chapman Associate Production Editor: Kate Stein Senior Marketing Manager: Sophie Fleck Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Achorn International Art: diacriTech Associate Photo Researcher: Sarah Cebulski Cover Design: Kristin E. Parker Cover Image: Top left: Courtesy of Andrea Booher/FEMA; Top Right: Courtesy of Win Henderson/FEMA; Bottom left: Courtesy of Jocelyn Augustino/FEMA; Bottom right: Courtesy of Cynthia Hunter/FEMA Printing and Binding: Malloy, Inc. Cover Printing: John Pow Company Library of Congress Cataloging-in-Publication Data Health care emergency management : principles and practice / [edited by] Michael J. Reilly and David S. Markenson. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-7637-5513-3 (pbk.) ISBN-10: 0-7637-5513-3 (pbk.) 1. Emergency medical services. 2. Emergency management—Planning. 3. Hospitals—Emergency services. I. Reilly, Michael J. II. Markenson, David S. [DNLM: 1. Disaster Planning—organization & administration. 2. Emergencies. 3. Emergency Service, Hospital—organization & administration. WX 185 H4336 2011] RA645.5.H38 2011 362.18068—dc22 2010001554 6048 Printed in the United States of America 14 13 12 11 10 10 9 8 7 6 5 4 3 2 1 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iii Dedication MICHAEL REILLY I dedicate this text to my family and friends who have supported me throughout this project. I especially thank my parents, who have provided their unwavering advice and support throughout my life and career. I also dedicate this text to my professional mentors Dr. Linda Degutis and Dr. Robyn Gershon, who continue to give me invaluable guidance throughout my professional development. Finally, I dedicate this book to my coauthor David, who has provided me with the opportunity to pursue academic emergency and disaster medicine professionally, and who continues to encourage and support my development as a scientist and scholar in this evolving area of medicine and public health. DAVID MARKENSON This text is dedicated to my parents, who have always guided, supported, and encouraged me, and who, as physicians, have shown me through their work that providing care to others in a compassionate and knowledgeable way can be a rewarding endeavor. This text is also dedicated to my brothers, sister, and sisters-in-law, who are a constant source of advice, support, and energy; without their help and involvement in my life none of my efforts could have been accomplished. Most importantly this text is dedicated to my wife Heidi and my wonderful children, Emily, Rachel, and George, who not only support me but who were willing to give of their time with me to allow me to write this text. iii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page iv iv | Dedication MICHAEL REILLY AND DAVID MARKENSON Lastly, this text is dedicated to all healthcare providers, emergency managers, and those in their care. Healthcare providers and emergency managers work each day in an environment that is unpredictable, often dangerous, and constantly challenging. They have become champions in changing the system to become better prepared. They dedicate their lives to aid the sick and the injured and prepare for any disaster, terrorism event, or public health emergency, driven only by their care for others and their devotion to this profession we call healthcare emergency management. We salute all of you in your professionalism and dedication. Also, we dedicate this to our patients who, in allowing us the privilege to provide them care, teach us each day about humanity. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page v Contents About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix Section I Chapter 1 Chapter 2 Principles of Emergency Management for Healthcare Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Introduction to Hospital and Healthcare Emergency Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Healthcare Incident Management Systems . . . . . . . . . . . . . 21 Arthur Cooper, MD, MS v 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vi vi | Contents Chapter 3 Chapter 4 Chapter 5 Chapter 6 Chapter 7 II Chapter 8 Section Chapter Chapter 9 10 Section III Chapter 11 Chapter 12 Improving Trauma System Preparedness for Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . 47 Michael J. Reilly, DrPH, MPH, NREMT-P Legal Issues and Regulatory Compliance . . . . . . . . . . . . . 67 Doris R. Varlese, JD Developing the Hospital Emergency Management Plan . . . 89 Nicholas V. Cagliuso, Sr., MPH; Nicole E. Leahy, RN, MPH; and Marcelo Sandoval, MD Introduction to Exercise Design and Evaluation . . . . . . . . 111 Garrett T. Doering, MS, EMT-P, CEM, MEP Integration with Local and Community Resources . . . . . . 143 Isaac B. Weisfuse, MD, MPH Hospital Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . 161 Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . 163 Sean M. Kelly, MA, CCEMT-P and Lindsey P. Anthony, MPA, CEM, CHEC-III Functional Roles of Hospital Workers in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . 187 Tony Garcia, RN, CCEMT-P Credentialing and Management of Volunteer Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Deborah Viola, PhD, MBA and Peter Arno, PhD Hospital Operations During Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 221 Quantitative Planning for Epidemic and Disaster Response: Logistics and Supply Chain Considerations . . . . . . . . . . . 223 Nathaniel Hupert, MD, MPH; John A. Muckstadt, PhD; and Wei Xiong, PhD, MS Risk Communication and Media Relations . . . . . . . . . . . . 233 Linda C. Degutis, DrPH, MSN and Lauren Babcock-Dunning, MPH 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page vii Contents | vii Chapter 13 Chapter 14 Chapter 15 Chapter 16 IV C h a p t e r 17 Section Chapter 18 V C h a p t e r 19 Section Chapter 20 Chapter 21 Chapter 22 Security and Physical Infrastructure Protections. . . . . . . . . 271 Robert Michael Schuler, BGS, NREMT-P and Veronica Senchak Snyder, MHS, MBA Hospital Decontamination and Worker Safety . . . . . . . . . . 299 Michael J. Reilly, DrPH, MPH, NREMT-P Pharmaceutical Systems Management in Disasters. . . . . . 317 David S. Markenson, MD, FAAP, FACEP, EMT-P Laboratory Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . 331 Ramon Rosal, PhD Clinical Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . 339 Principles of Disaster Triage . . . . . . . . . . . . . . . . . . . . . . . 341 E. Brooke Lerner, PhD and Richard B. Schwartz, MD Managing an Infectious Disease Disaster: A Guide for Hospital Administrators . . . . . . . . . . . . . . . . . 353 Ariadne Avellino, MD, MPH Special Topics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 369 Vulnerable Populations and Public Health Disaster Preparedness. . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Elizabeth A. Davis, JD, EdM; Rebecca Hansen, MSW; and Jennifer Mincin, PhD (ABD) Altered Standards of Care in Disasters and Public Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . 401 John Rinard, BBA, MSCPI Mass Fatality Management . . . . . . . . . . . . . . . . . . . . . . . 423 Barbara A. Butcher, MPH and Frank DePaolo, RPA-C Research in Emergency and Disaster Medicine . . . . . . . . 447 Kobi Peleg, PhD, MPH and Michael Rozenfeld, MA Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .463 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .469 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page viii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page ix About the Authors MICHAEL J. REILLY, DRPH, MPH, NREMT-P Dr. Michael Reilly is currently the Assistant Director of the Center for Disaster Medicine at New York Medical College in Valhalla, New York. Additionally, he is an Assistant Professor of Public Health Practice and the Director of the Graduate Program in Emergency Preparedness at the School of Health Science and Practice. Dr. Reilly has over a decade of multidisciplinary experience in emergency preparedness, public safety, intergovernmental relations, public health, and emergency management. He has been published in the world’s leading disaster medicine and public health preparedness journals, and received international awards and recognition for his work on trauma systems and health systems in the context of disaster and public health preparedness. Dr. Reilly is an internationally recognized expert in the areas of emergency medical services, and health system preparedness and response, with direct experience in responding ix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page x x | About the Authors to mass casualty events and public health emergencies. Dr. Reilly is frequently called upon to provide expert consultation, subject matter expertise, and to evaluate healthcare systems preparedness, emergency planning, and drills and exercises. Dr. Reilly has designed numerous educational curricula and training programs for a variety of preparedness functional roles for public health, emergency management, and public safety audiences at the professional and graduate levels. He is a senior lecturer for multiple federal agencies including the Department of Justice, Department of Homeland Security, and the Occupational Safety and Health Administration. Additionally, he is an active member of several state and national committees on homeland security and emergency management programs. He received his undergraduate education at Northeastern University in paramedic technology and health science. He earned his Masters of Public Health from Yale University, and a doctorate in public health from New York Medical College. Dr. Reilly remains active as a paramedic in the Metro New York City region and maintains numerous specialty and technical certifications and instructor credentials in the areas of emergency medical services, worker safety, environmental health, hazardous materials emergency response, emergency management, counterterrorism, and weapons of mass destruction preparedness and response. DAVID SAMUEL MARKENSON, MD, FAAP, FACEP, EMT-P Dr. David Markenson is a board-certified pediatrician with Fellowship training in both pediatric emergency medicine and pediatric critical care. He is the Vice President and Medical Director of Disaster Medicine and Regional Emergency Services at the Westchester Medical Center and Maria Fareri Children’s Hospital. In addition, he is the Director of the Center for Disaster Medicine and the Interim Chair of Epidemiology and Community Health at the School of Health Sciences and Practice at New York Medical College. Dr. Markenson is also a Professor of Pediatrics and an Associate Professor of Public Health at the School of Health Sciences and Practice at New York Medical College in Valhalla, New York. He is an active member of, and has served in leadership positions within, multiple professional societies, including the American Academy of Pediatrics (AAP), the American College of Emergency Physicians, the Society of Critical Care Medicine, the American College of Physician Executives, and the National Association of EMS Physicians. Dr. Markenson has been actively involved with the American Red Cross for over 20 years and currently serves as the National Chair of the Advisory Council which oversees disaster health, preparedness, and health and safety. In this role he directs the scientific and technical as- 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xi About the Authors | xi pects of all programs and products in these areas including their development, implementation, and research. Prior to coming to Westchester Medical Center and New York Medical College he was the Deputy Director of the National Center for Disaster Preparedness at the Mailman School of Public Health, Columbia University, and was also the Director of the Program for Pediatric Preparedness of the National Center, a program dedicated to improving the care children receive in times of disasters or acts of terrorism. His career has been dedicated to improving the approach to pediatric care, disaster medicine, EMS, and emergency medicine. He is the principal investigator on several federal grants related to pediatric disaster medicine, including Model Pediatric Component for State Disaster Plans and National Consensus Conference on the Needs of Children in Disasters. He has also addressed the needs of other special and vulnerable populations and directed a federal grant to develop the first and only national guidelines for emergency preparedness for persons with disabilities. In addition to this, he has conducted research on healthcare preparedness and healthcare provider and student education. In this area he was the principal investigator for a federal grant which developed the first competencies for all healthcare students in emergency preparedness and then piloted this set of competencies in a medical, dental, public health, and nursing school. Dr. Markenson has been recently appointed to the FEMA National Advisory Council as the In-Patient Medical Provider representative. The FEMA NAC is comprised of emergency management and law enforcement leaders from state, local, and tribal government and the private sector to advise the FEMA Administrator on all aspects of disaster preparedness and management to ensure close coordination with all partners across the country. He is a frequent presenter and lecturer at medical conferences across the country, serves in editorial roles for multiple professional scientific journals, and has authored numerous articles and books on pediatric care, disaster medicine, and prehospital medicine. His work in disaster medicine started during his college career when he worked in disaster services in upstate New York providing direct services and education to other disaster services workers on behalf of the local Red Cross and county office of emergency management. Dr. Markenson is a graduate of Albert Einstein College of Medicine in the Bronx, New York. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiii Contributors Lindsey P. Anthony, MPA, CEM, CHEC-III Operational Medicine Education Coordinator Center for Operational Medicine Medical College of Georgia Augusta, Georgia Peter Arno, PhD Professor Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York xiii 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xiv xiv | Contributors Ariadne Avellino, MD, MPH Research Associate Center for Disaster Medicine New York Medical College Valhalla, New York Lauren Babcock-Dunning, MPH Research Associate Center for Transportation Safety, Security and Risk Rutgers, The State University of New Jersey New Brunswick, New Jersey Barbara A. Butcher, MPH Chief of Staff Office of the Chief Medical Examiner City of New York New York, New York Nicholas V. Cagliuso, Sr., MPH Corporate Director Emergency Management Continuum Health Partners, Inc. New York, New York Arthur Cooper, MD, MS Professor of Surgery Columbia University College of Physicians & Surgeons Director of Trauma and Pediatric Surgical Services Harlem Hospital New York, New York Elizabeth A. Davis, JD, EdM Principal EAD & Associates, LLC Brooklyn, New York Linda C. Degutis, DrPH, MSN Associate Professor of Surgery (Emergency Medicine) and Public Health Director, Center for Public Health Preparedness Yale University School of Medicine New Haven, Connecticut 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xv Contributors | xv Frank DePaolo, RPA-C Director Special Operations Division Office of the Chief Medical Examiner City of New York New York, New York Garrett T. Doering, MS, EMT-P, CEM, MEP Director of Emergency Management Westchester Medical Center Valhalla, New York Tony Garcia, RN, CCEMT-P Training Specialist Texas Engineering Extension Service Texas A&M University System College Station, Texas Rebecca Hansen, MSW Senior Project Manager EAD & Associates, LLC Brooklyn, New York Nathaniel Hupert, MD, MPH Associate Professor of Public Health and Medicine Weill Cornell Medical College New York, New York Sean M. Kelly, MA, CCEMT-P Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York Nicole E. Leahy, RN, MPH Manager Burn Outreach and Professional Education New York-Presbyterian Hospital / Weill Cornell Medical Center New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvi xvi | Contributors E. Brooke Learner, PhD Associate Professor Department of Emergency Medicine Department of Population Health Medical College of Wisconsin Milwaukee, Wisconsin David S. Markenson, MD, FAAP, FACEP, EMT-P Medical Director and Vice President Disaster Medicine and Regional Emergency Services Westchester Medical Center Director, Center for Disaster Medicine Associate Professor, Public Health Practice Professor of Pediatrics New York Medical College Valhalla, New York Jennifer Mincin, PhD (ABD) Senior Project Manager/Director EAD & Associates, LLC Brooklyn, New York John A. Muckstadt, PhD Acheson/Laibe Professor Business Management and Leadership Studies School of Operations Research and Industrial Engineering Cornell University Ithaca, New York Kobi Peleg, PhD, MPH Director, Israel National Center for Trauma and Emergency Medicine Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Co-chair, The Multi-disciplinary Program for Emergency and Disaster Management School of Public Health Tel-Aviv University Tel-Aviv, Israel Michael J. Reilly, DrPH, MPH, NREMT-P Director, Graduate Program in Emergency Preparedness Assistant Director, Center for Disaster Medicine Assistant Professor of Public Health Practice New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xvii Contributors | xvii John Rinard, BBA, MSCPI Milano, Texas Ramon Rosal, PhD Chemical Response Director Public Health Laboratory New York City Department of Health and Mental Hygiene New York, New York Michael Rozenfeld, MA Researcher National Center for Trauma & Emergency Medicine Research Gertner Institute for Epidemiology and Health Policy Research Sheba Medical Center Tel Hashomer, Israel Marcelo Sandoval, MD Faculty, Department of Emergency Medicine Co-Chair, Emergency Management Committee Beth Israel Medical Center / Petrie Division New York, New York Robert Michael Schuler, BGS, NREMT-P Training Coordinator Texas Engineering Extension Service The Texas A&M University System College Station, Texas Richard B. Schwartz, MD Chair and Professor Department of Emergency Medicine Medical College of Georgia Augusta, Georgia Veronica Senchak Snyder, MHS, MBA Emergency Management Coordinator Emergency Management Services Geisinger Health System Geisinger Medical Center Danville, Pennsylvania Doris R. Varlese, JD Visiting Lecturer New York Medical College School of Health Sciences and Practice Valhalla, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xviii xviii | Contributors Deborah Viola, PhD, MBA Associate Professor of Public Health Practice Department of Health Policy and Management New York Medical College School of Health Sciences and Practice Valhalla, New York Isaac B. Weisfuse, MD, MPH Deputy Commissioner Division of Disease Control New York City Department of Health and Mental Hygiene New York, New York Wei Xiong, PhD, MS Instructor in Public Health Weill Cornell Medical College New York, New York 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xix Acknowledgments he material contained in this text reflects the contributions of many authors, editors, emergency managers, healthcare providers, reviewers, and others who provided assistance and valuable suggestions. While here we acknowledge them, our sincere appreciation for all of their efforts is truly hard to express in this limited space. In addition, we could not possibly acknowledge all those who participated in this important endeavor, and so we would like to also extend our sincere appreciation to every person who helped with this project, whether listed by name or not. Many talented people at Jones & Bartlett Learning have been involved in developing and producing this new text. As authors and editors, we turned our manuscript to the exceptional editorial staff and publishers at Jones & Bartlett Learning to create this finished product. We are fortunate to have been able to work with this team of people, who have contributed so much and had such a tremendous impact on T xix 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xx xx | Acknowledgments the quality of the textbook you now have in your hands. Specifically Michael Brown, Publisher, assisted by Catie Heverling and Kate Stein, has been our support at Jones & Bartlett Learning. As Publisher, Mike is committed to publishing quality books; his energy, intelligence, patience, and helpful efforts have enabled us to create an exceptional product. With the additional day-to-day support and guidance of both Catie Heverling and Kate Stein we were able to keep our project on track and ultimately produce this important text. A significant amount of coordinating and operational support in moving this project forward would not have been possible without the tireless work of our administrative assistant Patience Ameyaw. We thank her for her hard work and support of this project along with Geordana Roa, Nina Luppino, and our numerous disaster medicine interns over the past several years. Components of this text have been based on the exceptional work of the Center for Disaster Medicine at the New York Medical College, School of Health Sciences and Practice for which we serve as the Director and Assistant Director. Without the support of our Center, the prior research and models developed, and the strong and supportive academic environment of New York Medical College, this work would not have been possible. We would like to specifically thank Dean Robert Amler of the New York Medical College, School of Health Sciences and Practice, who in his own right is an internationally recognized expert in public health and healthcare preparedness, for providing his personal expertise and his leadership in creating an academic environment where work such as this text is not only encouraged but supported, and for his continued dedication to providing education to improve emergency preparedness. We would like to also acknowledge the Westchester Medical Center and its Maria Fareri Children’s Hospital, which serves as the regional center for healthcare emergency preparedness. The source and realworld testing of many of the theories and models in this text come from the preparedness efforts of this institution, which is recognized as not only a regional but as a national leader in emergency preparedness. We would like to thank the leadership of this institution for allowing us to use the wonderful preparedness work they have done as models for others to follow. While not being able to list all, we would like to acknowledge the members of the senior leadership who day in and day out support the preparedness activities: Mr. Michael Israel, Mr. Gary Brudnicki, Dr. Renee Garrick, Dr. Michael Gewitz, Ms. Marsha Casey, and Mr. Anthony Costello. Lastly, we would especially like to thank the institution’s Director of Emergency Management and chapter contributor Mr. Garrett Doering for sharing his professional insight and experience with us as we completed this project. 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxi Acknowledgments | xxi Finally, we are extremely grateful to the numerous healthcare providers, emergency managers, educational consultants, and members of the preparedness academic community who carefully critiqued the manuscript to ensure that the information in this text would be both relevant and appropriate. Many more dedicated professionals than we could name here gave unstintingly of their own time and expertise. Their enthusiastic participation has been a motivating force behind this project, and they received no compensation beyond the knowledge that they were helping to create a greatly needed resource. We hope the final product lives up to their efforts, hopes, and expectations. Our warmest and kindest regards, Michael and David 55133_FMxx_Reilly:Achorn Int’l 5/21/10 1:36 AM Page xxii 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 1 Section I Principles of Emergency Management for Healthcare Facilities 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 2 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 3 Chapter 1 Introduction to Hospital and Healthcare Emergency Management Michael J. Reilly, DrPH, MPH, NREMT-P and David S. Markenson, MD, FAAP, FACEP, EMT-P Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Describe the need for and responsibilities of healthcare emergency management. ■ Describe the role of the hospital emergency manager. ■ Identify the activities performed by healthcare emergency management. Emergence and Growth of Healthcare Emergency Management The concept of healthcare emergency management is not entirely new, but may seem strange and foreign to those who have worked in healthcare or emergency management and, until recently, have not known anyone working in this profession. If one looks back more than 30 years, it would be almost impossible to find a hospital role called hospital 3 55133_CH01_Reilly:Achorn Int’l 4 | Chapter 1 5/13/10 12:08 PM Page 4 Introduction to Hospital and Healthcare Emergency Management emergency management or even a position for a healthcare emergency manager in a hospital or medical center.Yet healthcare emergency management responsibilities have always been addressed by hospitals, such as fire safety, backup power, and the ability to handle victims from a mass casualty event. A fundamental tenet of emergency management is that institutions must prepare for events that may rarely occur while taking protective actions to mitigate any likelihood that they will occur at all. Due to the low frequency of events testing the health system’s ability to respond to a disaster, an act of terrorism, or a public health emergency, the ability to evaluate the strengths and weaknesses of hospital emergency preparedness is limited. In addition, the public has strong expectations of the roles hospitals should play during times of disaster. Healthcare institutions are expected to provide both emergency care and continuance of the day-to-day healthcare responsibilities regardless of the volume and demand. Recently, they have also become sites of community refuge, bastions of safety in a threatening and dangerous environment. The public believes that hospitals will have light, heat, air conditioning, water, food, and communications capabilities, regardless of the fact that the institution may itself be affected by the calamity. During the terrorist attacks in the fall of 2001 and the Northeast Blackout of 2003, the public flocked to hospitals, even when they did not require medical care. Furthermore, with increased intelligence of the vulnerabilities of the healthcare infrastructure and the desire of terrorists to exploit this, institutions have been forced to focus limited resources on safety and security rather than on comprehensive emergency management efforts. A major change in the way hospitals plan for hazards and vulnerabilities includes less planning for specific single issues or threats but rather the adoption of an all–hazards comprehensive emergency management planning process. Additionally, hospitals need to look beyond their emergency department doors and engage community stakeholders to assist in this process, reaching out to local and regional emergency planners to assist in larger communitywide emergency preparedness planning. The interest of nonhospital entities in health system emergency preparedness can be seen through several examples, including emergency management and public health initiatives on mass vaccination, pandemic planning, increasing hospitals’ ability to perform decontamination of casualties contaminated with hazardous materials, etc. Recent reflection of the role of the hospital in emergency management and population health can been seen in revised laws, regulations, and even accreditation standards. An example of this is The Joint Commission on the Accreditation of Healthcare Organizations’ (JCAHO) change from placing emergency preparedness standards in the Environment 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 5 Emergence and Growth of Healthcare Emergency Management | 5 of Care section to placing the standards in a separate and distinct section with specific goals and requirements, as well as the release of the Occupational Safety and Health Administration (OSHA) document Best Practices for Hospital-Based First Receivers.1–3 Over the past eight years we have embarked on an interesting marriage of these two separate disciplines—health care and emergency management—whose common ground has historically been brought together in the street or on the disaster scene by emergency medical services workers, or sometimes brought into the emergency departments of hospitals and trauma centers across the country. Both disciplines have separate roles and responsibilities, but where the seemingly disparate goals of these fields come together is the reduction of morbidity and mortality following disasters, acts of terrorism, and public health emergencies. Emergency management agencies have traditionally been responsible for bringing first responders, government agencies, and community stakeholders together to assist with comprehensive emergency planning or disaster response and recovery. A common cornerstone of emergency management has been to protect life, then property, then the environment. As a result, when conducting emergency planning activities, the health and medical needs of the population are among the most significant and are considered with basic public health and human needs including sheltering, mass care, sanitation, environment health, food and water, and other essential services. In addition, as public health professionals, we also believe that population health activities include the mitigation of increased morbidity and mortality during and following a disaster, act of terrorism, or public health emergency. In healthcare delivery, we attempt to meet the health and medical needs of the community by providing a place for individuals to seek preventative medicine, care for chronic medical conditions, emergency medical treatment, and rehabilitation from injury or illness. While a healthcare institution serves the community, this responsibility occurs at the level of the individual. Each individual expects a thorough assessment and treatment if needed, regardless of the needs of others. This approach is different than that practiced by emergency managers, whose goal is to assist the largest number of people with the limited resources that are available. As such, emergency management principles are focused on the needs of the population rather than the individual. When either planning for a disaster or operating in a disaster response mode, the hospital should be prepared at some point to change its focus from the individual to the community it serves and to begin weighing the needs of any individual patient versus the most good for the most patients with scarce resources. Moving from the notion of doing the most for each individual to doing the best for the many is a critical shift in thinking 55133_CH01_Reilly:Achorn Int’l 6 | Chapter 1 5/13/10 12:08 PM Page 6 Introduction to Hospital and Healthcare Emergency Management for healthcare institutions considering a program of comprehensive emergency management. While the initial planning for emergencies by hospitals is focused on maintaining operations and handling the care needs of actual or potential increased numbers of patients and/or different presentations of illness or injury than is traditionally seen, there is also the need to recognize that at some point during a disaster, act of terrorism, or public health emergency there may be an imbalance of need versus available resources. At this point the approach to delivering healthcare will need to switch from a focus on the individual to a focus on the population. This paradigm shift is one of the core unique aspects of hospital emergency management that allows the hospital to prepare to maximize resources in disasters and then to know when to switch to a pure disaster mode of utilizing its limited and often scant resources to help the most people with the greatest chance of survival. The healthcare delivery system is vast and comprised of multiple entry points at primary care providers, clinics, urgent care centers, hospitals, rehabilitation facilities, and long-term care facilities. The point of entry for many individuals into the acute healthcare system is through the emergency department (ED). Since the late 1970s, the emergency medical services (EMS) system has allowed victims of acute illness and injury to receive initial stabilization of life-threatening medical conditions on the way to the emergency department. Among the many strengths of the ED is the ability to integrate two major components of the healthcare system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in this process by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate life-saving medical care until specialty resources become available.4–11 In this context, the healthcare system is an emergency response entity. Healthcare Emergency Management Activities Hospital emergency management activities vary and can be categorized in many ways, however some common areas of focus within healthcare emergency management include the following areas: ■ ■ ■ ■ ■ ■ ■ communication surge capacity volunteer management security issues hazmat/CBRNE preparedness collaboration and integration with public health education and training 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 7 Healthcare Emergency Management Activities | 7 ■ ■ ■ ■ ■ equipment and supplies worker safety drills and exercises emergency department disaster operations trauma centers COMMUNICATION Communication issues in disaster preparedness and response are cited throughout the literature as a major source of frustration and inadequacy for coordinating and executing disaster operation plans.4–5,8,11–16 By identifying the vulnerabilities in the existing system of healthcare communication systems, we can take steps to address these issues and further increase our health system preparedness. Addressing the vulnerabilities in communication systems and planning how to overcome them is an essential responsibility of a hospital emergency manager. Many of the criticisms of the current state of health systems’ communication systems center around the inability to communicate easily with external agencies and share critical information. Disaster after-action reports and exercise improvement plans almost universally cite poor communication as one of the problems associated with incident management and the event being reviewed. Infrastructure support is an important consideration when examining whether adequate safeguards are in place to support the systems we will rely upon during a disaster. On September 11, 2001, while one New York City hospital was preparing to treat a large number of (anticipated) casualties from the disaster, they experienced a loss of their computer and information systems.17 This unplanned event arose because the communication system line that supported their system’s infrastructure ran beneath the World Trade Center.17 Additionally, other reports have cited problems with battery failure and the lack of a prolonged power supply as limiting communication systems’ abilities during an event.14 This example illustrates a major point in emergency communication systems: hospitals need the ability to connect all significant parties during a disaster or other emergency and the system should be based on a redundant infrastructure.5 Clearly, from a planning perspective, this would be a desirable option. However, the reality remains that investing in communication systems is a significant financial burden on already underfunded hospitals and healthcare systems. Risk communication is often overlooked during the planning phase of an event, and this can lead to frustration and confusion during disaster operations. Risk communication is sometimes the only way for the public to gain an understanding of the scope and severity of an incident. Additionally, risk communication information provided by hospitals may be used to help families of disaster victims find information about 55133_CH01_Reilly:Achorn Int’l 8 | Chapter 1 5/13/10 12:08 PM Page 8 Introduction to Hospital and Healthcare Emergency Management their loved ones’ condition. Reviews of risk communication have shown that a predesignated public information officer (PIO), who will liaise with the media and the public and who has specific training and experience in giving briefings and fielding questions, should perform all risk communication tasks during disaster operations.13 Specific elements of risk communication that may be conveyed to the public may include information on evacuations, scope and breadth of the event, where and how to obtain assistance if needed, whom to call for specific information, location of postexposure prophylaxis or vaccination clinics, and what to expect over the next several hours and/or days of the event. This is discussed in more detail in Chapter 12. SURGE CAPACITY The General Accounting Office (GAO), which changed its name to the Government Accountability Office (GAO) in 2004, finalized reports during 2003 on the public health and hospital preparedness for bioterrorism and emerging infectious diseases.9,16 These reports found that most hospitals in the United States do not have the means to care for a surge of patients during a public health emergency.9,16 They stated that, based on the national emergency department diversion rates in urban and suburban areas, shortages in the healthcare workforce, and the general lack of available supplemental medical equipment and supplies in hospitals, the medical community is not prepared to handle a patient surge caused by an infectious disease outbreak or bioterrorism related event.9,16 Emergency departments are being utilized more often as urgent care centers because the growing population utilizes the ED as their point of primary care. This increasing phenomenon is contributing to ED overcrowding and diversionary status (hospital EDs asking that ambulances refrain from bringing patients to their facility for a period of time) in virtually every healthcare and trauma system in the country. The current state of affairs in the nation’s EDs makes it very difficult to prepare for surge capacity when many hospitals cannot effectively handle their daily patient volume.18 Referral patterns of patients presented to medical facilities will vary in terms of how they arrive at the facility (EMS or self-transport) as well as which facilities they access (hospital ED or physician’s office), depending on the type of disaster or public health emergency. In cases of natural disasters, explosions, and acute catastrophic events where there is a clear and defined “scene,” many patients will be triaged, treated, and perhaps transported to hospitals or trauma centers by EMS personnel. In cases of bioterrorism or infectious disease outbreaks, patients would normally exhibit minor signs and/or symptoms of an illness (e.g., fever, rash, flu-like symptoms, etc.). These patients may be 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 9 Healthcare Emergency Management Activities | 9 presented to their primary care physician or an urgent care center to receive initial diagnosis and treatment. The patients that can be expected to arrive at the ED in these cases would be those who could not access a private physician, those too acutely ill to seek care in an office setting, those referred to the ED by their physicians, and those patients who called EMS for assistance. This latter group would yield the least number of ED arrivals.19–20 Incidents of chemical and biological terrorism as well as pandemic or epidemic incidents of infectious diseases may arguably produce the most significant burden on the healthcare system.9,13,16,18,21 A main reason for this is the unpredictable referral patterns of patients who fall victim to a chemical or biological hazard. Although some disaster after-action reports do suggest that even victims of conventional disasters will self-refer to medical facilities, the issues of delayed onset of symptoms, cross-contamination, and person-to-person disease transmission that are associated with a chemical, biologic, or radiologic incident call for more detailed contingency plans. An example of hospital referral patterns after a chemical agent event can be seen in the post-event summary of the sarin attack in the Tokyo subways in March of 1995.22 In this incident 12 people were killed, but more than 5000 people sought medical attention, and only 688 of them were medically transported to area hospitals.22 At some point during the evolution of a disaster or other public health emergency, patients will converge on acute care hospitals. Studies have consistently shown that despite rigorous planning initiatives, hospitals and emergency departments are not prepared to handle the mass influx of patients that a bioterrorism event or infectious disease outbreak would produce.9,16,19–20 During the sarin attack on the Tokyo subway in 1995, the nearest hospital had 500 patients in the first hour after the incident and more than 20% of its staff was secondarily contaminated.22 It is important that planners additionally recognize that in certain catastrophic disasters involving bombings, building collapse, etc., mass injuries and a patient surge may not occur as anticipated because of the high rate of mortality.17,23 The hospital emergency manager and all those involved in hospital emergency management must ensure that their hospital has adequate plans for the surge of patients that will arrive during a disaster, terrorism event, or public health emergency. VOLUNTEER MANAGEMENT The use of volunteers in disasters and public health emergencies presents a unique set of considerations for the hospital emergency manager. Volunteers can be utilized in several ways to assist in disaster relief services. However, the problems of volunteer management, credentialing, 55133_CH01_Reilly:Achorn Int’l 10 | Chapter 1 5/13/10 12:08 PM Page 10 Introduction to Hospital and Healthcare Emergency Management safety, and security often preclude their utility in the acute disaster environment unless significant pre-planning for their use has occurred and their arrival is through a pre-defined system. Cone et al. describe “convergent volunteerism” (the influx of citizens and/or health providers to a major incident) as a “critical problem” in disaster management.24 Intuitively, you may think that the outpouring of community support to assist in rendering aid during a disaster or other public health emergency is a welcome show of support for disaster victims. However, the reality is that convergent volunteerism brings with it security, resource, and worker safety problems that require personnel and critical resources to manage. In their discussion of convergent volunteerism in the September 11 terrorist attacks in NYC, Cone and colleagues discuss the myriad of additional challenges and problems that the unsolicited and often intrusive behavior of “Good Samaritans” imposed on the NYC responders. Issues included the unsupervised practice of medicine and paramedicine; credential verification of certified and/or licensed personnel; the performance of search and rescue operations by lay responders; the need to feed, shelter, and provide sanitary facilities for volunteers; potential injury and illness to volunteers who were unsupervised and lacked proper personal protective equipment; and personal vehicle congestion on scene access and egress.24 Many of these concerns may seem trivial to some who view a community response to a disaster as being the quintessential demonstration of altruism and support for fellow citizens. However, as mentioned by Cone and colleagues, untrained and unauthorized volunteers can ultimately put themselves and others in danger, and deplete emergency response resources by attempting to provide assistance at disaster scenes. This was most poignantly illustrated during the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, when an untrained and unprotected volunteer nurse was crushed by falling debris while trying to assist with urban search and rescue operations.24 SECURITY ISSUES Hospitals frequently overlook the need to maintain adequate security of the healthcare facility and overall medical operations as part of both daily operations and emergency planning. The concept of “locking down” or restricting access to a healthcare facility is often contradictory to the typical hospital design and approach of open access to both patients and their families and other visitors. But during a disaster this type of control is essential for many reasons, which include but are not limited to: control of the flow of patients to the areas where care will be provided; access to the facility only by authorized staff; accounting for staff and patients 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 11 Healthcare Emergency Management Activities | 11 in time of evacuation; prevention of potentially contaminated patients entering the hospital from contaminating staff, other patients, and facilities; and prevention of acts of terrorism. Security resources generally vary among hospitals. Some hospitals and trauma centers have sworn police officers present in their facilities 24 hours a day, and others may hire a private security firm to maintain safety or simply serve a concierge or customer service role. Security concerns during disasters and public health emergencies can become significant when considering the potential vulnerabilities associated with the chaotic response environment.15,17,24–25 Specifically cited issues with security during the response to a disaster or public health emergency include access control to medical facilities; credentialing of employees, responders, and volunteers; crime scene and evidence preservation; infrastructure and resource protection; and crowd control.15,17,24–25 HAZMAT/CBRNE PREPAREDNESS There is no question that in the current state of health system and public health preparedness the medical community is ill-prepared to deal with an incident that involves the management and treatment of multiple potentially contaminated victims, including those from chemical, biological, radiological, nuclear, and explosive (CBRNE) events. Multiple recent reports of hospital preparedness cite decontamination capabilities as a serious weakness of disaster readiness plans.4–5,8–9,11,15–16,26–27 One study cites as few as 6% of Level I trauma centers as having the necessary equipment on hand to safely decontaminate a single patient.26 Planning for these events has traditionally centered around the fallacy that patients will be decontaminated at the scene by first responders and then be triaged, treated, and transported to the ED. The decontamination process serves a dual purpose. First, it removes the potential agent that is causing harm to the patient, and second, it prevents the spread of secondary contamination to other patients and hospital staff. We have come to realize from recent incidents involving victim contamination that many ambulatory victims will leave the scene and bypass EMS decontamination and triage, seeking medical care on their own.11,15,19–20 The reality of dealing with an intentional release of chemical, biological, or radiological agent is that by the time acute care facilities can be made aware that an event has taken place, they may have already been contaminated themselves.22 The specifics of hospital decontamination and worker safety are discussed in Chapter 14. Throughout the nation, trauma systems, acute care hospitals, and first responders are unprepared for handling an event involving the release of a nuclear, biological, or chemical (NBC) agent.8,15,26 Largely, this is due to ineffective planning and relying on resources that may not be available 55133_CH01_Reilly:Achorn Int’l 12 | Chapter 1 5/13/10 12:08 PM Page 12 Introduction to Hospital and Healthcare Emergency Management during a disaster or public health emergency.15 The most often cited weaknesses are an overall lack of training, lack of personal protective equipment (PPE), lack of resources and equipment to rapidly and reliably perform preliminary agent detection, and lack of appropriate medical facilities, equipment and supplies to effectively isolate infectious patients and manage them through the course of their illnesses.8,15,21–22,26 COLLABORATION AND INTEGRATION WITH PUBLIC HEALTH In order for disaster preparedness and response to be successful, it must involve interagency resources and consider the 3C’s of emergency response planning: Collaboration, Cooperation, and Coordination. Response plans cannot be designed and implemented in a vacuum. Disaster response and recovery operations will certainly consist of a multiagency response at the local, state, and federal levels. In order to ensure that the response plan is valid, and will operationally integrate with other key responding agencies, the planner must collaborate with fellow agencies and develop plans that involve aspects of interagency response. Interagency planning groups, such as the Local Emergency Planning Committee (LEPC), operate under the assumption that if a hazardous event occurs, all key public safety and health agencies will respond in a unified approach with common goals to protect the welfare and safety of the community. These principles of collaboration, cooperation, and coordination among the agencies that will likely respond to a disaster or other public health emergency will minimize unnecessary redundancy in response plans and create partnerships with agencies that can provide expertise and resources during the public health emergency response. In a large-scale disaster or act of terrorism, such as the World Trade Center attacks in 1993 and 2001, the Oklahoma City bombing in 1995, and the 1994 and 1995 sarin attacks in Tokyo, continuous medical monitoring and follow-up of the survivors, responders, and participants in these events is needed to detect the associated long-term health effects. With the exception of large academic medical institutions that may perform epidemiologic analysis on specific cohorts of individuals, the public health community must recruit and maintain a database of affected individuals so they can study the long-term impact of these events on the health of the population. It is important to note that although the imminent threat of danger may no longer be present, the need for medical care, disease surveillance, and follow-up studies is essential to the completion of the public health role in a disaster or other public health emergency. Additionally, public health agencies at the federal, state, and local levels have the responsibility under the National Response Framework (NRF) to coordinate and serve as the lead agency for disasters involv- 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 13 Healthcare Emergency Management Activities | 13 ing mass care. This may include assisting both hospitals and communities to establish alternate care sites (ACS) where patients can be directed to receive medical treatment during a public health emergency, which will allow a hospital to use its resources to treat higher acuity patients and remain open to handle routine emergencies during a pandemic or other public health emergency. EDUCATION AND TRAINING Reports have suggested that healthcare workers lack the knowledge to detect and manage a patient who has been exposed to a chemical or biological agent.6,27–28 The Health Resources and Services Administration (HRSA) survey helped to illustrate the lack of training and education among trauma center and hospital staff by reporting that only eight states required employees to be trained in disaster-related topics, two states required training in biological agent topics, and two states required training for chemical-related topics.8 Additionally, training for EMS personnel was equally poor because only six states required prehospital providers to have education on disaster-related topics, only one state required biological agent training, and three states required education on chemical agents.8 EQUIPMENT AND SUPPLIES In the GAO’s report of hospital preparedness in August 2003, they reported several findings on hospital equipment and supply resources. The survey showed that for every 100 beds, 50% of hospitals had fewer than 6 ventilators, fewer than 3 PPE suits, fewer than 4 isolation beds, and could only handle fewer than 6 patients per hour through a 5-minute decontamination shower, given their current state of preparedness.9 Additionally, the GAO reports that most first responders lack a reliable means to detect chemical and/or biological agents in the field, and do not typically have the proper PPE to protect themselves from agent exposure.9 The HRSA evaluation of state trauma systems showed that the availability of PPE for healthcare workers was significantly lacking among states because only one state (Ohio) had enough PPE resources immediately available for its EMS personnel, and only one state (New Jersey) had enough PPE resources immediately available for its hospital personnel if a chemical or biological agent release occurred.8 In addition to PPE issues, hospitals and trauma centers often lack the inventory of equipment and supplies necessary to effectively treat an influx of potentially affected patients.8–9,14–16,26 Many hospitals, in a strategy to reduce overall costs, replenish their central supply on a “just-in-time” basis, clearly ineffective in preparing to treat a mass 55133_CH01_Reilly:Achorn Int’l 14 | Chapter 1 5/13/10 12:08 PM Page 14 Introduction to Hospital and Healthcare Emergency Management influx of patients.18 Pharmaceutical access is another concern among healthcare facilities. As demonstrated in the fall 2001 anthrax scare, hundreds of postal and healthcare workers required postexposure prophylaxis after potential exposure to the agent. Maintaining an adequate pharmaceutical stock of essential antibiotics, antidotes, and specialty medications in case of a disaster is often viewed as cost prohibitive due to the shelf life and daily usefulness of certain drugs.18 Although this has improved slightly over the past 6 years, hospitals around the country still struggle to build the internal capacity necessary to perform emergency decontamination of patients from hazardous substance incidents and properly protect their staff, patients, and visitors from secondary contamination. WORKER SAFETY A report released by HRSA on the national state of the trauma system and EMS preparedness for disasters and mass causality events showed that only one state in the country thought that its hospital workers would be adequately protected in the event of a biological (but not chemical) agent attack.8 Additionally, only one state reported that its EMS system would have access to PPE in the event of a bioterrorism event.8 Similar research has underscored a general lack of protection for the public health workforce against any type of chemical, biological, or radiological contamination in the event of a disaster.8 A major role for the public health community during an event is to ensure the health and safety of all disaster workers.13,15 DRILLS AND EXERCISES Criticisms regarding drills and exercises are notable throughout the preparedness literature.6,9,11,15,21,26 Comments include statements that exercises are not realistic, drills tend to be conducted with advanced warning on shifts with favorable staffing levels, and with equipment and resource levels at their best, etc. Therefore, the drills bias any useful results from the exercise.15 The purpose of conducting drills and exercises (besides remaining in compliance with accrediting bodies) is to assess whether or not a facility is adequately prepared to handle an incident with relatively low probability, but with extremely significant impact on the health system, and to identify areas that need improvement on an operational and planning level.15 Exercises that simply go through the motions or are conducted with limited realism, under optimal conditions, or are simply haphazardly conducted to meet regulatory or legal requirements are futile and worthless assessment tools that will only perpetuate a hospital’s state of unpreparedness.15 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 15 The Role of the Hospital/Healthcare Emergency Manager | 15 EMERGENCY DEPARTMENT DISASTER OPERATIONS The importance of the ED’s role in disaster and emergency preparedness is discussed in several sources.4–12 The American College of Surgeons mentions that the ED is a major strength of a trauma center.12 They refer to the ED staff as “highly competent” and often “experts” in the medical management of chemical, biological, and radiological casualties.12 Among the many strengths of the ED is the ability to integrate two major components of the trauma system: prehospital and definitive care. The emergency department maintains constant communications with the EMS system and serves as the direct point of entry for prehospital providers into the hospital or trauma center. Emergency physicians represent a critical link in the chain of survival by anticipating the resources that ill and injured patients will need upon arrival at the ED, and initiating appropriate lifesaving medical care until specialty resources become available.4–11 TRAUMA CENTERS The roles of trauma centers during a disaster or public health emergency are consistent with their daily activities in the treatment of injured patients. Triage and treatment of injured victims after a disaster is frequently discussed as a central role of the trauma center in the aftermath of a disaster.6,8–11,13,15–16,18,23,25–29 It is well documented that trauma centers are adept at the care of the injured victim, and are viewed as the best choice for the triage and treatment of disasterrelated injured victims.4–10,12,14,17,23,25–31 Trauma care is identified most frequently as the major strength of the trauma center and the trauma system. Another expectation is that trauma centers and acute care hospitals will be able to treat mass numbers of affected patients as well, including the rapid triage and treatment of all casualties (including those from CBRNE events), decontamination and/or isolation, and quarantine of contaminated or potentially infectious patients. Trauma centers are also expected to have access to essential equipment, supplies, and pharmaceutical agents.4–6,8,14–15,17,23,27–29,32 The Role of the Hospital/Healthcare Emergency Manager What then, is a hospital or healthcare emergency manager? A hospital or healthcare emergency manager is an individual employed by a healthcare organization whose job is to coordinate the emergency management functions of the hospital. This may include many responsibilities 55133_CH01_Reilly:Achorn Int’l 16 | Chapter 1 5/13/10 12:08 PM Page 16 Introduction to Hospital and Healthcare Emergency Management depending on the hospital or healthcare system, the location of the facility, the size and type of facility or organization, and specific local issues or threats and activities. While there may be variation in the role, almost universally the hospital/healthcare emergency manager will perform hazard vulnerability analysis, planning activities, coordination of the hospital’s disaster and other emergency management planning groups or committees, design and conduct training programs, perform drills and exercises, interact with other agencies and organizations involved in healthcare emergency management (e.g., local public health department, local office of emergency management, EMS, local law enforcement, and state agencies), and maintain compliance with regulatory agencies and accreditation organizations such as the JCAHO. Many hospital or healthcare emergency managers are individuals who have these duties in addition to their normal occupational roles in the healthcare organization. Typical positions within healthcare organizations that also perform emergency preparedness activities include nursing managers, educators, administrators, security managers, environmental health and safety administrators, facilities or physical plant directors, or emergency medical services coordinators. Few hospitals have taken the initiative to hire a full-time emergency preparedness coordinator for several reasons. First, there is no direct revenue return on investment in hospital preparedness. Emergency management is rather a fixed but necessary operating cost. In the United States, hospitals and healthcare organizations need to generate a profit. Even in not-for-profit hospitals, CEOs need to be able to show that profit increased in order to justify growth and add services for their patients. Activities that cannot improve the profitability of the organization often remain unfunded. Second, there is a shortage of qualified individuals to fill these positions. As mentioned before, most hospitals have added the duties and responsibilities of preparedness onto an existing full-time employee and this individual had to teach themselves how to perform these added duties. Most individuals who serve in full-time hospital emergency manager positions have a public safety background or a clinical background and have had to learn the discipline of emergency management. Until recently there have been few higher educational opportunities for people who wish to learn the discipline of healthcare emergency management. In 2010, the Federal Emergency Management Agency’s (FEMA) Higher Education Program listed only 10 undergraduate and graduate programs combined that focus on both healthcare and emergency management. Many of these are new programs that have only been in existence for a few years. There have been degree programs in general emergency management, but only a few that apply this discipline to the public health or hospital environment. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 17 References | 17 If you don’t seek out a formal degree, how do you become knowledgeable in hospital emergency planning? Initially, it begins with your current role. If you are a healthcare worker who needs to learn the finer points of emergency planning, drills and exercises, and incident management, then you could benefit from FEMA’s independent study program or professional development series. On the other hand, if you are an emergency management professional with little knowledge of the healthcare environment, you may benefit from continuing education in health and medical issues such as the strategic national stockpile, emerging infectious diseases and pandemics, the health and medical impact of terrorism and weapons of mass destruction, and the health impact on populations displaced as the result of disasters. This text is designed specifically for individuals who wish to learn the applied discipline of healthcare emergency management, and for all other personnel in a hospital or from other disciplines who will work with either a hospital or any other aspect of a healthcare system in planning for and responding to disasters, terrorism, and public health emergencies. Whether you are a college or graduate student learning the fundamentals of public health or healthcare emergency management, or a current healthcare professional looking to increase your current knowledge in order to apply emergency management principles to your trade, this book is designed to meet your needs. There is a lot to learn, and this text is just the beginning. This emerging field is exciting, challenging, and rewarding. We wish you luck on your journey! References 1. 2. 3. 4. 5. 6. U.S. Department of Labor, Occupational Safety and Health Administration. Best Practices for Hospital-Based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. Washington, DC: OSHA; 2005. OSHA publication 3249–08N. Joint Commission Resources. Emergency management standards. Environ Care News. 2007;10(12):2–8. Joint Commission Resources. Preparing for catastrophes and escalating emergencies. Environ Care News. 2008;11(1):1–3, 11. American College of Surgeons. Resources for Optimal Care of the Injured Patient: 1999. Chicago: American College of Surgeons; 1999. American Trauma Society and U.S. Department of Transportation, National Highway Traffic Safety Administration. Trauma System Agenda for the Future. National Highway Traffic Safety Administration; October 2002. Report #3P0138. American College of Surgeons. [ST-42] Statement on disaster and mass casualty management [by the American College of Surgeons]. American College of Surgeons Web site. http://www.facs.org/fellows_info/statements/st-42.html. Published 2003. Accessed December 28, 2009. 55133_CH01_Reilly:Achorn Int’l 18 | Chapter 1 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 5/13/10 12:08 PM Page 18 Introduction to Hospital and Healthcare Emergency Management Bledsoe BE, Porter RS, Cherry RA. Essentials of Paramedic Care. Upper Saddle River, New Jersey: Brady/Prentice Hall Health; 2003. U.S. Department of Health and Human Services, Health Resources and Services Administration. A 2002 National Assessment of State Trauma System Development, Emergency Medical Services Resources, and Disaster Readiness for Mass Casualty Events. Washington, DC: Health Resources and Services Administration; 2002. U.S. General Accounting Office. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response. Washington, DC: U.S. General Accounting Office; August, 2003. Report GAO-03-924. Frykberg ER. Disaster and mass casualty management: a comment on the ACS position statement. Bulletin of the American College of Surgeons. 2003;88(8):12–13. White SR. Hospital and emergency department preparedness for biological, chemical, and nuclear terrorism. Clin Occup Environ Med. 2002;2(2):405–425. Trunkey DD. Trauma centers and trauma systems. JAMA. 2003;289:1566–1567. Landesman LY. Public Health Management of Disasters: The Practice Guide. Washington, DC: American Public Health Association; 2001. May AK, McGwin G Jr, Lancaster LJ, et al. The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries. J Trauma. 2000; 48(4):666–672. Rubin, JN. Recurring pitfalls in hospital preparedness and response. J Homeland Security. January, 2004. http://www.homelanddefense.org/journal/Articles/ rubin.html. Accessed August 18, 2009. U.S. General Accounting Office. SARS Outbreak: Improvements to Public Health Capacity Are Needed for Responding to Bioterrorism and Emerging Infectious Diseases. Washington, DC: U.S. General Accounting Office; May 7, 2003. Publication GAO-03-769T. Feeney J, Parekh N, Blumenthal J, Wallack MK. September 11, 2001: a test of preparedness and spirit. Bulletin of the American College of Surgeons. 2002;87(5). Barbera JA, Macintyre AG, DeAtley CA. Ambulances to nowhere: America’s critical shortfall in medical preparedness for catastrophic terrorism. In: Howitt AM, Pangi RL, eds. Countering Terrorism: Dimensions of Preparedness. Cambridge, MA: MIT Press; 2003:283–297. Reilly MJ, Markenson D. Hospital emergency department referral patterns in a disaster. Prehosp Disast Med. 2009;24(2):s29–s30. Reilly MJ. Referral patterns of patients in disasters—who is coming through your emergency department doors? Prehosp Disast Med. 2007;22(2):s114–s115. Kellerman A. A hole in the homeland defense. Modern Healthcare. 2003;33(16):23. U.S. Department of Defense, Army, SBCCOM, Federal Domestic Preparedness Program. NBC Domestic Preparedness Senior Officials’ Workshop (SOW) [CD-ROM]. SBCCOM; 1999. Cushman JG, Pachter HL, Beaton HL. Two New York City hospitals’ surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma. 2003;54:147–155. Cone DC, Weir SD, Bogucki S. Convergent volunteerism. Ann Emerg Med. 2003;41(4):457–462. Feliciano DV, Anderson GV Jr, Rozycki GS, et al. Management of casualties from the bombing at the Centennial Olympics. Am J Surg. 1998;176(6):538–543. Ghilarducci DP, Pirallo RG, Hegmann KT. Hazardous materials readiness of United States Level 1 trauma centers. J Occup Environ Med. 2000;42(7):683–692. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 19 References | 19 27. 28. 29. 30. 31. 32. American College of Surgeons. Disasters from biological and chemical terrorism—what should the individual surgeon do?: a report from the Committee on Trauma. American College of Surgeons Web site. http://www.facs.org/ civiliandisasters/trauma.html. Accessed December 30, 2009. American College of Surgeons. Statement on unconventional acts of civilian terrorism: a report from the Board of Governors. American College of Surgeons Web site. http://www.facs.org/civiliandisasters/statement.html. Accessed December 30, 2009. Jacobs LM, Burns KJ, Gross RI. Terrorism: a public health threat with a trauma system response. J Trauma. 2003;55(6):1014–1021. MacKenzie EJ, Hoyt DB, Sacra JC, et al. National inventory of hospital trauma centers. JAMA. 2003;289:1515–1522. Mann NC, Mullins RJ, MacKenzie EJ, Jurkovich GJ, Mock CN. Systematic review of published evidence regarding trauma system effectiveness. J Trauma. 1999; 47(3);S25–S33. Peterson TD, Vaca F. Commentary: Trauma systems: a key factor in homeland preparedness. Ann Emerg Med. 2003;41(6):799–801. 55133_CH01_Reilly:Achorn Int’l 5/13/10 12:08 PM Page 20 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 21 Chapter 2 Healthcare Incident Management Systems Arthur Cooper, MD, MS Photo by Jocelyn Augustino/FEMA News Photo Learning Objectives ■ Discuss the fundamental principles of healthcare incident management systems. ■ Describe the incident command system structure and its application to the healthcare environment. ■ Discuss the importance of interagency cooperation and collaboration when managing disasters and public health emergencies that impact the healthcare system. Overview Making method out of madness The aim of this chapter is to arm the busy healthcare staff, clinician, or emergency manger with a basic understanding of incident management 21 55133_CH02_Reilly:Achorn Int’l 22 | Chapter 2 5/13/10 1:15 PM Page 22 Healthcare Incident Management Systems systems as applied to the healthcare and hospital environment, including the Hospital Incident Command System (HICS), not as a substitute, but as a rationale for incident management training and the need to understand the application to a hospital or healthcare system. This chapter will cover the fundamental principles of healthcare incident management systems, including one system modified specifically for the hospital, the Hospital Incident Command System. Such systems are vital to the management of disasters, acts of terrorism, and public health emergencies involving healthcare organizations because, without the effective coordination of resources achieved through use of a healthcare incident management system, chaos, rather than order, will prevail. After a concise introduction to set the stage, the chapter will consider the historical background, foundational principles, incident leadership, command structures, HICS organization, training systems, HICS implementation, logistic concerns, practical concerns, and interagency relationships essential to successful healthcare incident management, before delivering its conclusions. Case Study A Cloud in the Midnight Sky You are the administrator on duty (AOD) when you are called by the physician in charge of the emergency department, who reports that numerous arriving patients are exhibiting spasms of severe coughing triggered by “something in the air.” While you consider your next steps, your spouse calls to tell you there has been a large explosion at a nearby tank farm adjacent to a large industrial facility. Television reports document widespread panic at the scene and in the immediate vicinity of your hospital, which is located about two miles (three kilometers) east of the site. It is past midnight; only caretaker staff are on duty (except in your critical and acute care units) and hospital staff await your orders. The following questions race through your mind. How would you begin to answer them? ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ Does a bona fide disaster exist? Should I declare a disaster now? Should I seek additional information before declaring a disaster? Should I implement the hospital’s emergency operations plan? Should I activate the hospital’s command center? How will I ensure the safety of staff and patients? Should I mobilize additional hospital staff? Should I lock down the facility? Should all emergency patients be decontaminated? Should public health agencies be notified? 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 23 Historical Background | 23 ■ ■ ■ Who should I ask for necessary additional resources? Are there potential threats to the hospital itself? How will I coordinate and supervise all the staff? The decisions are yours to make. The answers may be found in this chapter. Introduction “Who’s in charge? They’re all in charge!”1 Understanding the Incident Command System (ICS) applied during disasters may prove a daunting task, even for healthcare executives experienced in interpreting complex tables of organization that baffle other managers, clinicians accustomed to solving and treating complex medical problems, and staff prepared to work in the complex healthcare environment. However, as recently stated so eloquently by Lieutenant Thomas Martin of the Virginia State Police in the illuminating video, The Many Hats Of Highway Incident Command (http://cts .virginia.edu/incident_mgnt_training.htm), the principles of incident command are fundamentally no different from the everyday manners children learn as youngsters, as elegantly and clearly described in the poignant work by author Robert Fulghum, All I Really Need To Know I Learned In Kindergarten.1,2 Within this simple framework, the responsible healthcare emergency manager can readily answer the question, “Who’s in charge?” The answer, of course, is that they’re all in charge, of what they’re in charge of—because all those involved in the disaster response are responsible for their immediate tasks, their communication with others, and first and foremost, their own and others’ safety. Historical Background “The best way to predict the future is to create it.”3 Modern incident command grew from the experience of firefighters in combating the California wildfires of the mid 1970s. Inadequate communication and ineffective collaboration between the numerous agencies battling these natural disasters led to the deaths of many firefighters whose lives need not have been lost. The subsequent after-action reports identified numerous critical weaknesses in the organization and delivery of many responders’ agencies and efforts, including lack of accountability, barriers to communication, poor planning processes, 55133_CH02_Reilly:Achorn Int’l 24 | Chapter 2 5/13/10 1:15 PM Page 24 Healthcare Incident Management Systems overloaded incident commanders, and absent response integration. The dawning realization that deficient and defective command and control were mostly responsible for these tragic fatalities led California fire chiefs to develop an “interoperable” system for emergency response, whereby all the involved agencies could communicate with one another and collaborate in the field, based upon a common organizational structure that all such agencies could understand and apply. This new system, called FIRESCOPE (Firefighting Resources of California Organized for Potential Emergencies), was based upon principles gleaned from military experience and management theory, especially the management by objectives concepts introduced in 1954 by Peter F. Drucker in his classic work, The Practice of Management.4 Its core purpose was to provide a standardized, on-scene, all-hazard incident management dogma that allowed its users to quickly implement an integrated organizational structure that was not impeded by jurisdiction boundaries, and was flexible and scalable enough to match the needs and resources for single, expanding, multiple, and complex incidents, despite their special circumstances and unique demands. It rapidly evolved into the Incident Command System (ICS) that has gradually been adopted by most fire and emergency services nationwide, the purposes of which are to ensure the (1) safety of responders and others, (2) achievement of tactical objectives, and (3) efficient use of resources. As a result, ICS was subsequently designated for use throughout the United States by the federal Superfund Amendments and Reauthorization Act (SARA) of 1986 (PL 99-499), Occupational Health and Safety Administration (OSHA) rule 1910.120, and, most recently, Homeland Security Presidential Directive 5 (HSPD 5),5 in addition to numerous other state and local regulations. Its early success also led the California Emergency Medical Services Authority to adapt and periodically revise it for use in all disasters involving hospitals, such that it now serves as the basis of the Hospital Incident Command System (HICS) used by most hospitals in the Americas and, increasingly, worldwide. Specific instruction in HICS is available through both the California Emergency Medical Services Authority HICS Web site (http://www.emsa.ca.gov/HICS/default.asp), and the Emergency Management Institute’s Web site (http://training .fema.gov), within the independent study ICS courses IS-100.HC and IS-200.HC revised in 2007 for healthcare providers.6 Foundational Principles “Management by objectives”4 The three key strategies of the disaster response, in order, are to (1) protect and preserve life, (2) stabilize the disaster scene, and (3) protect and preserve property. Healthcare providers intuitively understand the first 55133_CH02_Reilly:Achorn Int’l 5/13/10 1:15 PM Page 25 Incident Leadership | 25 purpose, and intellectually understand that the third purpose is essential to the first because healthcare providers cannot perform their lifesaving tasks without the appropriate facilities, equipment, and resources. The second purpose, however, may be less obvious. This is because an organized disaster response can occur only within the context of a stable work environment—an environment that is difficult to achieve in the first minutes after disaster strikes, when chaos is the rule, even in greatly complex work environments, such as hospitals, that are highly self-regulated. Thus, an incident management system is needed to bring order to the chaos, the sine qua non of which is an incident command structure characterized by the three key tactics that must underlie all of incident command—unity of command, span of control, and clarity of text. Unity of command refers to the principle that sharing of information among all personnel involved in a disaster response is vital, but such individuals receive formal orders from, and make formal reports to, a single supervisor in order to preserve the viability of the chain of command. Span of control refers to the principle that in a high stress environment, no line supervisor can effectively coordinate the efforts of more than three to seven, and ideally no more than five, subordinate personnel. Clarity of text refers to the principle that all communications, written and spoken, must be transmitted in the simplest, most generic language possible, avoiding the use of words or jargon likely beyond the understanding of many emergency responders, so as to ensure that all personnel involved in the disaster response understand both the general strategy of the Emergency Operations Plan (EOP) and the special tactics being applied to combat the disaster. Incident Leadership “Coordination, Communication, Cooperation”1 Healthcare incident management systems achieve their goals by ensuring what have been termed the “3 Cs” of incident command: coordination, communication, and cooperation, of which the most important is cooperation, because it makes coordination and communication feasible. However, effective incident management requires not only universal education in disaster management appropriate to the functional job description of the individual healthcare employee—awareness, technical, and professional—but also frequent drilling in the implementation of the hospital disaster plan, especially its incident command structure. Most texts and training rightly emphasize that the individuals designated to fulfill specific functional job descriptions must be appropriately trained to do so; therefore, hospital executives who perform similar tasks during routine hospital business must step aside and yield these responsibilities to those who have been trained 55133_CH02_Reilly:Achorn Int’l 26 | Chapter 2 5/13/10 1:15 PM Page 26 Healthcare Incident Management Systems to do so. However, this notion ignores long-established realities of human behavior—the boss is still the boss, even if untrained in disaster management—so every effort should be made by senior executives to ensure that all hospital executives receive training in disaster management and incident command that will enable supervisors to function in their assigned roles even when disaster strikes. Physicians commonly presume that because the first key purpose of incident management is to protect and preserve life, they should be in charge of emergency operations. However, physicians often overlook the fact that while they must clearly be in charge of all aspects of medical care, they generally comprise no more than approximately 10% of the total number of hospital personnel. Typically, the healthcare needs of the hospitalized patient require an average of 10 other personnel to support the treatments prescribed and the operations performed by a single physician or surgeon. Moreover, the physician’s expertise—and most valuable contribution to the hospital disaster response—lies in the medical care of the hospitalized patient, rather than its operational, logistical, or planning support. Command Structure “[ICS is] the system to achieve the coordination necessary to carry out an effective and efficient response.”7 Two basic command structures, and variations thereof, are utilized worldwide: (1) the Hospital Incident Command System (HICS), developed by the California Emergency Medical Services Authority and promulgated both by its originator (http://www.ems…
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