Traditionally, health and medical preparation measures are among the last factors considered when planning a large-scale public event. Law-enforcement concerns and intelligence related to political matters are usually foremost, but this way of thinking does not reflect the historic reality of various events and the numerous, and frequently complex, preparations by medical and health agencies that also must be factored into the equation. For both practical and operational reasons, a more broad-based approach in the planning for major events is needed and should include institutional components of the various health and medical sectors – more specifically, public health agencies, hospitals, and emergency medical services (EMS) units – that are likely to play an important role in preparing for, responding to, and caring for a major influx of patients when a large-scale event is disrupted by an unforeseen incident or event, natural or manmade.
One of the first questions that must be answered is whether the event will be, or has been, designated as a National Special Security Event (NSSE). If it has been, the event will receive higher visibility and/or political significance. For that reason, an NSSE designation also means that various federal agencies – e.g., the Secret Service, the Federal Bureau of Investigation (FBI), and the Federal Emergency Management Agency (FEMA) – will play lead roles both in the advance planning and during the course of the specific event.
After the chain of authority has been established, it is the responsibility of all of the entities involved to ensure that they are able to participate fully during the entire planning process for the event. Such participation is especially important for EMS agencies, hospitals, and public health entities. Depending on the size, complexity, and other factors related to the event, planning can begin as early as one year or more prior to the actual event. Following are brief summaries of some, but by no means all, of the more important healthcare, medical, and related information that should be on the short- and long-range checkoff lists.
Hospitals – Beware of the “Worried Well”: Hospitals of all sizes should be made aware of any and all large-scale events planned in their immediate geographic and operational areas. The hospital’s own advance preparations must ensure that: (a) there are a sufficient number of on-call staff available as well as enough beds and medical supplies to meet surge capacity (or more); and (b) all staff are fully informed on what the EMS system plans to do with incoming patients. It is particularly important not to overwhelm a large trauma center with non-trauma patients. Here it should be remembered that, according to the National Association of County & City Health Officials (NACCHO), the “worried well” usually comprise 80 percent of the people seeking medical care in the aftermath of a major incident or event, and caring for that 80 percent “affects care for the more urgently injured 20 percent.”
Another important consideration that will affect the hospitals closest to a large-scale event is the reality that a number of those injured in such incidents frequently bypass the established EMS system and self-transport themselves (or are taken by others) to nearby medical facilities. Several mass-casualty incidents, including a number of New York City hospitals on 11 September 2001, saw that reality verified in the immediate aftermath of the terrorist attacks.
EMS – Geography Matters & Air-Evac Requirements: The EMS system should be an element of the planning process for all large-scale pre-planned events. EMS preparations must include understanding the nature of the event, researching the specific geographical area where the event will occur, knowing the emergency response challenges posed by the geographical location, recognizing the possible need for on-site medical personnel and ambulances, and determining the assistance of basic life-support personnel vs. advanced life-support personnel. In addition, a transport scheme in incidents involving multiple patients is a necessity so as not to overwhelm the medical facilities closest to the event. Other factors to be considered are the possible need for aeromedical resources and/or on-scene physicians familiar with both the EMS system and mass events.
Public Health – ESF #8 in the Field and at the EOC: Because public health entities play a lead role in most DHS/FEMA (Department of Homeland Security/Federal Emergency Management Agency) ESF #8 missions, it is imperative that they coordinate their operations, ensure they can communicate with their partners at all times, and are present at all critical meetings. (ESF is federal shorthand for the Emergency Support Functions and responsibilities assigned to DHS and FEMA; ESF #8 covers health and medical matters.)
Another issue that must be addressed is ESF #8 representation at the emergency operations center (EOC). Traditionally, the primary drivers of extensive public health planning for mass gatherings reflect geographic spread, the number of international visitors likely, and event duration as well as, sometimes but not always, various political and religious considerations. In these instances, the implementation of a formal risk assessment prior to the event, complemented by ongoing daily reviews, is important forentifying public health hazards.
Developing and using event-specific surveillance to provide early-warning systems that address the specific risksentified through the risk-assessment process are essential. The extent to which additional resources are required will vary, and will depend in large part on the current level of surveillance infrastructure. If the existing public health work force has been regularly trained in emergency response procedures, then far less effort and resources will be needed to prepare for each mass-gathering event. The use of formal emergency management structures and co-location of surveillance and planning operational teams during events facilitates timely communications and action.
The reality is that large-scale events have the potential to generate a large influx of patients, thereby requiring a shift from business as usual to a “surge-capacity” situation. Planning in advance and ensuring that all personnel, equipment, and systems needed are in place ahead of time to handle the possible surge is a paramount planning factor. Fortunately, current training and experience can and should be augmented by using large-scale events already on the calendar to ensure that critical personnel are informed about other critical players, that all plans needed are in place beforehand, and that critical personnel know how to access those plans very quickly.
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For additional information about: NACCHO, click on “http://www.naccho.org/topics/modelpractices/database/practice.cfm?practiceID=518“
FEMA’s Emergency Support Function #8, click on “http://www.fema.gov/pdf/emergency/nrf/nrf-esf-08.pdf“
Raphael Barishansky
Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations, his most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.
