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!
