Engaging the Private-Sector Health Care System in Building Capacity to Respond to Threats to the Public's Health and National Security Proceedings of a Workshop (2018) / Chapter Skim
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5 Looking to the Future
5 Looking to the Future
Pages 51-80
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From page 51... ...
For that reason, successful models more often resemble adaptive networks rather than hierarchical structures. Successful models, said Kellerman, combine the best attributes of individual institutions and communities and of local, state, and federal governments.
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From page 52... ...
Open discussions followed each of the three panels. The first panel on best practices was moderated by Skip Skivington from Kaiser Permanente, and included Eileen Bulger from the University of Washington and the American College of Surgeons Committee on Trauma; James Jeng from the Mount Sinai Healthcare System and the American Burn Association; John Halamka from Beth Israel Deaconess Medical Center; and Gina Piazza from the Charlie Norwood VA Medical Center, the Medical College of Georgia of Augusta University, and the American College of Emergency Physicians' High-Threat Emergency Casualty Care Task Force.
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From page 53... ...
"When events get larger, the trauma system is able to surge in a way that can deal with a much larger group of patients, but still in a time-sensitive fashion," said Bulger. During a mass casualty event, she noted, the trauma system engages both the trauma centers and all of the acute care facilities in a region.
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From page 54... ...
The committee also believes it is important to designate and distribute trauma centers based on the needs of the population. The goal, said Bulger, is regionalization rather than centralization, which requires defining a region based on patient flow and a network of hospitals that work together.
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From page 55... ...
STRAC's approach illustrates how an entire arm of disaster preparedness can be built from the trauma council structure, said Bulger. In Bulger's opinion, trauma systems are the backbone for disaster planning because they offer a preexisting multidisciplinary governance structure, integration across health care systems, integration with EMS and air transport, established communication channels, and patient tracking strategies.
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From page 56... ...
There then needs to be support for trauma system development as part of disaster preparedness funding, something that Bulger said has been lacking since 2005, and optimized engagement between existing trauma systems and health care coalitions. She also explained that some mechanism is needed to facilitate the movement of licensed health care providers across state lines during a disaster, and trauma centers need to stand up and provide support to nontrauma centers, particularly during mass shooting events.
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From page 57... ...
Today, whenever there is a mass casualty event, or even when the President is speaking to a large crowd, ASPR and the Office of Emergency Management are in close contact with the American burn community. In fact, if ASPR and other federal agencies had not developed what Jeng called a symbiotic relationship with the U.S.
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From page 58... ...
Unfortunately, approximately 80 percent of the nation's burn beds are occupied on a typical day, and even moving some patients to normal beds would open only 500 to 600 burn beds in a crisis. He said the burn community is working with ASPR's Office of Emergency Management to feed detailed situational awareness data into ASPR's online geographical information system.
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From page 59... ...
Today, for example, seven petabytes of patient-identified information of all health care in Boston are stored in the Amazon cloud, a distributed, worldwide network with 50,000 employees. "In a mass casualty, who is going to be more resilient, a regional health care delivery system or Amazon?
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From page 60... ...
As an example, she described a 2018 event involving an active shooter. At the time, influenza cases were overwhelming emergency departments and all of her hospital's beds were full, as were those of every other hospital in the area.
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From page 61... ...
One challenge to such a learning emergency response system is that there is no standardized methodology for gathering data around these events or a repository in which to place data for ongoing analysis. To Piazza, DoD's work on reducing battlefield deaths represents a best practice for a learning health care system.
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From page 62... ...
, Piazza's task force at the American College of Emergency Physicians suggests developing rapidly deployable multidisciplinary teams of subjectmatter experts with the ability to gather discipline- and casualty-specific qualitative and quantitative data and develop best practices. Establishing such teams would likely require legislation and is another area, she said, where the public, a unified house of medicine, and public safety associations could bring their weight to bear to see such legislation passed.
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From page 63... ...
The Red Cross believes it can train 20 million people. Piazza added that efforts like these to train law enforcement officers to provide initial medical care were resisted when she first started working with law enforcement, but that is no longer the case.
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From page 64... ...
The American College of Emergency Physicians has a big initiative to figure out how to assemble those data during a large-scale event in a way that is quick, comprehensive, and does not compromise law enforcement investigations to enable learning and improvement. She noted that there are no data showing how many people Stop the Bleed has saved, something that would be good to know.
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From page 65... ...
LEADING CHANGE ACROSS THE FIELD Skip Skivington opened the second panel in this session by noting that change is at the heart of what must happen to improve the nation's disaster preparedness and response, yet change is hard for both individuals and balkanized organizations. Nevertheless, he said, the four panelists all had experiences with fomenting change in their organizations.
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From page 66... ...
The best successes he has seen occur during mass casualty events, when EMS is in charge of transporting those who have been hurt to the hospitals best able to care for specific injuries. The times when public- and private-sector entities do not work well, he said, is when one of the hospitals in a system goes down and patients have to be moved, along with their medical records, and clinicians need to work in a new hospital.
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From page 67... ...
McKee said these standards are excellent for being prepared to deal with a catastrophe within the walls of a hospital, and good if the disaster happens within a community, such as in a mass casualty bus accident. Where the Joint Commission, and the nation as a whole, needs to improve is in setting standards for regional disasters and for situations with massive infrastructure damage.
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From page 68... ...
She is optimistic, though, that the standards and expectations that are being introduced to hospitals will produce the necessary change. Commenting from his experience as the Boston health commissioner during 9/11, as the Massachusetts health commissioner during the H1N1 influenza outbreak, and at CDC when it was grappling with Ebola and Zika, John Auerbach offered five observations to the workshop.
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From page 69... ...
Regarding long-term care, he said the experience in recent regional disasters has been that the nation is not well prepared to evacuate nursing homes and long-term care facilities that are forced to close. Auerbach's fourth point was that the focus is too often on the acute phase of an emergency, with little attention paid to the postemergency phase.
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From page 70... ...
DISCUSSION Jeng started the discussion by coining a phrase -- crisis standards for health care regulation -- that he proposed using to get traction with both the Executive branch and Congress to reduce the regulatory burdens that lead to "we cannot do that" and the challenges of moving personnel across state lines during a regional disaster. Vanderwagen thanked Jeng for that suggestion and noted that the Pandemic and All-Hazards Preparedness Reauthorization Act offers an opportunity to develop legislative language that would be useful to this community.
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From page 71... ...
Brendan Carr, with the last comment of the discussion period, wondered if there should be a Public Health Emergency Medical Countermeasures Enterprise equivalent developed for the private-sector delivery system and private health care insurance sector. LEADING CHANGE AT THE LOCAL LEVEL In Houston, which has a dense population, hurricanes and flash floods are always a concern along with hazardous material spills, terrorism, and public health emergencies, said Engle.
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From page 72... ...
During the hurricane, many larger hospital systems closed their satellite emergency departments out of concern that they would have a patient who could not be transferred to a more appropriate facility. As a result, area EMS, which usually does not transport patients to freestanding emergency departments, started bringing patients to his system's facilities.
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From page 73... ...
"There was a need for pediatric critical care nurses, and we have plenty of those, but we could not get a clear answer for how many were needed, where they should go, how long they would be deployed, what clearances they needed, and whether or not their license was appropriate because they came from many different states," he explained. Shifting gears, Kaplan talked about the possibility of embedding a health care provider into a civilian tactical team as one way to build change from the ground level up.
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From page 74... ...
When it comes to crossing state lines, the EMS community developed the Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA) program.
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From page 75... ...
AMR also tracks the movement of personnel and pharmaceuticals, including narcotics, across state lines in regional disasters in a manner that follows the intent of the laws governing those issues, said Hinchey. DISCUSSION Kaplan, referring to Engle's comment about wanting more regional involvement in conducting hazards vulnerability assessments, said that doing so in the context of a community partnership is essential because it then will include the perspective of everyone else who affects what happens at a given hospital.
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From page 76... ...
Kivela pointed out that freestanding emergency departments may be called on to provide surge capacity or pick up the slack if a hospital closes, but they are not eligible for reimbursement from CMS for Medicare or Medicaid beneficiaries. Engle confirmed that and noted that emergency departments attached to the CMS license of a hospital are able to accept Medicare, Medicaid, and Tricare patients.
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From page 77... ...
"The last thing you want is somebody going out in the flood trying to get somewhere and that place does not exist," he said. Bruce Evans from the Upper Pine River Fire Protection District said that as a fire chief, his equipment is listed in a number of databases, include AMR's national ambulance strike team, the national interagency resource ordering and status system, a Web Emergency Operations Center (WebEOC)
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From page 78... ...
Kaplan noted that regional advisory committees are effective, if a region has one. In the absence of one, a regional trauma center or regional coalition can serve as a coordinating body.
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From page 79... ...
She also noted that of the 3.1 million registered nurses, only 37,000 of them define themselves as public health nurses. "We have a potential shortage here for events where we need nurses outside of the hospital acute care health system," she said.
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