Five years ago, a DomPrep Journal article “The Design of the Future U.S. Hospital System” proposed a significant shift in the roles played by U.S. hospitals in general, and by their emergency departments in particular, in the preparedness plans developed to cope with major incidents. As community resource centers, hospitals would be assigned a principal role in delivering effective and comprehensive healthcare even in the worst of circumstances. The challenge today, though, is to meet that daunting concept with current needs in preparedness, and in a still evolving health system.
The high marks given to the lifesaving role played by local hospitals during and after the April 2013 Boston Marathon bombings provided a critical demonstration of the positive aspects of health system preparedness. Nonetheless, the nation’s hospitals and healthcare providers are now once again at a crossroads in setting priorities and allocating limited funding.
The Terrorism Dilemma: Prevention vs. Resilience Many publications have noted the need for change in preparedness priorities at the federal level. In a 29 July 2013 article published in Bloomberg Businessweek, for example, staff writer Devin Leonard discussed the planned movement of various branches of the U.S. Department of Homeland Security (DHS) to a new, central, and more easily protected location in the southeastern quadrant of Washington, D.C. The article also noted the various changes in organization, culture, and budget that have taken place in recent years of this relatively young federal agency. With 240,000 employees and an annual budget of $60 billion or so, DHS is still under significant scrutiny about the safety and cost effectiveness of many of its more ambitious programs (some of them still untested).
The Bloomberg article suggested that the billions of dollars spent for border protection and transportation safety are not cost effective. In an era of fiscal constraints, some analysts have suggested that much of that funding could be better spent by a shift from the prevention of terrorism to an increased emphasis on “resilience.” The same analysts also argue that a more cost-effective way of coping with terrorist threats would be to develop the capacity to recover and rebuild when terrible events – whether natural or as a result of human actions – do occur.
Adoption of that approach, though, might well mean that at least some relatively costly Pentagon weapon systems would receive less funding. But, in return, more funding would be available for healthcare providers, local public safety forces, and first responders. The latter resources are the ones that saved lives and impacted communities following: the Boston Marathon bombings; Hurricanes Katrina and Sandy, which caused numerous blackouts; the explosion earlier in 2013 of a fertilizer plant in West, Texas; and the 2011 tornadoes that devastated Joplin, Missouri, and Moore, Oklahoma.
The article further suggested that the many linkages built at the local level in recent years are the ones that would be most useful in managing future crises. In Boston, on-scene emergency medical personnel handled the crisis quickly and effectively, moving dozens of injured people through triage tents and into hospitals – most of them within a matter of minutes. Surgical resources – operating rooms, trained surgeons, and a broad spectrum of medical systems and equipment – also were immediately available, and the combination of rapid triage and transport, plus immediate access to operating rooms, clearly reduced the death toll. It should be noted, of course, that the greater Boston area possesses extensive and high-quality healthcare resources – including the operational experience of numerous highly trained medical practitioners – and also has a rich tradition of sophisticated disaster planning and drills.
Addressing the Global Threat Environment There has certainly been a change, in recent years, in the global threat environment. The Boston bombing attacks – which followed other low-budget and relatively low-sophistication events such as the Eric Rudolph bombings, the Oklahoma City tragedy, and several domestic terrorism attacks in which anthrax was used – strengthen what seems to be a growing need for: (a) more-effective, all-hazards preparedness; and (b) the development of more-effective resilience at the local level.
Another factor to be considered is that the need for improved health system preparedness occurs simultaneously with the massive plans to change the basic economics of the U.S. healthcare system. The current political/budgetary battle in Congress on funding the Patient Protection and Affordable Care Act (PPACA, or Obamacare) is one of the more visible efforts to prioritize the health of the general public. No matter what else happens, it seems clear that the hospital role as the primary site of acute care is being replaced, at least in part, by the hospital as a major hub of medical information, qualitative medical improvements, and improved health for the entire community.
Many metropolitan areas now have workgroups that link hospitals more closely with public health and public safety. To achieve compliance with the federally mandated National Incident Management System (NIMS) requirements, for example, local hospitals must participate much more closely than ever before in community all-hazard planning. Public health agencies also are cooperating to: (a) help facilitate the more active role played by the U.S. Centers for Disease Control and Prevention (CDC), which has been developing and sharing some very important healthcare primers on terroristic health threats; and (b) to speed the activation of regional surveillance systems to help them cope with an already large, and increasing, number of biological threats.
What must come next is more effective use of community resources for disaster preparedness to replace the shrinking budgets of hospitals required to provide more comprehensive acute care for patients. Matching resources can be effectively carried out, though, only with knowledge of local hazards and local assets. Innovative funding for hospitals and public health functions must represent a value proposition for the community. Fortunately, evaluating emergency preparedness priorities and available funding has been an increasingly valuable skill set for emergency management agency planners as well as for finance and other “resource” officers within fire departments, police agencies, and public works offices.
National Preparedness & Security Programs In line with these local planning efforts is the concurrent need for a commitment of federal dollars – repurposed, perhaps, from other less-effective preparedness and security programs. The Hill-Burton Act (Hospital Survey and Construction Act of 1946) was the federal government’s principal post-World War II effort to fund improvements of the physical plant of the nation’s hospital system to enhance preparedness. The same Act still provides a legal and financial foundation for federal funding of local medical preparedness plans and exercises.
When focusing on the resources needed to create a more resilient healthcare workforce, hospital and healthcare planners can find several relevant planning documents for these efforts – the National Fire Protection Association Standard 1600 (NFPA1600) is one good example. What is officially called the Standard on Disaster/Emergency Management and Business Continuity Programs includes provisions that outline the development, implementation, assessment, and maintenance of programs for prevention, mitigation, preparedness, response, continuity, and recovery. A critical element of those provisions focuses on the continuity of operations, a particularly important component of the overall national healthcare system.
Financial resilience, for many reasons, is important to every community. The economic disruption caused by the Boston bombings has been estimated to be about $300 million, with some of that cost borne by the local health systems involved. There still are major questions, though, about the ability of most U.S. cities and states to build better systems that can quickly restore continuity of operations after a major destructive incident has actually occurred.
One troubling factor does seem certain, though: Other would-be terrorist groups are now fully aware that a major metropolitan area was almost totally neutralized for almost a week, by a relatively unsophisticated act of terrorism that was carried out by two brothers. If nothing else, the United States now has an opportunity to design and train the providers needed to restore operations rapidly after an incident. Using that opportunity well is at the heart of resilience, and may well serve as a timely challenge in determining the allocation of more resources from the federal government to state and local agencies.
________________________ James J. Augustine, M.D., is an emergency physician who serves with the Atlanta Fire Rescue Department and Hartsfield Jackson Atlanta International Airport. A clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio, he previously served as chair of ASTM Task Group E54.02.01, which developed ASTM Standard E2413 on Hospital Preparedness, under Committee E54 on Homeland Security Applications. He also served as chair of the Atlanta Metropolitan Medical Response System.