Skip to main content

Currently Skimming:

Workshop Summary
Pages 1-66

The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.


From page 1...
... Some of the work is as simple as creating common language: defining medical surge capacity, and creating standards and metrics to guide planning so that the highest priority requirements can be addressed in a timely manner. Some of the work is blisteringly complex, such as developing data systems that reach across the boundaries of states and regions, public and private healthcare systems, and outside the healthcare environment into the work of emergency management organizations.
From page 2...
... in HHS's ASPR sponsored the workshop on medical surge capacity. HPP's mission is to help prepare the nation's healthcare system to respond appropriately to masscasualty incidents, whether due to bioterrorism, natural disaster, or other public health emergencies.
From page 3...
... , mortuary services, and other providers) , and healthcare and hospital administrators.
From page 4...
... It is not going to happen without definable metrics that the funding agencies can actually say ‘Yes, you have done this.'" Medical Surge Capacity: Conventional, Contingency, and Crisis Capacity The term "medical surge capacity" has many different meanings to many different people. This can cause confusion and even an inability to have a meaningful discussion about the issues.
From page 5...
... Hick presented a conceptual framework from the Medical Surge Capacity and Capability project at HHS. Grossly defined for the workshop's purposes, surge capacity is the ability to rapidly accommodate a large number of patients from a defined mass-casualty incident or pandemic.
From page 6...
... Healthcare systems can better compete with other sectors for homeland security grant funding when specific requirements are known. However, where should standards originate?
From page 7...
... HHS has broad authority to reshape critical parts of the legal landscape to enable an effective response during a disaster. In order for HHS and others to act, however, a public declaration of a disaster or of a public health emergency is required.
From page 8...
... These waivers include: • Waiver of Emergency Medical Treatment and Labor Act (EMTALA) sanctions for 72 hours, except in the case of pan demic infectious disease; • Waivers concerning various conditions of participation, program participation requirements, certification requirements, and Stark self-referral sanctions for 72 hours; • Waiver of deadlines and timetables for the performance of re quired activities; and • Waiver of the requirements that healthcare providers hold li censes in the state where they provide services (for the purposes of Medicare, Medicaid, and SCHIP only)
From page 9...
... In the wake of Hurricane Katrina, for instance, volunteers came from across the country and around the world. Each individual arrives on the scene with different skills and experience.
From page 10...
... 1. Certain states explicitly note in law that license reciprocity exists for the duration of a state of emergency, state of disaster, or state of public health emergency, as long as the license is in good standing in another jurisdiction.
From page 11...
... Federal agencies cannot legally respond within a state unless they are requested or authorized by the state's government. This delayed some federal assets, including DMAT teams, from moving into affected areas in the chaotic days following Hurricane Katrina.
From page 12...
... While the medical care and emergency response systems -- hospitals, physicians, pharmacists, emergency medical technicians (EMTs) -- focus on individual patient care, the public health system focuses on population care.
From page 13...
... This will ultimately help ensure a primary goal of public health, to mitigate transmission of the disease from infectious individuals to those who are well. Hospital Surge Capacity Is Not Ideal Professor of Emergency Medicine and Associate Dean for Health Policy at the Emory University of Medicine, Arthur Kellermann emphasized that "form follows finance" and the way hospitals are incentivized to generate revenue and control costs contradicts core principles of preparedness.
From page 14...
... The first time in patient nurses treat patients in a hallway should not be during a disaster, he observed. Kellermann also called for more rigorous assessment of hospital surge capacity and independent drills of disaster plans, applying some of the techniques described by Dr.
From page 15...
... "You need to bring them all together, plan together, and start thinking about how you deliver care together," said Levy. For example, Levy and the CDC work to bring together local leadership and individuals representing various stakeholders, including emergency 911 call centers, nurse help lines, EMS, emergency departments, hospital administrators, health system administrators, primary care providers, urgent care clinics, pharmacists, home health, long-term care facilities, hospice, public health, outpatient specialty services such as dialysis centers, medical examiners/coroners, and funeral directors.
From page 16...
... Plans "work well when you know the people you are working with -- be it on the ground at the scene, or at the command level -- and those relationships come from having worked in previous incidents or in drills or day to day." One way to both build these relationships and test surge capacity outside the hospital is to look at large community events as "planned disasters" and use them to test operations and try alternate approaches. Richard Serino, former chief of the Boston EMS and current deputy administrator of the Federal Emergency Management Agency (FEMA)
From page 17...
... Response needs to be coordinated locally and regionally so that one decision in one area does not cause difficulties in another. Unfortunately H1N1 provided an example of an uncoordinated response during its early stages: "We had the Board of Education telling all the kids that they could not come back to school without a note from the ED [emergency department]
From page 18...
... The new entity had the mission to build, develop, and maintain a regional emergency-preparedness program for its members. Along with creating standards for surge capacity, decontamination, and communications, the Alliance also built a regional hospital-coordinating center that functions like an emergency operations center.
From page 19...
... The model has been adopted throughout Virginia, with the six regions of the state each mandated to have a hospital coordinating center and a regional plan. Each region also partners with local emergency management, public health, and law enforcement agencies for emergency preparedness.
From page 20...
... The benefit of this plan is that the community physicians and health centers work to keep hospitals from being overrun. The example of Israel was not discussed at the workshop as a model for the development of medical surge capacity in the United States -- there was broad understanding that Israel, with a national infrastructure, an urban and dense population, and a relatively small geography, faces very different challenges with very different resources.
From page 21...
... Peleg recommends could be adapted in the United States, such as regional monitoring of hospital capacity, benchmarks for maintenance of surge capacity, a commitment to keep emergency departments from becoming gridlocked with admitted patients, and the rapid opening of alternate care sites for casualties that do not require emergency department care. ESTABLISHING ALTERNATE CARE FACILITIES During a mass-casualty incident, the health system will not be able to rely solely on the nation's hospitals to care for the population during large-scale disasters or pandemics -- they would be quickly overrun.
From page 22...
... "It's all about influence management," explained Dan Hanfling of Inova Health System. "It's trying to influence demand and trying to figure out if we have the mechanisms for managing what will be a rush on healthcare services." This is just one example of what Hanfling referred to as "Main Street triage." But although alternate care facilities can be as simple as medical aid stations at marathons or inaugurations, they can also be much larger and complex, such as the Houston Astrodome after Hurricane Katrina.
From page 23...
... Demobilization Workshop participants stressed the importance of the temporary nature of alternate care facilities. Rubinson of HHS stated, "Even though it's going to be the safest care we can provide, this is clearly not everyday care, and we need to close these down as soon as we can to make sure that we don't just do business as usual and start using this as a patchwork for a broken healthcare system." The solution is to make demobilization part of the core plan, creating the triggers and processes to quickly and cleanly take alternate care facilities offline as soon as they are not required.
From page 24...
... Koonin related the results of a study done by Robert Blendon at the Harvard School of Public Health. The results indicated that regardless of the ethnicity or socioeconomic level of a person, a large majority reported a willingness to stay home.
From page 25...
... For large-scale, in-home care to succeed, all parts of the healthcare system -- from private physicians to large hospital systems -- need to send out the same messages to the patient population. There cannot be multiple treatment regimes, or people will be confused and not trust the system.
From page 26...
... Depending on who is staffing the call centers, many different types of information and support can be offered. Staffing can be changed quickly in response to a mass-casualty event or public health emergency.
From page 27...
... The usual 2,000 calls per day expanded rapidly to over 20,000, and the call center was able to assist in helping to determine who was "probably exposed and required referral for care versus those who were not and needed shelter-in-place and useful information to keep them safe." The Ontario call volume fluctuation reflected directly on emergency department visits for respiratory illness, In the first 10–14 days many callers were experiencing fear and anger that they might already be exposed, a similar finding seen in past "silent disasters" (i.e., biological, radiation, and chemical events)
From page 28...
... called and got information required no further care," explained Phillips. "Approximately 15 percent were able to delay it to a subsequent day, and the rest didn't need emergency care." Bilateral Communications Information from a call center can go both ways.
From page 29...
... cases and hantavirus cases in Colorado, well before our state health department knows, and they love that -- that we can actually give them that early warning." Additionally, call centers can be parts of mass-risk communication and community-care strategies. Mass media are obviously critical in a mass-casualty or pandemic situation, but there's no substitute for twoway communication.
From page 30...
... It is the ability to look at a huge variety of data, determine what is relevant, synthesize the data, and act on it. In a masscasualty event or public health emergency, situational awareness is the ability to collect the correct information, analyze it, and project what will come next, so the appropriate actions can be taken.
From page 31...
... The goal is not automation, but informing human decision making. Perhaps most importantly, situational awareness drives policy decisions.
From page 32...
... Paul Biddinger, chair of the Massachusetts Medical Society Committee on Preparedness, highlighted some of the key areas: • The public needs to know where their loved ones are -- reunification after an event is a huge concern and a huge job. Af ter Hurricane Katrina it took 9 months for the last child to be re patriated to its family.
From page 33...
... The next critical step toward better situational awareness is to move toward integrated systems. "We need to harness health information technology to improve digital linkages between hospitals and healthcare systems, public healthcare systems," suggested University of Pittsburgh's Toner.
From page 34...
... " he asked. "Want to know actually how to keep surge capacity from happening by forward-deploying resources instead of sending out explanations of benefits?
From page 35...
... Seattle Healthcare Coalition Cynthia Dold, hospital emergency preparedness administrator for King County in Washington, shared some of the Seattle Healthcare Coalition's efforts to create an integrated system for situational awareness. The project includes hospitals, home health providers, nursing homes, and dialysis providers -- the whole gamut of healthcare providers, all sharing information about resources, staffing, clinical data, and infrastructural impacts in a variety of ways.
From page 36...
... However, in order for this project to translate into a national effort, there is a need for national data standards, commented David Gruber, New Jersey Department of Health and Senior-Services Senior Assistant Commissioner for the Division of Health Infrastructure Preparedness and Emergency Response, the Office of Emergency Medical Services and the Division of Public Health and Environmental Laboratories. Once these standards are set, individually developed products meeting these standards will be able to plug into a national system through the existing Hippocrates high level architecture.
From page 37...
... Hippocrates not only brings together data from disparate systems, but it allows different users to view the data at different levels, giving each user the data they need to make the best decisions possible, given the information at hand -- which is exactly the goal for situational awareness systems. AT-RISK POPULATIONS: BEHAVIORAL HEALTH EFFECTS AND MEDICAL NEEDS Public health emergencies and pandemics are not equal opportunity offenders.
From page 38...
... PECARN is working on a new set of performance measures for the Emergency Medical Services for Children Program. "We are proposing that there be a new performance measure on state preparedness for children and disasters, and this might be an opportunity to really get engagement of multidisciplinary folks," said Wright.
From page 39...
... Not all students who stayed home were sick, leading workshop participants to ask: What do we do about the "worried well"? The NYC Department of Health and Mental Hygiene estimated that two-thirds of the absenteeism was due to parents keeping their children home as a result of parental anxiety.
From page 40...
... Each group has different specific characteristics and needs, and needs increase as the population ages. Charlotte Yeh, chief medical officer of AARP Services Incorporated, shared some characteristics of the over-65 Medicare population with the workshop: • More than 80 percent of all Medicare beneficiaries have at least one chronic illness, with 20 percent of them having four or more; • 42 percent of women 65 and older have arthritis; • Roughly 50 percent of men and 33 percent of women have hear ing difficulties; • 20 percent of all men and women have visual impairment or vis ual difficulty; • 42 percent of the 65-and-older population is compromised in ac tivities of daily living (trouble with handling the telephone, shopping, managing money, cleaning the house, etc.)
From page 41...
... Raymond Swienton, codirector of the Section of Emergency Medical Services, Homeland Security and Disaster Medicine at University of Texas Southwestern Medical Center, explained, "The reality of most special
From page 42...
... The higher incidence of arthritis in the population causes complication boarding public transportation to get to alternate care facilities, and those sites need to be accessible to those who use a wheelchair, walker, or cane. Even communication can be a challenge.
From page 43...
... Workshop participants shared numerous anecdotes from Hurricane Katrina about nursing homes that were not evacuated in time. The natural reaction is always "Why?
From page 44...
... Because responses to mass-casualty events can be long lasting, special needs must be met to sustain alternative care facilities and home care. Support needs to be available to caregivers and first responders.
From page 45...
... Family Assistance Centers Family assistance centers came into the national spotlight after the 1996 mid-air explosion of TWA Flight 800 off the coast of Long Island, New York. Out of this tragedy came the Family Assistance Act of 1996, which set standards for dealing with mass-casualty and mass-fatality incidents in aviation.
From page 46...
... "Many of the folks who are working in these fields are working in environments that do not really test their skills." Dealing with the stress of grieving and worried families isn't part of most volunteers' day-to-day experiences. Family assistance centers work well for discrete events such as airline incidents and building collapses, but in a pandemic environment they become problematic.
From page 47...
... Medical examiners are also responsible for the accurate and efficient identification of victims. They interact with surviving family members, providing them with information and support -- often working through family assistance centers.
From page 48...
... It is a comprehensive disaster management system that addresses everything from setting up call centers to managing family assistance centers. It also can manage both ante-mortem and postmortem reporting needs.
From page 49...
... Disaster Mortuary Operational Response Team DMORT is the Federal National Mortuary Affairs Support system, and is made up of 10 teams distributed within the FEMA regions. The team members are pulled from within each region and primarily are people actively engaged in the funeral industry.
From page 50...
... Additionally, their daily contact with local medical examiners for routine matters, such as obtaining death certificates and arranging transportation, put them in a good position to be effective during a surge event. If there is a gap, it is in connecting the private funeral industry with emergency preparedness planning, Fitch commented.
From page 51...
... Just as this remains a thorny problem in crisis standards of care for the living, it remains an issue in dealing with the deceased. Finally, workshop participants noted that fatality management is not addressed in most federal frameworks or local response plans.
From page 52...
... . I believe that if we could do one thing … if we can get some language into those two documents, we can make a significant difference throughout this country." DePaolo also recommended that collaboration among hospitals, healthcare facilities, and medical examiners/coroners be required in mass-fatality initiatives.
From page 53...
... Without these services, long-term economic stability and vitality of a community will not exist. Planning to Recover -- Lessons Learned from Hurricane Recovery Efforts The key to recovery starts during emergency preparedness planning, even before an event occurs.
From page 54...
... Hospitals that closed due to flooding after Hurricane Katrina were able to take advantage of their business interruption insurance to return to normal operations. Hospitals that stayed open, even though patients were unable to get to them because of floodwaters, were not, even though they were not treating patients.
From page 55...
... Finally, after trying to care for patients the best they could, they resorted to calling 911 to have the patients taken to other hospitals for care. This put the hospital, which was simply doing the best it could, in the position of violating EMTALA (Emergency Medical Treatment and Active Labor Act)
From page 56...
... "We mobilize our daycare facilities immediately," said Robitaille of Martin Memorial Health Systems. "We have a very comprehensive associate-assistance program to facilitate their ability to get back to normal -- whether it's housing, food, shelter, or childcare," he explained.
From page 57...
... Workshop participants noted that this broad, long-term resource drain is an area that needs further research, discussion, and funding. FINANCING SURGE CAPACITY AND PREPAREDNESS A continued theme throughout the workshop was that current financing strategies have not and will not be able to support efforts to plan,
From page 58...
... As William Smith, senior director for emergency preparedness at University of Pittsburgh Medical Center, said, "We have lots of stuff, but we don't have the money to pay people to learn how to use it properly and how to deploy it properly." The need to fund training exists at all levels of medical surge, from front-line emergency workers, clinic staff, nurses, and physicians to non-medical staff who will be called on in a crisis. The old adage "form follows finance" was brought up many times throughout the workshop, and participants noted that the existing finance system is not helping.
From page 59...
... This means that rules about fee-for-service payments or about transferring patients between acute care facilities cannot be abridged. This issue was particularly important in Arkansas when patients were evacuated from Louisiana after Hurricane Katrina.
From page 60...
... Workshop participants noted that local EMS surge ability currently comes through local or regional mutual-aid relationships. Nationally, there are two systems for mutual aid in a disaster -- the Emergency Management Assistance Compact and the FEMA ambulance contract.
From page 61...
... He suggested starting by calculating the costs to provide basic emergency medical services to the community -- ambulance, first response, and medical communications -- all of the components that the community wants to include. The community can then determine what amount of surge capacity the community wants above that, realizing that those resources would be idle on a day-to-day basis specifically so they could be available when needed.
From page 62...
... At the time of the workshop, the draft bill on healthcare reform from the Senate Committee on Health, Education, Labor, and Pensions committee contained a component relating to a pilot project for regional EMS systems that dealt with, among other concerns, surge and the development of adequate surge funding. Looking Ahead Throughout the workshop, participants noted that the way we fund medical surge capacity and emergency preparedness in this country does not work.
From page 63...
... The picture that emerged of a successful medical surge was a planning and response system that goes beyond just hospital and that has the following features: politicians who rapidly issue disaster proclamations, and legal teams who work immediately on credentialing and authorizations; contingency staffing plans that snap into place, and hospital triage teams that are ready to function; activation of contingency plans throughout the health system including alternate care facilities that are staffed, and funeral directors that have local-language translators on hand, ready to help; hospital daycare facilities that are activated, payers who keep the necessary funds flowing, EMS who are ready, and an engaged public. It is a web of support, and failures at any one point lead to lost lives and lost opportunity.
From page 64...
... Just as school children are taught "stay low and go" they also need to understand the basic steps of protecting themselves in an emergency or pandemic situation. Another key to emergency preparedness and meeting medical surge demand is the staff that are in the trenches, doing the work.
From page 65...
... Many workshop participants believe that preparedness is fundamentally a national security issue, and suggested that funding can come from that arena. As the University of Pittsburgh Medical Center's Toner said, "We always find ways to pay for national security projects.


This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More information on Chapter Skim is available.