Background Paper – No. 65 August 8, 2008 Strong as the Weakest Link: Medical Response to a Catastrophic Event Eileen Salinsky, Consultant Overview — Natural disasters and acts of terrorism have placed a spot- light on the ability of health care providers to surge in response to catastrophic conditions. This paper reviews the status of efforts to develop the capacity and capabilities of the health care system to respond to disasters and other mass casualty events. Strategies for adapting routine medical practices and protocols to the demands posed by extraordinary circumstances and scarce resources are summarized. Existing federal roles, responsibilities, and assets relative to the contributions of state and local government and the private sector are described, including specific programmatic activities such as the Strategic National Stockpile, the National Disaster Medical System, and the Hospital Preparedness Program. Opportunities for federal policymak- ers seeking to strengthen and expedite preparations for medical disaster response are highlighted. national health policy forum Facilitating dialogue. Fostering understanding. Background Paper – No. 65 August 8, 2008 Contents Beyond Surge...................................................................................... 3 . contingency Planning...................................................................... 5 Figure 1: National Planning Scenarios............................................. 5 The Current Federal Role.................................................................. 7 Response Resources........................................................................... 7 Figure 2: Medical Countermeasures Pipeline. ................................. 8 . Figure 3: FY 2006 Pandemic Influenza Supplemental Funding................................................................ 9 Figure 4: Strategic National Stockpile and National Disaster Medical System Funding History. ...................... 10 . Support for State and Local Preparedness........................................ 10 Figure 5: Hospital Preparedness Program and Public Health Emergency Preparedness Funding, FY 2002–2008 ........................................................................ 11 opportunities for improvement......................................................13 Hospitals: Divided They Fall.............................................................. 14 Government Role in Planning and Response..................................... 16 Conclusion........................................................................................ 23 Endnotes............................................................................................ 23 National Health Policy Forum Facilitating dialogue. Appendix. ............................................................................................ 27 . Fostering understanding. 2131 K Street NW, Suite 500 *** Washington DC 20037 202/872-1390 The author would like to thank and acknowledge Elin Gursky, ScD, whose guidance, 202/862-9837 [fax] research, and writings significantly contributed to and informed this paper. nhpf@gwu.edu [e-mail] www.nhpf.org [web] Judith Miller Jones Director Sally Coberly, PhD Deputy Director Monique Martineau Publications Director Project Manager Sally Coberly, PhD Deputy Director National Health Policy Forum | www.nhpf.org 2 Background Paper – No. 65 August 8, 2008 Strong as the Weakest Link: Medical Response to a Catastrophic Event As storms, flooding, and brush fires threaten property and lives across the country, concerns about the adequacy of disaster medical response linger in the public consciousness. When Hurricane Katrina slammed into the Gulf Coast in August 2005, Americans were shocked by grave deficiencies in disaster response efforts. This tragedy—coupled with the Minneapolis bridge collapse, the looming potential of an influenza pandemic, catastrophic natural disasters around the globe, and the omni- present threat of terrorism—underscore the urgency of developing more robust and flexible capacity for responding to major medical emergencies. While significant progress has been made in recent years, additional work remains. Many experts have voiced concern that funding for, and commit- ment to, medical preparedness development are lagging. Ensuring that progress made to date is sustained and that unresolved weaknesses are addressed will require the renewed focus and attention of policymakers at all levels of government. Beyond Surge Surge capacity—the health care system’s ability to quickly expand normal service capacity in response to a sharp increase in demand for medical care—is a familiar, but evolving, concept for most health care organiza- tions. Performance expectations, as articulated by state regulations, the Joint Commission standards, and Medicare and Medicaid Conditions of Participation, have long required hospitals to develop and assess plans for managing emergency situations. However, traditional “disaster plans” have typically focused on emergency events (such as major transportation accidents) likely to yield multiple casualties, rather than catastrophic events resulting in mass casualties.1 In the past, these plans often focused solely on general trauma victims and did not consider the specialty care needs generated by biological, chemical, or radiological events. Furthermore, hospitals have historically developed their own institution-specific plans in isolation without considering broader community-wide capabilities. Non- hospital medical resources have rarely been challenged to consider their role in disaster response.2 Traditional approaches to emergency prepared- ness seek to stretch the capacity of the existing system—not restructure the fundamental nature and interoperability of that system. National Health Policy Forum | www.nhpf.org 3 Background Paper – No. 65 August 8, 2008 Health care organizations are beginning to shift their approach to di- It is unlikely that con- saster management in order to prepare for casualty loads measured in ventional approaches thousands, rather than tens. In doing so, they must consider practices and protocols that significantly depart from “business as usual” models. to health care delivery As acknowledged in the President’s Homeland Security Directive-21 on could be sustained in a Public Health and Medical Preparedness,3 the structure and operating catastrophic event. principles of routine health care delivery are poorly suited to meet the needs created by a catastrophic health event. The Directive calls on medi- cal service providers to develop “an operational concept for the medical response to catastrophic health events that is substantively distinct from and broader than that which guides day-to-day operations.” This transformed vision of disaster response necessitates a redefinition of how and by whom medical services should be delivered. Conventional approaches to health care delivery likely could not be sustained under the scale and severity of a major disaster or catastrophic event. Under such circumstances, with staggering numbers of casualties and the possibility that the health care service infrastructure would itself be compromised, the goal becomes “graceful degradation” of service capabilities.4 In essence, Defining Disaster Medical Response Taxonomy for defining the magnitude of a public health emergency and its impact on demand for medical services is not well established. The terms “emergency” and “major disaster” have specific meanings in the Stafford Act,* which provides authority for federal assistance to states and communities pending a presidential declaration. The statute provides for greater levels of assistance under a major disaster declaration, but statutory language limits this designation to natural catastrophes or other incidents resulting in severe physical destruction (such as fire, floods, or explosions). Emergency declarations provide less assistance, but the President has broader discretion in defining the circumstances that constitute an emergency. Statutory language does not establish clear parameters for differentiating events based on the magnitude of medical needs. For the purposes of this paper, the terms catastrophe, disaster, and public health emergency are used to describe urgent events that are likely to overwhelm a community’s entire health care system. The intent is to distinguish the health care needs relating to these incidents from normal fluctuations in health care demand, which can at times overwhelm the capacity of individual provider organizations. * Robert T. Stafford Disaster Relief and Emergency Assistance Act, P.L. 100-707, signed into law November 23, 1988; amended the Disaster Relief Act of 1974, P.L. 93-288. This Act constitutes the statutory authority for most federal disaster response activities especially as they pertain to Federal Emergency Management Agency (FEMA) and FEMA programs. National Health Policy Forum | www.nhpf.org 4 Background Paper – No. 65 August 8, 2008 health care organizations would seek to “engineer system failure” in a de- liberate, rational manner in order to protect the most critical services and optimize patient outcomes under exceptionally challenging conditions. Effective performance during a major disaster relies on a variety of strate- gies that are not routinely practiced during normal operations, but require advance planning and clear communication. Regionalized deployment of medical assets, coordinated decision making through an incident command system, use of alternate care sites, altered standards of care, expanded scope of practice authorities for health care professionals, and triage-based protocols for allocating scarce resources are examples of strategies with significant potential to maximize the capacity and effectiveness of medical response. These approaches can require hospitals and other health care organizations to work with public officials—and each other—in ways that are often radically different from their day-to-day relationships. Developing these plans in advance of a catastrophic emergency is extremely challenging in large part because many of these strategies have limited utility in achieving immediate, normal objectives and may, in fact, conflict with routine priorities. Yet because a community’s preparedness ultimately rests on the strength of the “weakest link” in its planning chain, all parties have an obligation to confront these difficult decisions. contingency Planning The uncertain nature of future emergencies further complicates planning efforts. Different threats place different types of demands on medical Figure 1 response capacity, and these contingencies must be carefully consid- National Planning Scenarios ered. Public health emergencies can take many forms, varying in the number and acuity of casualties, the nature of victims’ medical needs, the time frame for impact and recovery, the degree to which medical assets are compromised, and the scope of the affected area. As summarized in Figure 1, the National Preparedness Guidelines issued by the Department of Homeland Security (DHS) have identified 15 scenarios depicting a diverse set of high-consequence, high- risk events to help focus contin- gency planning.5 The manner and degree to which medical surge response practices would deviate from routine norms would depend greatly on the nature, scale, and severity of the public health emergency. Source: DHS, National Preparedness Guidelines, September 2007, p. 31; While the threats identified in the National available at www.dhs.gov/xlibrary/assets/National_Preparedness_Guidelines.pdf. National Health Policy Forum | www.nhpf.org 5 Background Paper – No. 65 August 8, 2008 Planning Scenarios have the potential to result in large casualty loads, it isimportant to note that even a relatively small number of exotic, commu- nicable disease cases can place extraordinary strains on health care orga- nizations and seriously disrupt normal operations. As the SARS outbreak demonstrated, novel infectious agents have the potential to cause wide- spread contagion and fear and can be difficult to characterize. Therefore, treatment protocols demand scarce specialized resources (such as personal protective equipment, patient isolation facilities, and dedicated laboratory capabilities), as well as rigorous infection control practices to minimize exposure and transmission risks. Intentional incidents, whether involving bio-agents or other health threats, also raise specific demands for the health care system Prospective planning can be costly, both in order to allow for successful coordination with law enforcement activities, as well as financially and politically, as private sector to address purposeful efforts to undermine organizations and government agencies medical response capabilities. confront difficult decisions that may arise at The short-term incentives for tackling the some point in the future. diverse challenges of disaster planning are low for both health care organizations and policy officials, and the im- mediate risks of addressing these concerns in advance of a disaster are high. Prospective planning can be costly, both financially and politically, as private sector organizations and government agencies confront difficult decisions that may arise at some point in the future. One’s willingness to address these questions proactively in a meaningful way is often governed by the perceived probability of a catastrophic event actually occurring. This perception is, in turn, influenced by prior disaster experience, the credibility of threat assessment processes, and the level of leadership committed to building medical response capacity. Developing medical response capacity and capabilities to address cata- strophic threats is a collective responsibility. This shared responsibility involves both private and public sector health care organizations (such as hospitals and nursing homes), individual health care providers (such as physicians, nurses, and emergency medical technicians), private sector assets outside of the health domain (such as transportation fleets, food service vendors, and child care providers), local and state health and emergency management agencies, and various components of the federal government. Much of this nation’s medical services infrastructure resides in the private sector, and state governments are primarily responsible for coordinating and regulating private sector efforts to prepare for medical emergencies. However, the federal government has a critical role to play in encouraging state and local officials to pursue these objectives proac- tively, as well as in facilitating inter-state collaboration through funding incentives and policy guidance. National Health Policy Forum | www.nhpf.org 6 Background Paper – No. 65 August 8, 2008 The Current Federal Role Measured in terms of financial investment, the role of the federal gov- ernment in developing medical disaster response capabilities is largely focused on creating new and improved medical countermeasures against particular public health threats, such as pandemic influenza, anthrax, smallpox, and nuclear explosions. Relatively fewer resources have been directed at providing financial support and technical assistance to state governments or developing federal personnel capacity to assist in medical response activities. This section of the paper provides a brief overview of federally sponsored activities to develop medical preparedness, including a synopsis of federal assets that could be deployed in the event of a major medical disaster and a summary of the funding programs that provide financial and technical support to states. (More detailed descriptions of select federal disaster medical response programs are provided in the Appendix.) The subse- quent section reviews the perceived status of preparedness development efforts by private, local, state, and federal stakeholders and identifies concerns and tensions that have been raised by these stakeholders and expert observers. Response Resources The federal role in providing direct, operational support for disaster medical response is defined by the National Response Framework (NRF).6 The NRF assumes that state authorities will be primarily responsible for coordinating all disaster response activities, but acknowledges that federal assistance may be requested if state resources are exceeded or exhausted. Federal responsibilities specific to medical response are delineated by the Plan’s Emergency Support Function #8: Public Health and Medical Services Annex.7 The Annex identifies the Department of Health and Human Services (HHS) as the primary agency responsible for coordinating and imple- menting federal public health and medical assistance to states and localities. The Office of the Assistant Secretary for Preparedness and Response (OASPR) has primary responsibility for carrying out this function by utilizing the resources of that office, managing other HHS assets, and coordinating with other federal agencies. These federal public health and medical activities are nested within the broader NRF, which incorporates a range of response functions including mass care and housing, transportation, communications, and public works. Overall coordination of the federal response is implemented by the DHS. Co- ordination is extremely important in that effective medical treatment may depend on support provided through mass care, transportation, and other functions.8 National Health Policy Forum | www.nhpf.org 7 Background Paper – No. 65 August 8, 2008 Key federal assets that could be deployed to support state and local medi- cal response include: QQ The Strategic National Stockpile (SNS), a repository of pharmaceuti- cal agents and medical supplies QQ The National Disaster Medical System (NDMS), a federally co- ordinated network of private sector medical personnel and inpatient facilities, as well as military medical transportation resources QQ The Public Health Service (PHS) Commissioned Corps Rapid De- ployment Teams, consisting of clinical and support staff employed by the federal government who can be mobilized to assist in disaster medical response Over the last several years, HHS has taken a variety of steps to enhance the capacity and capabilities of these response resources. The federal government has made a significant investment in developing and acquiring additional medical countermeasures for inclusion in the SNS.9 The stockpile includes a variety of commonly available medications and supplies, but substantial resources have been devoted to creating and purchasing new and improved medical countermeasures for which com- mercial demand is limited. HHS has established both “push” and “pull” incentives to spark development of the priority medical countermeasures needed to respond to high-risk threats (Figure 2). Push — The National Institutes of Health supports a variety of research and development activities focused on biological, radiological, and chemi- cal countermeasures. NIH devoted approximately $1.7 billion in fiscal year (FY) 2008 funding to biodefense-related research focused on a range of public health threats including traditional agents with the potential to cause mass casualties (such as Bacillus anthracis), enhanced agents that Figure 2 Medical Countermeasures Pipeline ACADEMIA Basic Pathogen Vaccines Project Strategic Research Biology Target Preclinical Clinical Therapies Bioshield National Identification Development Evaluation Diagnostics “Pull” Stockpile NIH “Push” Host Response INDUSTRY Source: Adapted from Office of Public Health Disaster Medical Countermeasures, Project Bioshield, Annual Report to Congress: July 2004 through July 2006, Office of Public Health Disaster Preparedness, HHS, July 31, 2006, p. 19; available at www.hhs.gov/aspr/barda/documents/bioshieldannualreport.pdf. National Health Policy Forum | www.nhpf.org 8 Background Paper – No. 65 August 8, 2008 have naturally evolved to circumvent available countermeasures (such as multi-drug resistant plague), emerging agents (such as H5N1 avian influenza), and advanced agents that have been artificially engineered to be more severe or less vulnerable to traditional treatments (such as multi- drug resistant B. anthracis).10 Because there is little to no current market demand for these products, public funds are needed to seed research and early development activities. Pull — Dedicated federal funds have also been designated to support the advanced development and procurement of medical countermeasures for the SNS. These funding mechanisms assure pharmaceutical manufacturers that a market will exist for their products to encourage private sector invest- ment in late-stage development. The $5.6 billion Project Bioshield fund was established in the FY 2004 Department of Homeland Security Appropriations Act and is administered by the Biomedical Advanced Research and Develop- ment Authority (BARDA) within the OASPR. Approximately $1.8 billion was drawn from this fund between July 2004 and July 2006 for the acquisition of anthrax vaccine, anthrax therapeutics, botulinum antitoxin, and pediatric formulations of potassium iodine.11 In addition to these Bioshield-related procurements, substantial resources have also been devoted to enhancing the SNS inventory in preparation for an influenza pandemic. Congress ap- propriated $5.6 billion in emergency supplemental FY 2006 funding to sup- port pandemic influenza preparedness, and this funding has largely been committed to vaccine and antitoxin stockpiles.12 (See Figure 3.) In addition to the funding increases Figure 3 for specialized product acquisition, FY 2006 Pandemic Influenza general funding for the SNS has also risen in recent years. The SNS is oper- Supplemental Funding [$ billions] ated by the Centers for Disease Control and Prevention (CDC). The stockpile Total Funding — $5.59 billion State and Local Preparedness was established at CDC in 1999. Al- [$0.60] International Collaboration though budgetary authority for the Medical Supplies [$0.18] program was transferred to DHS by the [$0.17] Other Domestic Activities Homeland Security Act of 200213 and [$0.28] transferred back to HHS in 2004 by the Risk Communications Project Bioshield Act,14 CDC has man- Antivirals [$0.05] aged the SNS since its inception. Gen- [$1.08] eral SNS funding is used to support the basic management, storage, rotation, and security of stockpile inventories Vaccines and to augment stockpile holdings for [$3.23] the many types of products not covered by specialized procurement programs (such as psychotropic medications). SNS funds have also been used to sup- Source: HHS, “Report to Congress: Pandemic Influenza Preparedness Spending,” port the development of Federal Medi- prepared in response to request in conference report 109-359, December 2007, p. 4; cal Stations (FMS), mobile facilities that available at www.hhs.gov/aspr/barda/mcm/panflu/spending.html. National Health Policy Forum | www.nhpf.org 9 Background Paper – No. 65 August 8, 2008 are designed to provide low- to mid-acuity hospital Figure 4 bed surge capacity. Strategic National Stockpile and Financial investments in the workforce-based National Disaster Medical System Funding, components of federal disaster medical as- FY 2004–2008 [$ millions] sistance have been less substantial than those Millions directed at fortifying the SNS (Figure 4), but HHS $600 has pursued enhancements to the NDMS and PHS $524 $552 Commissioned Corps Rapid Response Teams. $500 In light of perceived inadequacies in the federal $467 $496 response to Hurricane Katrina, the Pandemic and All-Hazards Preparedness Act 15 (PAHPA) $400 Strategic National authorized transfer of the NDMS to HHS from $398 Stockpile DHS. This transfer was initiated in 2007, and a $300 comprehensive review of NDMS functionality has been conducted by HHS, DHS, the Department of National Disaster Defense, and the Veterans Administration.16 Simi- $200 Medical System larly, policies and procedures for deploying the PHS Commissioned Corps have been reviewed, $100 and HHS has proposed some enhancements to the $47 $47 $47 $47 $46 training and management of Rapid Deployment teams within the Corps. $0 | | | | | FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 (enacted) Support for State and Local Preparedness The operationally oriented programs described above often receive a high Source: HHS, “Budget in Brief,” 2006, 2007, 2008, and 2009; and HHS, “Justification for level of visibility and critique, but federal officials stress that these assets Estimates for Appropriations Committees FY are designed to supplement state and local capabilities and are not inde- 2009: General Departmental Management”; pendently sufficient to support response to a mass casualty event. Major available at www.hhs.gov/budget. efforts to strengthen the ability of states and localities to mount their own disaster medical response include the Hospital Preparedness Program (HPP), the Public Health Emergency Preparedness Program (PHEP), and the Metropolitan Medical Response System (MMRS). QQ HPP provides grants to states to aid hospitals and health care systems in preparing for and responding to bioterrorism and other public health emergencies. This program is the dominant source of federal preparedness dollars for health care provider organizations, as states are required to redistribute a majority of HPP funds to participating hospitals and other clinical sites. Originally instituted in 2002 within the Health Resources Services Administration as the National Bioter- rorism Hospital Preparedness Program, the program was transferred to OASPR in 2007.17 The grant program has identified the following priority areas for FY 2008 funding: developing interoperable communications systems, track- ing bed availability, registering and mobilizing health care volunteers, managing fatalities, implementing medical evacuations and shelter in National Health Policy Forum | www.nhpf.org 10 Background Paper – No. 65 August 8, 2008 Figure 5 Hospital Preparedness Program and Public Health Emergency Preparedness Funding, FY 2002–2008 [$ millions] Millions $915 $897 $900 $870 $850 $863 $766 $800 Public Health Emergency $705 $700 Preparedness (includes CRI) $600 $515 $516 $491 $500 $450 $415 $398 $400 Hospital $300 Preparedness Program $200 $135 $100 $0 | | | | | | | FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007 FY 2008 Source: Health Research Institute (HRI), Closing the Seams: Developing an Integrated Approach to Health System Disaster Preparedness, PricewaterhouseCoopers, 2007; and HHS, Public Health Emergency Preparedness guidance, May 29, 2008, p. 24, and Hospital Preparedness Program Coopera- tive Agreement guidance, 2008, p. 22. place protocols, and developing partnerships and coalitions. Past prior- ity areas that grantees can continue to enhance after priority funding areas are addressed include developing alternate care sites, securing mobile medical assets, building pharmaceutical caches, purchasing protective personal equipment, developing decontamination capacity, and protecting critical infrastructure. (See Figure 5.) QQ PHEP provides funds to state health departments to build public health preparedness capabilities at both the state and local level. Adminis- tered by the CDC, the PHEP is largely used to support public sector, population-based preparedness functions (such as disease surveillance systems), rather than private sector medical response capacity. How- ever, public health agencies utilize PHEP funds to improve their own emergency medical management and response capabilities, to plan and conduct mass prophylaxis (such as the mass distribution of antibiotics to counter aerosolized anthrax), and to more broadly support the receipt and distribution of the SNS.18 While these types of countermeasure distribution activities are likely to be conducted in concert with private health care providers, PHEP funds are not typically redistributed to community-based health care organizations. National Health Policy Forum | www.nhpf.org 11 Background Paper – No. 65 August 8, 2008 QQ MMRS provides funding to 124 urban jurisdictions to help prepare for mass casualty events. Created within HHS in 1996 following the Sarin nerve agent gas attack in Tokyo and the bombing of the Alfred P. Mur- rah Federal Building in Oklahoma City,19 the MMRS officially became part of DHS in 2003.20 Most jurisdictions have focused these funds on the needs of first responders, such as fire and rescue personnel, emer- gency medical technicians, and emergency management agencies, rather than hospitals, physician organizations, or other clinical sites. However, local jurisdictions receiving MMRS funds have a significant degree of flexibility in how they utilize these resources, and variability across grantees exists. These core preparedness assistance programs have been augmented by a number of smaller, more targeted capacity building efforts. For example the Cities Readiness Initiative (CRI), which is incorporated into PHEP funds, was initiated in 2004 to improve the efficiency of major metropolitan areas in delivering SNS medicines and medical supplies within 48 hours during a large-scale public health emergency.21 Initially, 21 cities had been selected to receive direct funding and assistance. By 2006, the initiative had expanded to include 72 metropolitan areas, with at least one funded city in every state. Approximately $64.2 million were allocated to the CRI in FY 2008. Targeted federal funds have also been focused on helping state and local governments mobilize volunteer health care providers in the event of a disaster. The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) assists states in registering health profes- sionals willing to serve as volunteers in order to expedite confirmation of credentials, licensing, accreditation status, and hospital privileges should a disaster occur. Administered as part of the HPP, successful implementation of an ESAR-VHP is a condition of the HPP grant award. In FY 2008 $3.9 million were allocated to ESAR-VHP. HHS also provides a modest level of funds directly to local communities through the Medical Reserve Corps (MRC) to aid in the recruitment and training of health care volunteers. (For more details on the ESAR-VHP and MRC programs, see Appendix.) Technical assistance provided through these various funding programs is enhanced by research and development activities intended to inform and facilitate the management of disaster medical response. The Agency for Healthcare Research and Quality (AHRQ) has played an important role in developing guidance and tools that can assist states, localities, and health care organizations in improving medical preparedness. For example, AHRQ published a guide to help community planners address the range of logistical, legal, and ethical challenges inherent in providing mass medical care with scarce resources,22 convened an expert panel to develop recommendations for the use of altered standards of care during mass casualty events,23 and developed a tool that hospitals can use to evaluate disaster drills.24 AHRQ has also supported the development of the National Hospital Available Beds for Emergencies and Disasters System (HAvBED), National Health Policy Forum | www.nhpf.org 12 Background Paper – No. 65 August 8, 2008 an electronic tracking system to monitor inpatient bed availability which includes standardized definitions for types of beds (such medical-surgical, pediatric, critical care, psychiatric, and burn beds).25 In addition to these tools and guidelines, AHRQ has also supported the creation of a variety of continuing education training modules to build the preparedness skills of health care professionals. The CDC has supported complementary health services research activi- ties related to disaster medical response. For example, CDC convened an expert panel to explore the surge capacity needs generated by terror- ist events using conventional weapons. The panel highlighted critical resource constraints related to imaging and blood bank services.26 The agency also developed FluSurge, a modeling software program for the prediction of surge capacity needs related to an influenza pandemic based on a range of variables including disease incidence, morbidity, severity, and transmission rates. CDC also created an interactive self-study train- ing module to provide clinical education pertinent to a radiological or nuclear terrorism incident. OASPR has released playbooks for 2 of the 15 scenarios identified in the National Preparedness Guidelines (hurricanes and aerosolized anthrax) and is close to completing several others. These playbooks provide a stra- tegic overview of the key decisions points, actions, capabilities, and assets that could be initiated in the provision of federal assistance. Working with the HHS Office of Disability, OASPR has also developed a training toolkit to help emergency managers better anticipate and address the needs of at-risk populations in their preparedness planning. [For a comprehensive inventory of federal guidance and technical assistance published for state use in preparing for medical surge, please see Appendix III, Table 3 in the recent report by the Government Accountability Office (GAO), “Emergency Preparedness: States Are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Re- sources,” GAO-08-668, June 2008 (www.gao.gov/new.items/d08668.pdf).] opportunities for improvement These federal initiatives, together with preparedness efforts undertaken by states, localities, and private sector organizations, have improved disaster medical response capabilities over the last several years, but gaps remain. A variety of deficiencies persist and experts believe that the amount of progress made varies significantly across jurisdictions.27 Although numer- ous studies and expert panels have raised concerns about the adequacy of medical preparedness, efforts to both evaluate incremental improvements and gauge the magnitude of jurisdictional differences are limited by the nascent nature of performance standards.28 Developing meaningful performance measures for medical prepared- ness is challenging, in part, because preparedness planning depends on National Health Policy Forum | www.nhpf.org 13 Background Paper – No. 65 August 8, 2008 establishing new and largely untested types of functional relationships. Interdependency is necessary for achieving preparedness goals, but it also leads to a diffusion of responsibility and ambiguity regarding the appropriate “unit of analysis” for evaluative studies. Although individual organizations each have responsibility for contributing to medical pre- paredness and response, these capacities and capabilities ultimately rely on collective action. The following narrative describes attempts to refine performance expectations for key players in disaster medical response and highlights concerns that have been raised regarding the need for further improvement. Hospitals: Divided They Fall For a variety of reasons, hospitals have typically served as the focal point of discussions about medical preparedness. Hospitals have historically served as a hub of community medical resources; most are not-for-profit organizations with legally binding com- munity benefit obligations29 that include Hospitals are undoubtedly key players in disas- emergency services; hospitals maintain ter medical response, but their effectiveness ongoing relationships with a variety of health professionals through both hinges on integrating their individual plans employment contracts and medical staff with community-wide efforts. privileges; and the public has tradition- ally viewed hospital emergency departments as the place to go in the event of a life threatening injury or illness. Hospitals are undoubtedly key players in disaster medical response, but their effectiveness often hinges on how well the disaster plans of individual hospitals are integrated into robust community-wide and regional planning efforts. The Joint Commission has revised its emergency management standards for hospitals over the last several years and continues to explore additional changes in order to encourage collaboration across institutions and with other community assets. Prior to 2001, Joint Commission standards as- sumed that hospitals implementing plans would be operating within the context of an intact community and did not clearly acknowledge the need to coordinate with external planning efforts. In revising these standards in January 2001, the Joint Commission began requiring hospitals to (i) inte- grate hospital-based planning efforts with community-wide coordination of resources, (ii) complete a hazard vulnerability analysis, (iii) involve hos- pital leaders in disaster planning, (iv) utilize an all-hazards approach, and (v) address mitigation, preparation, response, and recovery goals in their plans. In order to fully implement these standards, the Joint Commission explored the experience of hospitals in communities that had previously encountered some type of disaster, either natural or man-made. The Joint Commission determined that the hospitals that performed best under emergency conditions were those that had planned most care- fully concerning logistical issues.30 Most frequently, these hospitals were National Health Policy Forum | www.nhpf.org 14 Background Paper – No. 65 August 8, 2008 members of larger hospital networks and able to rely on the broader system for supplies (such as large generators, fuel, food, water, staff, and medica- tions). In one example, a disaster-affected community lost power for one week and the community hospital required 85,000 gallons of fuel to run the hospital’s power generators. Nearly 90 percent of this fuel was supplied by the network’s headquarters, located 500 miles away from the affected com- munity; only 10 percent was provided through public sector assistance. Numerous studies and expert panel recommendations have echoed the importance of developing collaborative disaster management plans that rely on regional coordination and asset sharing.31 Unfortunately, the Joint Commission determined that few hospitals had the benefit of strong community-wide planning that could serve as a foundation for individual facility plans. The competitive tensions inherent in day- to-day operations can often undermine cooperative disaster planning across health care organizations in the absence of strong public sector leadership. Hospitals that are not part of a broader system face particular challenges in developing regional relationships through memoranda of understanding (MOUs) and other formal agreements for mutual aid. While network-based hospitals have some advantages in arranging “intra-system” cooperation and coordination, working with unaffili- ated hospitals and non-hospital resources can pose challenges similar to those faced by independent institutions. Routine capacity constraints in hospital emergency department (ED) ca- pacity may further compound market-based disincentives to collaborative planning. Medical response to a disaster would likely mobilize resources well beyond the ED. However, the individuals poised to take on leader- ship roles in preparedness planning and response functions are often ED managers and clinical staff with specialized expertise in patient triage and trauma care. EDs are struggling to meet daily surge demands, and crowding is widespread.32 This daily pressure limits the time, attention, and resources that ED personnel can devote to disaster planning efforts and undermines cooperation across health care organizations. Similar constraints in staff capacity in nursing and other professional disciplines utilized by health care organizations limit the availability of personnel to train for public health emergencies. The hospital industry has argued that insufficient resources are available to support preparedness efforts. The Center for Biosecurity estimates that the minimum costs of developing and maintaining pandemic influenza surge capacity for an average size hospital are close to a $1 million one-time investment with additional $200,000 annually in maintenance expenses.33 PricewaterhouseCoopers’ Health Research Institute (HRI) calculates that the HPP provided an average of roughly $82,500 per hospital nationally in 2007,34 and reports that some hospitals have not applied for funding because the financial demands of grant requirements significantly exceed funding levels.35 The actual amount of HPP funding distributed to individual fa- cilities varies considerably. Less than half of all hospitals receive any HPP National Health Policy Forum | www.nhpf.org 15 Background Paper – No. 65 August 8, 2008 funds, as some states restrict funding to “lead” institutions.36 Despite this variation, an HRI survey of hospital managers, state and local officials, and health care professionals found that 83 percent of respondents believed that preparedness funding was insufficient, and over one-third reported major unmet planning needs due to funding constraints.37 The hospital industry has suggested that additional public funds should be made available to support preparedness, but others contend that not-for-profit hospitals are obligated to make these investments themselves in light of the preferential tax status they enjoy as charitable The financial condition of hospitals and organizations. The Internal Revenue Service their ability and willingness to absorb (IRS) established the community benefit stan- the costs of preparedness planning varies dard that currently guides determinations of charitable intent in 1969. IRS ruling 69-545 sug- significantly across institutions. gests that tax-exempt hospitals should provide emergency care to all persons requiring such services regardless of their ability to pay. While disaster planning is a recognized community- building activity for hospitals that supports broadly defined community benefit obligations, federal tax law does not explicitly require tax-exempt hospitals to engage in such activities. The financial condition of hospitals and their ability and willingness to absorb the costs of preparedness planning vary significantly across institutions. HRI highlighted the low margins of the public hospitals in which trauma centers and burn centers are frequently housed. Echoing these concerns, a recent hearing by the House Committee on Oversight and Government Reform explored the potential impact of proposed reductions in Medicaid payments on hospital preparedness efforts.38 While not all hospitals are financially vulnerable, a study by the Center for Studying Health System Change suggests that most hospitals in the sentinel markets studied rely heavily on federal funds to support their disaster planning activities.39 Government Role in Planning and Response State and local government officials recognize the need for a more co- ordinated approach to disaster medical planning, but face challenges in orchestrating private sector efforts. Government regulators are often uncertain about how to constructively increase performance expectations for hospitals and other health care organizations. Public sector efforts to coordinate regional approaches to medical preparedness are critically important. As stated previously, many key decisions related to preparedness development such as triage protocols, altered standards of care; interoperable standards for communications, equipment, and training; and patient transfer plans cannot be made by individual hospitals acting in isolation. The lack of dedicated preparedness National Health Policy Forum | www.nhpf.org 16 Background Paper – No. 65 August 8, 2008 planning staff in public health agencies and hospitals has been cited as an important barrier to the development of regional disaster medical response plans.40 States have pursued a variety of different strategies to develop disaster medical preparedness. Both the level of state leadership exhibited to guide and coordinate planning efforts and the mechanisms used to redistribute federal grant funds across provider organizations have varied substantially from state to state. The state of California has been at the forefront of the development of disaster medical response capacity. California has made major invest- ments in preparedness development beyond the federal grant dollars it has received and was the first state to release detailed standards and guidance for health care surge during emergencies.41 The guidance clearly acknowledges that the delivery of care during a disaster will differ from routine practices, identifies the legal and administrative mechanisms to support this shift, and clarifies the anticipated roles of hospitals, govern- ment-authorized alternate care sites, clinics, long-term care facilities, and other non-hospital providers. Similar efforts are under way elsewhere, but some states have been less proactive in facilitating hospital preparedness planning and coordinating state and regional collaboration. Federal officials are seeking to clarify expectations and strengthen per- formance objectives for states in order to stimulate a more coordinated approach to planning. These performance objectives have shifted over time, evolving from structural measures (such as personnel added, equip- ment acquired, and plans developed) to process measures that seek to assess program capabilities. These revised expectations include require- ments related to compliance with National Incident Management System (NIMS) principles, education and training standards, evaluation of drills and exercises, and attention to the needs of at-risk populations. Although some disconnects between PHEP and HPP measures continue, goals for these complementary programs have become more tightly integrated over time with increased cross-references to each other’s objectives. Grantees have also been charged with meeting increasingly specific, quantifiable measures of performance. Performance measures for the FY 2008 HPP grants are summarized in the text box (see next page). FY 2009 awards will be contingent on achieving these objectives. A recent report by the GAO suggests that most states are well positioned to meet performance objectives related to bed tracking and the electronic registra- tion of volunteers.42 Yet, in light of heightened performance expectations, state officials are calling for more support from the federal government not only in terms of funding, but also in the development of more ex- plicit, detailed policy guidance and improved operational assistance for disaster response. National Health Policy Forum | www.nhpf.org 17 Background Paper – No. 65 August 8, 2008 Performance Measures for the FY 2008 HPP Grants Performance measures for the FY 2008 HPP grants are summarized below. FY 2009 awards will be contingent on achieving these objec- tives. A recent report by the GAO suggests that most states are well positioned to meet performance objectives related to bed tracking and the electronic registration of volunteers. Measures State can report available beds for at least 75 percent of par- ticipating hospitals according to HAvBED definitions. State can query their ESAR-VHP system during a functional drill, exercise, or actual event to generate a list of potential volun- teer health professionals, by discipline and credential level, within 2 hours or less of a request State can compile an initial list of volunteer health profes- sionals by discipline and credential level, within 12 hours or less of a request and report a verified list of available volunteers within 24 hours of a request. State conducts statewide and regional exercises including hospitals that incorporate NIMS concepts and principles. Proportion of participating hospitals that... OO Can report available beds according to HAvBED definitions within 60 minutes of a request. OO Demonstrate dedicated, redundant communications capa- bility during an exercise or incident as evidenced by evalu- ations or after-action reports. OO Demonstrate sustained two-way communications capabil- ity with the local Disaster Operations Command and other health coalition partners during an exercise or incident. OO Have written plans to address mass fatalities. OO Have written plans to address medical evacuation. OO Incorporate NIMS concepts and principles OO Have identified appropriate personnel for training and veri- fied their completion of required courses. Source: Federal Register, 73, no. 96 (May 16, 2008): pp. 28472–28478. National Health Policy Forum | www.nhpf.org 18 Background Paper – No. 65 August 8, 2008 Funding levels — Health care executives and state and local government officials have been vocal in raising concerns that federal funding levels have diminished as performance requirements have grown. Funding available through the HPP cooperative agreement has decreased by over 20 percent since 2003. The President’s proposed 2009 budget calls for an additional decrease of $60 million, consistent with a number of other proposed reductions in assistance to states and localities for homeland security preparedness.43 After the National Strategy for Pandemic Influ- enza Implementation Plan was released in July 2007, experts and local officials were sharply critical of the plan’s failure to adequately address the financial needs of the health Federal officials have maintained that care system in providing care to the sick. 44 public health and medical prepared- Federal officials have maintained that public health ness is primarily a function of state and medical preparedness is primarily a function of and local government. state and local government as defined in our nation’s constitutional framework and stress that significant federal resources have been invested to help states fulfill their responsibilities. HHS published a proposal in the Federal Register in May 2008 to require recipients of the HPP cooperative agreement to contribute matching funds in an amount equal to 5 percent of their award beginning in 2009.45 For 2010 and subsequent years, a 10 percent match is proposed. Policymakers have also considered the need for a risk-based allocation of preparedness dollars. Some have argued that the mechanism used to distribute HPP funds across states should incorporate a more meaning- ful assessment of the risk of a major medical emergency within a given jurisdiction, including the risk of natural disasters and intentional acts of terrorism. Others argue that some risks, such as the threat of influenza pandemic, are pervasive and attempts to define relative risk across juris- dictions would be highly subjective and difficult to defend. Policy guidance and technical assistance — Although critiques of federal leadership are often framed around perceptions of funding insufficiency, these concerns have also been more broadly articulated to include a call for more explicit guidance on the difficult decisions raised by disaster medical response. Disaster response will require difficult decisions regarding the allocation of scarce resources and alteration of care standards. Although some states and localities have begun to tackle many of these thorny issues, many would welcome the protection and standardization that national guidelines would confer. A recent report by the GAO noted that only 7 of the 20 states sampled have made progress in defining altered standards of care during a mass casualty event.46 Some states indicated that federal efforts to convene medical, public health, and legal experts to address these complex issues would be helpful. A public-private Task Force for Mass Critical Care recently released guid- ance for the allocation of scarce resources during a mass casualty event.47 The guidance establishes a clinically based algorithm on which triage National Health Policy Forum | www.nhpf.org 19 Background Paper – No. 65 August 8, 2008 and resource allocation decisions could rest to ensure uniformity across provider organizations. Experts have noted the confusion and animosity that could arise if jurisdictions apply disparate assumptions and priori- ties in rationing care or altering quality standards. While the Task Force’s guidance provides organizational models for the implementation and oversight of triage protocols, the need for further government action was highlighted. The Task Force encouraged policymakers to endorse a clearly defined algorithm process and to develop mechanisms for monitoring compliance during a mass casualty event. Some have also called for the federal government to take a more active role in brokering cooperation and assistance among states. A number of metropolitan areas have already begun to establish inter-state regional partnerships, but additional federal support might enhance the spread and strength of these medical compacts. The $18.1 million award made by HHS to 11 emergency medical partnership collaboratives in September 2007 has been hailed as a positive step in building regionalized medical response capacity. However, the decision to fund these Healthcare Facility Partnerships through a reduction in HPP cooperative agreement dollars has added to discontent over funding adequacy. State and local officials have sought more federal support for peer-to-peer learning across states. Many jurisdictions are tackling similar challenges (such as integrating various volunteer resources like the MRC and the American Red Cross, recruiting and training emergency management personnel, and developing interoperable communications systems). Federal efforts to broker consensus on best practices are often viewed as lacking. A need for increased federal engagement in resolving legal and operational conflicts across states has also been noted. For example, some believe that increased federal involvement could help to resolve a range of issues that hamper inter-state sharing of personnel (such as those related to recip- rocal recognition of professional licensure and credentialing, workers’ compensation coverage, and malpractice liability protections). Similarly inter-state differences regarding Medicaid coverage and payment for dis- placed persons have been cited as creating administrative hurdles that could benefit from federal intervention. States have also sought more explicit policies regarding the suspension or relaxation of federal requirements concerning the provision of health care services during a disaster. Section 319 of the Public Health Service Act gives the Secretary of HHS broad authority to determine that a pub- lic health disaster exists and also confers power to waive or streamline a range of administrative and certain statutory requirements when a Presidential declaration of emergency or disaster has been made.48 Au- thority exists for the waiver of some requirements, such as Conditions of Participation for Medicare, Medicaid, and the State Children’s Health Insurance Program (SCHIP); certain provisions of the Emergency Medi- cal Treatment and Active Labor Act (EMTALA); and the Health Insurance National Health Policy Forum | www.nhpf.org 20 Background Paper – No. 65 August 8, 2008 Portability and Accountability Act (HIPAA). However, the circumstances necessary to trigger such a waiver are unspecified. The Centers for Medi- care & Medicaid Services (CMS) recently waived certain documentation requirements for providers in flood-stricken areas of Iowa and Indiana. The limited application of these waivers to date, including those related to Hurricanes Katrina and Rita, make it difficult to interpret the extent to which Medicare is prepared to accommodate significant alteration of care standards and other regulatory standards under catastrophic conditions. Clearer processes and parameters related to petitioning for, and grant- ing of, emergency federal waivers could further expedite state efforts to develop pragmatic approaches to medical preparedness. Operational assistance — Calls to strengthen the federal role in medical response during a disaster have generally focused on improving the nature, rather than expanding the scale, of federal assistance. Although some have argued that the capacity of federal response assets should be increased, most recognize that the federal government is unlikely to develop a sig- nificant level of reserve medical capacity that could be leveraged in the event of a disaster. More concerns have been raised about the capabilities of federal response resources currently avail- able, as well as the ability to integrate these Most recognize that the federal govern- resources into local response efforts. ment is unlikely to develop a significant Medical response to Hurricane Katrina re- level of reserve medical capacity that could vealed numerous problems in capabilities be leveraged in the event of a disaster. at the local, state, and federal levels. Federal officials have taken a variety of steps to resolve deficiencies in federal as- sistance as required by both administrative and legislative directives. A clear and overarching weakness in federal medical response to Katrina stemmed from ambiguity and miscommunication within the federal chain of command. In response to this issue, the PAHPA authorized the transfer of NDMS from DHS back to HHS, consolidated a number of medical re- sponse responsibilities under the OASPR, and mandated a comprehensive review of NDMS management and implementation. Although federal personnel provided valuable medical assistance in the Gulf Coast area following Hurricane Katrina, numerous problems were encountered.49 Travel difficulties delayed the arrival of both NDMS teams and equipment and, once in place, teams had trouble coordinating with local emergency management and with HHS, which was responsible for managing federal medical assets. NDMS staffing models were geared toward the provision of trauma care while patient needs were often char- acterized by lapsed chronic disease management and mental health crises. Military medical evacuation capacity was limited and not well configured to short-haul transportation needs. PHS Commissioned Corps staff was insufficiently prepared to deploy and serve in a response capacity. The ongoing review of NDMS is likely to identify the need for addi- tional changes, but steps have already been taken to address some of the National Health Policy Forum | www.nhpf.org 21 Background Paper – No. 65 August 8, 2008 shortcomings observed in the Katrina response. The President’s FY 2009 budget requested a $7 million increase in NDMS funding to enhance re- gional coordination efforts, improve training, bolster logistical support, and complete implementation of an electronic patient medical record that was pilot tested during the California wildfires in 2007. A recent GAO investigation found that DHS and HHS have successfully collaborated with states to more clearly delineate the federal role in patient evacuation from health facilities, although additional clarity is needed to address evacuation of nursing home residents.50 Consolidation of authori- ties under OASPR have been beneficial, but some ambiguities in federal respon- Some federal responsibilities remain ambigu- sibilities remain, including those related ous, including those related to intersections to intersections between medical and between medical and mass care functions (such mass care functions (such as sheltering disaster victims). as sheltering disaster victims). Enhancements to PHS Commissioned Corps capabilities have also been proposed. The President’s FY 2009 budget includes a $26 million increase to support the transformation of Commissioned Corps capabilities, includ- ing expanded recruitment and training, as well as the development of two dedicated Health and Medical Response (HAMR) teams. Each team will be designed for rapid deployment (within 12 hours) and will be composed of 105 highly trained, dedicated staff members who will not have concurrent responsibilities for staffing other PHS activities. Deployment of SNS resources in the Gulf Coast region following Katrina was generally viewed as successful, although some problems were noted. Federal investigators determined that more SNS supplies should have been placed in the region before the hurricane made landfall, given the advance warning provided by storm tracking data. Concerns were also raised that inventories of pre-packaged SNS supplies were overly oriented toward biological threats and therefore some supplies went unused. In contrast, supplies for chronic care medications, such as antihypertensive and psy- chotropic drugs, were in short supply. Some experts have cautioned that the content of the SNS should be adjusted to better address pediatric needs as required by PAHPA. Some also believe that stockpile request procedures should be revised to minimize the potential for inter-state competition for resources. The CRI effort has markedly improved most participating cities’ ability to distribute SNS supplies, but some jurisdictions are still working to fully establish this capacity. State and local officials are encouraged by developments to improve fed- eral response assistance, but many harbor lingering concerns about the reliability and utility of federal medical assets. Some have suggested that more drills and exercises need to include federal participants in order to provide valid assessments of preparedness levels. State and local stakehold- ers hope the OASPR playbooks are part of a continuing evolution toward improved interoperability and effective partnership. National Health Policy Forum | www.nhpf.org 22 Background Paper – No. 65 August 8, 2008 Conclusion The willingness of federal, state, local, and private planners to confront the realities of a potential public health emergency, acknowledge weaknesses in the existing infrastructure, and adapt to the challenges of catastrophic medical response is both necessary and remarkable. It is human nature to avoid difficult decisions, particularly those that do not demand immediate action. Overcoming this inertia involves complex economic, political, and ethical challenges. Yet across the country, significant progress is being made to develop a more realistic, integrative approach to preparedness planning. These efforts will require ongoing support, policy oversight, and leadership to address the pitfalls that are sure to arise, mediate con- flicting priorities, and galvanize tenuous links in the chain of disaster response capabilities. Federal policymakers are being called on to play an even more proactive role in addressing these “weak links.” Unresolved concerns regarding the structure, priorities, and utility of federal medical response assets have been identified. The adequacy of existing funding levels, the suitability of performance expectations, and the rigor of accountability mechanisms for both states and providers have been questioned. Furthermore, the need for more explicit federal law sanctioning acceptable approaches to altered medical practices during disaster response has been raised. Planning for the dire circumstances posed by disaster scenarios exposes many of the unseen fissures and unspoken compromises inherent in the health care system. Preparing for these demanding contingencies, particularly in the face of day-to-day pressures, will require ongoing public-private collabo- ration and cooperation across all levels of government. Endnotes 1. Joseph A. Barbera, Anthony G. Macintyre, Craig A. DeAtley, “Ambulances to No- where: America’s Critical Shortfall in Medical Preparedness for Catastrophic Terrorism,” BCSIA Discussion Paper 2001-15, John F. Kennedy School of Government, Harvard Uni- versity, October 2001; available at http://belfercenter.ksg.harvard.edu/publication/2788/ ambulances_to_nowhere.html. 2. The Joint Commission, Health Care at the Crossroads: Strategies for Creating and Sustaining Community-Wide Disaster Preparedness Systems, 2003; available at www.jointcommission.org/ NR/rdonlyres/9C8DE572-5D7A-4F28-AB84-3741EC82AF98/0/emergency_preparedness.pdf. 3. “Homeland Security Presidential Directive-21: Public Health and Medical Prepared- ness,” Office of the Press Secretary, The White House, October 18, 2007; available at www.whitehouse.gov/news/releases/2007/10/20071018-10.html. 4. The Joint Commission, Health Care at the Crossroads, p. 26. 5. U.S. Department of Homeland Security (DHS), National Preparedness Guidelines, September 2007, p. 31; available at www.dhs.gov/xlibrary/assets/National_Preparedness_ Guidelines.pdf. 6. DHS, National Response Framework, January 2008; available at www.fema.gov/pdf/ emergency/nrf/nrf-core.pdf. Endnotes / continued ä National Health Policy Forum | www.nhpf.org 23 Background Paper – No. 65 August 8, 2008 Endnotes / continued 7. DHS, Disaster Support Function #8: Public Health and Medical Services Annex, January 2008; available at www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf. 8. Sarah A. Lister, “Report to Congress: The Public Health and Medical Response to Disasters: Federal Authority and Funding,” Congressional Research Service, order code RL33579, updated June 23, 2008. 9. “Homeland Security Directive 18: Medical Countermeasures Against Weapons of Mass Destruction,” Office of the Press Secretary, The White House, January 31, 2007; available at www.whitehouse.gov/news/releases/2007/02/20070207-2.html. 10. National Institutes of Health (NIH), “Estimates of Funding for Various Diseases, Conditions, Research Areas,” U.S. Department of Health and Human Services (HHS), updated February 5, 2008, available at www.nih.gov/news/fundingresearchareas.htm; and National Institute for Allergy and Infectious Diseases (NIAID), “NIAID Strategic Plan for Biodefense Research: 2007 Update,” NIH, HHS, September 2007; available at http://www3.niaid.nih.gov/topics/BiodefenseRelated/Biodefense/PDF/biosp2007.pdf. 11. Office of Public Health Disaster Medical Countermeasures, Project Bioshield, Annual Report to Congress: July 2004 through July 2006, Office of Public Health Disaster Preparedness, HHS, July 31, 2006; available at www.hhs.gov/aspr/barda/documents/bioshieldannualreport.pdf. Potassium iodine is a prophylactic countermeasure used to protect the thyroid from radioac- tive, nuclear fall-out. 12. HHS, “Report to Congress: Pandemic Influenza Preparedness Spending,” prepared in response to request in conference report 109-359, December 2007, p. 4; available at www.hhs.gov/aspr/barda/mcm/panflu/spending.html. 13. “Homeland Security Act of 2002,” P.L. 107-296, November 25, 2002. 14. “Project BioShield Act of 2004,” P.L. 108-276, July 21, 2004. 15. “Pandemic and All-Hazards Preparedness Act,” P.L. 109-417, December 19, 2006. 16. HHS, “Pandemic and All-Hazards Preparedness Act Progress Report,” November 2007, p. 7; available at www.hhs.gov/aspr/conference/pahpa/2007/pahpa-progress-report-102907.pdf. 17. As mandated by the Pandemic and All-Hazards Preparedness Act (P.L. 109-417). 18. The Public Health Emergency Preparedness (PHEP) mechanism was also used to provide supplemental funds for pandemic influenza preparedness planning in 2006 and 2007, but guidance for the upcoming budget period (August 2008–2009) indicates that these targeted supplemental funds have been discontinued. 19. For more information, see www.mmrs.fema.gov. 20. Authorized by the Homeland Security Act of 2002 (P.L. 107-296). 21. “Key Facts about the Cities Readiness Initiative (CRI),” fact sheet, Centers for Disease Control and Prevention (CDC), updated April 2, 2008; available at www.bt.cdc.gov/cri/ facts.asp. 22. Agency for Healthcare Research and Quality (AHRQ), Mass Medical Care with Scare Resources: A Community Planning Guide, AHRQ Publication No. 07-0001, February 2007; available at www.ahrq.gov/research/mce. 23. AHRQ, Altered Standards of Care in Mass Casualty Events, AHRQ Publication No. 05-0043, April 2005; available at www.ahrq.gov/research/altstand. 24. AHRQ, Evaluation of Hospital Disaster Drills: A Module-Based Approach, AHRQ Publication No. 04-0032, April 2004; available at www.ahrq.gov/research/hospdrills/hospdrill.htm. 25. AHRQ, National Hospital Available Beds for Emergencies and Disasters (HAvBED) System: Final Report, AHRQ Publication No. 05-0103, December 2005; available at www.ahrq.gov/ prep/havbed. Endnotes / continued ä National Health Policy Forum | www.nhpf.org 24 Background Paper – No. 65 August 8, 2008 Endnotes / continued 26. CDC, In a Moment’s Notice: Surge Capacity for Terrorist Bombings, April 2007; available at http://emergency.cdc.gov/masscasualties/surgecapacity.asp. 27. Trust for America’s Health, Ready or Not? Protecting the Public’s Health from Dis- eases, Disasters, and Bioterrorism, 2007, Issue Report, December 2007; available at http://healthyamericans.org/reports/bioterror07/BioTerrorReport2007.pdf. 28. GAO, “Emergency Preparedness: States Are Planning for Medical Surge; Government Accountability Office, “Status of Implementation of GAO Recommendations on Evacua- tion of Transportation-Disadvantaged Populations and Patients and Residents of Health Care Facilities,” GAO-08-544R, April 1, 2008, available at www.gao.gov/new.items/d08544r. pdf; GAO, “Public Health and Hospital Disaster Preparedness: Evolution of Performance Measurement Systems to Measure Progress,” GAO-07-485R, March 23, 2007, available at www.gao.gov/new.items/d07485r.pdf; and Nicole Lurie, Jeffrey Wasserman, and Christopher D. Nelson, “Public Health Preparedness: Evolution or Revolution?” Health Affairs, 25, no. 4 (July/August 2006): pp. 941–944, available with subscription at http://content.healthaffairs.org/ cgi/content/abstract/25/4/935. 29. For more information on community benefit obligations of not-for-profit hospitals, see Eileen Salinsky, “What Have You Done for Me Lately: Assessing Hospital Commu- nity Benefit,” National Health Policy Forum, Issue Brief 821, April 19, 2007; available at www.nhpf.org/pdfs_ib/IB821_HospitalCommBenefit_04-19-07.pdf. 30. R. Wise, “The Creation of Disaster Health Care Standards for Catastrophic Events,” Academic Emergency Medicine, 13, no. 11 (November 2006): pp. 1150–1153. 31. CDC, In a Moment’s Notice; B. Maldin et al., “Regional Approaches to Hospital Prepared- ness,” Biosecurity and Biodefense, 5, no. 1 (March 2007): pp. 43-53; and The Joint Commission, Health Care at the Crossroads. 32. For more information on crowding in emergency departments, see Jessamy Taylor, “Don’t Bring Me Your Tired, Your Poor: The Crowded State of America’s Emergency Departments,” National Health Policy Forum, Issue Brief 811, July 7, 2006; available at www.nhpf.org/pdfs_ib/ IB811_EDCrowding_07-07-06.pdf. 33. E. Toner et al., “Meeting Report: Hospital Preparedness for Pandemic Influenza,” Bios- ecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 4, no. 2 (2006): pp. 207–217. 34. Actual funding levels per hospital may be less, as only 75 percent of all grant funds must be distributed to health care organizations and non-hospital providers may have access to funding in some states. 35. Health Research Institute (HRI), Closing the Seams: Developing an Integrated Approach to Health System Disaster Preparedness, PricewaterhouseCoopers, 2007. 36. Pandemic and All-Hazards Preparedness Act (PAHPA) stakeholders meeting, No- vember 8, 2007, panel summary; available at www.hhs.gov/aspr/conferences/pahpa/2007/ pahpa-summary-grants.pdf. 37. HRI, Closing the Seams, p. 13. 38. Committee on Oversight and Government Reform, U.S. House of Representatives, hearing on “The Lack of Hospital Disaster Surge Capacity: Will the Administration’s Medicaid Regulations Make It Worse?” May 5 and 6, 2008. 39. Laurie E. Felland et al., “Developing Health System Surge Capacity: Community Ef- forts in Jeopardy,” Center for Studying Health System Change, Research Brief No. 5, June 2008; available at www.hschange.com/CONTENT/991/991.pdf. 40. Maldin et al., “Regional Approaches to Hospital Preparedness,” p. 50. Endnotes / continued ä National Health Policy Forum | www.nhpf.org 25 Background Paper – No. 65 August 8, 2008 Endnotes / continued 41. California Department of Public Health, Standards and Guidelines for Healthcare Surge During Emergencies, http://bepreparedcalifornia.ca.gov/EPO/CDPHPrograms/PublicHealth- Programs/EmergencyPreparednessOffice/EPOProgramsServices/Surge/SurgeStandards- Guidelines/SurgeStandardsGuidelines.htm. 42. GAO, “Status of Implementation,” GAO-08-544R, April 1, 2008. 43. Jennifer E. Lake et al., “Homeland Security Department: FY 2009 Request for Appro- priations,” Congressional Research Service, Report for Congress, Order Code RL34482, May 6, 2008, p. 53. 44. C. Lee, “US Flu Outbreak Plan Criticized: It Does Not Anticipate Strain on Hospitals, Local Health Officials Say,” Washington Post, February 2, 2008, p. A3. 45. Federal Register, 73, no. 96 (May 16, 2008): pp. 28471–28472. 46. GAO, Emergency Preparedness: States Are Planning for Medical Surge,” GAO-08-668, June 2008, p. 21. 47. Asha Devereaux et al., “Definitive Care for the Critically Ill During a Disaster: A Frame- work for Allocation of Scarce Resources in Mass Critical Care,” CHEST, 133, no. 5, suppl. (May 2008): pp. 51S–66S; available at www.chestjournal.org/cgi/reprint/133/5_suppl/1S. 48. Lister, “The Public Health and Medical Response to Disasters.” 49. Crystal Franco et al., “The National Disaster Medical System: Past, Present, and Sug- gestions for the Future,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 5, no. 4 (2007): p. 322. 50. GAO, “Status of Implementation,” GAO-08-544R, April 1, 2008, p. 3. The National Health Policy Forum is a nonpartisan research and public policy organization at The George Washington University. All of its pub- lications since 1998 are available online at www.nhpf.org. National Health Policy Forum | www.nhpf.org 26 Background Paper – No. 65 August 8, 2008 Appendix Strategic National Stockpile (SNS) Descriptions of The SNS is a repository of medications, equipment, and supplies, such as antibi- Select Federal otics, chemical antidotes, antiviral agents, antitoxins, and airway maintenance Disaster Medical supplies. The SNS is designed to supplement and resupply jurisdictions at the request Assistance Programs of the Governor(s) of the affected state(s). The SNS is administered by the Centers for Disease Control and Prevention (CDC) and includes two major components: •Push-Packs — A relatively small proportion of the total SNS inventory is pre- packaged in push-packs which are designed to be delivered within 12 hours of a federal decision to deploy. These push packs are maintained by HHS at regional caches in undisclosed locations. Upon arrival at a designated receiving and storage site, SNS assets are transferred to state and local authorities for breakdown and distribution. •Specific Material Support — The bulk of the SNS stockpile is maintained through Vendor Managed Inventory (VMI) and inventory managed directly by the CDC. These inventories can make a wider, more flexible range of supplies available to affected communities within 24 to 36 hours. CDC contracts with a select group of vendors to maintain inventories of defined supplies and medications which can be called upon if initial push-pack supplies are exhausted or if specialized supplies not included in the push packs are needed. Because specialized resources (such as anthrax and smallpox vaccines, antitoxins, and ventilators) are not included in the push packs, these specialized resources may serve as the initial response from the SNS program depending on the nature of the incident. Procurement of some specialized medical countermeasures included within the SNS, such as anthrax and smallpox vaccines, has been funded through the Project Bioshield special reserve fund. This $5.6 billion fund was established in the FY 2004 Department of Homeland Security Appropriations Act and is administered by the Biomedical Advanced Research and Development Authority (BARDA) within the Office of the As- sistant Secretary for Preparedness and Response (OASPR). Approximately $1.8 billion was drawn from the Project Bioshield fund between July 2004 and July 2006.* National Disaster Medical System (NDMS) NDMS was formed in 1984 in order to provide medical evacuation and care to military and civilian casualties returning from overseas wars.† Never deployed for its original purpose, the NDMS has since evolved to provide civilian support to communities experiencing major disasters. Originally housed in the U.S. Public Health Service within HHS, the program was transferred to the Department of Homeland Se- curity (DHS) in 2003, and transferred back to HHS in 2007. NDMS is now coordinated by the OASPR and has three distinct components: •Response teams can be deployed to disaster sites to provide emergency triage and care. Several types of teams are designed to respond to specific needs (see sidebar). Teams are mobilized within 6 hours of notification, are capable of arriv- ing on-site within 48 hours, come with equipment, supplies, and logistical support APPENDIX – continued > National Health Policy Forum | www.nhpf.org 27 Background Paper – No. 65 August 8, 2008 Descriptions of Select APPENDIX ­> National Disaster Medical System Federal Disaster Medical to sustain medical operations Assistance Programs without external support for 72 Types of NDMS Response Teams hours, and are designed to remain deployed for two-week periods. A Disaster Medical Assistance Team (DMAT) is designed to provide general The federal government is in the medical assistance. Approximately 55 process of developing Federal regionally organized DMATs are in Medical Stations (through the SNS place across the country. Each team program), which will further sup- includes about 35 health care profes- port response team functionality sionals including physicians, nurses, by providing deployable medical medical technicians, as well as ad- facilities complete with equip- ditional logistics and support staff. If ment, supplies, and a limited teams are providing care to patients inventory of pharmaceuticals. requiring treatment comparable to the type delivered in inpatient settings, all Although designed to be self- the DMATs working together could sustaining, NDMS response teams serve about 1,400 patients per day. are intended to supplement local and state response assets at the A National Medical Response Team direction of the local incident (NMRT) is designed to provide medical commander. While deployed, care following a nuclear, biological, or team members are paid as part- chemical incident and has specialized expertise in mass casualty decontami- time federal employees and are nation, medical triage, and care provi- protected from malpractice claims sion in a hazardous material environ- under the Federal Tort Claims Act. ment. Each team typically consists of Although team members become 50 staff members, and four teams are federalized once deployed, most in place nationwide. serve as practicing civilian health care providers in their home Approximately 21 Specialty Care communities when not activated Teams are organized to provide specific under NDMS. types of response capabilities includ- ing burn teams, pediatric DMATs, and •Patient Evacuation includes mental health teams. communication and medical transportation of disaster vic- A Disaster Mortuary Operational Response Team (DMORT) provides tims from identified mobiliza- assistance in identifying and process- tion centers to NDMS treatment ing deceased victims. Eleven DMORTs facilities in unaffected areas by have been established nationwide. Department of Defense aircraft and vehicles. Transportation of patients from the disaster site to the mobilization centers or to local care sites is considered a responsibility of state and local authorities. •Definitive Hospital Care provides for inpatient medical treatment be- yond emergency stabilization. Approximately 2,000 hospitals, including private, Veterans Administration, and Department of Defense facilities, APPENDIX – continued > National Health Policy Forum | www.nhpf.org 28 Background Paper – No. 65 August 8, 2008 Descriptions of Select APPENDIX ­> National Disaster Medical System Federal Disaster Medical participate in NDMS and have offered roughly 1,000 patient care beds for Assistance Program definitive care through the system.‡ Hospitals participating in NDMS do not receive financial support for entering into this commitment, but are eligible for compensation for services rendered through the NDMS during emer- gency response at a rate equal to 110 percent of Medicare’s payment rates. Public Health Service (PHS) Commissioned Corps Teams The teams include approximately 6,000 public health professionals trained in clinical disciplines and other related fields, such as engineering. Commissioned Corps officers serve in managerial and clinical positions throughout HHS. Al- though the Corps was not designed as a deployable medical response asset, select Commissioned Corps personnel with relevant skills have been organized into five Rapid Deployment Teams each with a 105 multidisciplinary staff complement.§ Teams serve on a rotating call basis, and on-call teams are available to support states and localities within 12 hours of notification. A specialized Mental Health Team and an Applied Public Health Team have also been established with the Commissioned Corps. Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) The ESAR-VHP program assists states in registering health professionals willing to serve as volunteers in order to expedite confirmation of credentials, licensing, accreditation status, and hospital privileges should a disaster occur. Administered as part of the HPP, successful implementation on an ESAR-VHP is a condition of the HPP grant award. In FY 2008, $3.9 million were allocated to ESAR-VHP. States have some flexibility in structuring their system, but these designs must be consistent with HHS guidelines. The Pandemic and All-Hazards Preparedness Act (PAHPA) requires that state-based ESAR-VHP systems be linked through a national database to allow for inter-state verification of volunteer cre- dentials. A number of states have integrated the registry of health professionals with broader efforts to proactively identify and certify emergency volunteers from a variety of nonmedical service sectors. Medical Reserve Corps (MRC) The Office of the Surgeon General within HHS began implementing the MRC in March 2002 as part of the White House’s USA Freedom Corps Initiative. In FY 2008 the MRC program provided $9.6 million in grant funds to communities across the country to help organize and utilize volunteers (such as physicians, nurses, pharmacists, and others) to provide and support medical services. These APPENDIX – continued > National Health Policy Forum | www.nhpf.org 29 Background Paper – No. 65 August 8, 2008 Descriptions of Select APPENDIX ­> Medical Reserve Corps Federal Disaster Medical services can be provided in response to public health emergencies, as well as Assistance Program on a routine basis to promote population health. As of January 2008, over 720 MRC units have been established with almost 150,000 volunteers. Although the majority of these units receive federal grant awards ($5,000 to $10,000 per unit), some communities have established MRC units without receiving direct federal funds to do so. MRC units are organized locally to meet the needs in their community. Unlike the medical response teams organized under NDMS, the structures of MRC units are not standardized, team members are not compensated for services provided during disaster response, and training requirements are less prescriptive. While MRC units are primarily intended to support disaster response in the locality in which they are organized, the PAHPA authorized deployment capacity which is currently being developed. MRC units receive funding through a cooperative agreement established with the National Association of County and City Health Officials, which also provides technical and logistical support for the units. MRC volunteers can be incorporated into the ESAR-VHP registry, but states report problems in coordinating these programs.¶ Appendix Endnotes *Office of Public Health Disaster Medical Countermeasures, Project Bioshield, Annual Report to Congress: July 2004 through July 2006, Office of Public Health Disaster Preparedness, U.S. Depart- ment of Health and Human Services (HHS), July 31, 2006; available at www.hhs.gov/aspr/barda/ documents/bioshieldannualreport.pdf. †Crystal Franco et al., “The National Disaster Medical System: Past, Present, and Suggestions for the Future,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, 5, no. 4 (2007): p. 320. ‡Franco et al., “The National Disaster Medical System,” p. 321. §HHS, “Federal Public Health and Medical Assistance”; available at www.hhs.gov/disasters/ discussion/planners/medicalassistance.html#usp#usp. ¶U.S. Government Accountability Office (GAO), “Emergency Preparedness: States Are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Re- sources,” GAO-08-668, June 2008, p. 26; available at www.gao.gov/new.items/d08668.pdf. 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