What Would They Say Today?
By Maurice
Ramirez
Eighteen months after the terrorist attacks of 9/11, America's
healthcare leadership announced that while they had not been ready
on September 11, 2001, now they were. On March 13, 2003, in a much
ballyhooed statement, still sited to this day, the American College
of Healthcare Executives announced:
"HOSPITAL CEOs SAY BIOTERRORISM PLANS ARE IN PLACE CHICAGO
Since September 11, 2001, hospitals have faced new challenges protecting
and caring for their communities, especially the threat of bioterrorism.
According to a new survey conducted by the American College of
Healthcare Executives (ACHE), 84 percent of hospital CEOs agree
that since 9/11, their hospitals have worked more closely with
public agencies (e.g. fire, police, and public health departments).
Further, 95 percent of the respondents said their hospitals already
have, or within six months will have, a bioterrorism disaster
plan in place, developed in coordination with local emergency
or health agencies."
Little did they know the sense of false security and the cooling
of momentum this assertion would cause from that day forward.
The Clear View of Reality
Since 2003, multiple independent evaluations of hospital preparedness
and hospital disaster planning have found the reality in each
successive year to be far below that purported in 2003. A brief
survey three reports by the Institutes of Medicine in June, 2006
serve as proof that any hint of hospital preparedness is false
and that momentum towards preparedness has been lost. These reports, Hospital-Based
Emergency Care: At the Breaking Point, Emergency
Care for Children: Growing Pains, and Emergency
Medical Services at the Crossroads found a disparity
between self reported preparedness on multiple association and
government surveys compared to actual preparedness measured across
the five core indicators of hospital preparedness.
"Evaluations of ED disaster preparedness
consistently yield the same finding: EDs are better prepared
than they used to be, but still fall short of where they should
be"
At first blush, this seems to confirm the ACHE assertions, but
the report goes on to point out that hospitals lack patient surge
capacity due to cost related downsizing, nursing shortages, loss
of specialists, physical space constrains and overcrowding. Failures
of planning and coordination were also identified and linked to
erroneous planning assumptions.
"When a disaster occurs, the normal operating
assumptions about patients, responses, and treatments often must
be jettisoned. Depending on the type of event, some of the nonroutine
things that can happen include the following:
· Victims who are less injured and mobile will often self-transport
to the nearest hospitals, quickly overwhelming those facilities.
· Casualties are likely to bypass on-site triage,
first aid, and decontamination stations.
· EMS responders will often self-dispatch. Providers from
other jurisdictions may appear at the scene and transport patients,
sometimes without coordination or communication with local officials.
· In some cases, local facilities are not aware of the event
until or just before patients start arriving. Hospitals may receive
no advance notice of the extent of the event or the numbers and
types of patients they can expect.
· There may be little or no communication among regional
hospitals, incident commanders, public safety, and EMS responders
to coordinate the response region wide."
The Institute of Medicine reports goes on to call for improved
communications and integration across disaster response services
including Emergency Medical Services (EMS), community emergency
operations and most importantly the implementation of the standardized
Incident Command System.
"To respond effectively, hospitals must
interface with incident command at multiple levels and be prepared
to deal with transitions between levels, for example, when incident
command shifts from the local to the state or federal level.
Each hospital should be familiar with the local office of emergency
preparedness and know how hospitals are represented at the emergency
operations center during an event, whether through the hospital
association, the health department, the EMS system, or some other
mechanism."
They Didn't Think of That Either
Beyond the problems common to all disaster care environments, special
needs populations (children, elderly, mentally and physically
challenged) have needs and preparedness issues unique to them.
Unfortunately, the "one size fits none" approach taken by America's
hospitals has ignored issues highlighted by the Institutes of
Medicine Emergency Care for Children: Growing Pains report.
"The needs of children have traditionally
been overlooked in disaster planning. Historically, the military
was considered the only target of potential biological, chemical,
and radiological attacks, so the focus for training, equipment,
and facilities was on the care of healthy young adults."
"Younger patients require specialized
equipment and different approaches to treatment in the event
of a disaster. Children cannot be properly decontaminated in
adult decontamination units because they require adjustments
to the water temperature and pressure (heated, high-volume, low-pressure
water). Rescuers also need to have child-size clothing on-hand
for use after the decontamination."
The problems are compounded for rural hospitals. Despite the fact
that many both inside and outside hospital leadership believe that
rural hospitals are at lower risk and thus require less commitment
to preparedness, the truth is quite the opposite.
"The focus of emergency preparedness has been on urban areas in
part because of the perceived increased risk of terrorism in these
areas. However, there is a danger associated with neglecting rural
areas. Indeed, one might argue that rural areas may be even more
vulnerable to a terrorist attack. Many nuclear power facilities,
hydroelectric dams, uranium and plutonium storage facilities, and
agricultural chemical facilities, as well as all U.S. Air Force
missile launch facilities, are located in rural areas and are potential
targets for attack. Additionally, if individuals with infectious
diseases, such as smallpox, enter the country through Canadian
or Mexican borders, rural providers may be the first to identify
the threat."
A Problem of Their Own Making
The greatest indictment of hospitals by the Institute of Medicine
Reports however dealt with disaster preparedness training and
drills finding great variability in the training of even key
healthcare personnel with even less training for non-clinical
hospital staff.
"Serious clinical and operational deficiencies,
fragmentation, and lack of standardization exist across a broad
spectrum of key professional personnel (nurses, physicians, ancillary
care providers, administrators, and public health officials)
in both individual training and coordination of a team response."
This failure to provide training not only
effects patient care, but hospital employee safety. Despite public
statements by hospitals that "safety is worth the cost" and "preparedness is priceless" The
American College of Emergency Physicians (ACEP) and the Agency
for Healthcare Quality and Research (AHQR) separately found a very
different financial and leadership commitment to preparedness and
training.
"Many hospitals report inadequate funding
to cover the attendance costs (e.g., time off, tuition, travel)
of training (ACEP, 2001). At the University of Pittsburgh Medical
Center, a disaster drill in the Emergency Department costs $3,000
per hour in staff salaries alone (AHRQ, 2004)."
"Additionally, the failure of hospital
administrators or Emergency Department personnel to recognize
the importance of training can result in a lack of support (ACEP,
2001)."
Multiple agencies, including the Institutes of Medicine have called
for an increased coordinated financial commitment to preparedness
on the part of individual hospitals, hospital corporations, hospital
management / holding companies, as well as local, state and federal
governments.
"This lack of coordination is reflected
in the haphazard funding of preparedness initiatives. EMS and
trauma systems have consistently been underfunded relative to
their presence and role in the field."
"States and communities should play an
important role in determining how they will prepare for emergencies.
To the extent that they are supported in this effort through
federal preparedness grants, the critical role and vulnerabilities
of hospitals must be more widely acknowledged, and the particular
needs of hospitals and hospital personnel must be taken explicitly
into account"
Despite this, funding for preparedness has decreased across the
board including congressional cuts in healthcare preparedness funding
for 2007, 2008 and again for 2009. These cuts have been mirrored
in state funding initiatives; meanwhile hospitals continue to believe
that they are prepared despite evidence to the contrary.
So What Should They Say Today?
Given these realities leaders in the field of healthcare and hospital
management must now confront the fact that self reporting on
preparedness is a failed method, no different than asking a 10
year old to grade their own final exam. With the curtain pulled
back it is time for healthcare and hospitals to say:
"It is our corporate and personal responsibility
to ensure the safety and preparedness of our entire staff, clinical
and non-clinical as well as prepare to respond to the needs of
the patients we serve every day and the patients we will serve
when disaster strikes."
The problem is that healthcare and hospital leaders have done
everything in their power to quietly avoid the need to make this
statement much less bring this statement into reality. In the two
years since the Institutes of Medicine published their reports,
hospitals have lobbied first to delay and forestall the deadlines
for both Joint Commission preparedness guidelines and National
Incident Management System (NIMS) compliance elements. The effect
of this has been to make such things as facility beautification
a higher financial priority than facility preparedness.
What is Needed?
While the Institutes of Medicine and many other organizations have
made recommendations to improve hospital disaster preparedness,
the sad fact is that the only way to force hospitals to properly
and adequately prepare is to enforce the existing guidelines,
mandate meaningful external certification of compliance and engage
the public in demanding local hospitals "just do it." There is
an old adage in healthcare law:
"No change in healthcare has ever come
without regulation, legislation or litigation."
Enforcement of existing guidelines will require that the applicable
government agencies including the Department of Homeland Security,
FEMA, the Department of Justice, the Department of Health and Human
Services and the Center for Medicare Services mandate full and
complete NIMS compliance by the original September 30, 2008 deadline.
Further, these agencies must be willing to use the full force of
law to induce hospitals to invest in preparedness rather than pianos
and fountains. Federal preparedness legislation carries with it
implications of Medicare fraud, Sarbanes-Oxley violations and federal
false claims issues. It is an unfortunate reality that government
must all too often prosecute to create compliance.
The private sector has a responsibility
to enforce preparedness guidelines as well. Joint Commission
has repeatedly chosen to "partner
with hospitals" rather than "punish" the recalcitrant faculties
who repeatedly delay and curtail preparedness efforts. Joint Commission
accreditation is a powerful force for change in hospital healthcare.
The current tendency of hospitals to do as little as possible as
slowly as possible necessitates that Joint Commission enforce the
original preparedness compliance deadline in January of 2009 rather
than permitting yet another extension.
Perhaps the best thing everyone in healthcare oversight and leadership
can say to the American people is:
"We're Sorry and We Will Do Better!
