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Healthcare systems still have work to do to be better prepared for next disaster


June 1, 2018

The U.S. experienced an onslaught of major emergencies over the past year that has tested the response and resolve of the healthcare systems in those respective communities.

There were the floodwaters that swarmed Houston during Hurricane Harvey, the hurricanes that ripped through Puerto Rico, and the wildfires that torched California, along with the harrowing mass shootings at a country music concert outside of the Mandalay Bay casino in Las Vegas and, most recently, at Stoneman Douglas High School in Parkland, Florida.

A timely, recent report by the Johns Hopkins Center for Health Security, A Framework for Healthcare Disaster Resilience: A View to the Future, has examined how the U.S. healthcare system has fared while responding to emergencies both large and small.

The report’s authors, led by Eric Toner, MD, did not include the aforementioned events in their research, as the scope of their work covered a five-year span near the start of this decade. In reviewing similar disasters, they concluded that the bigger the emergency, the less prepared healthcare facilities are for handling the crush of patients that come through their doors.

“Although the healthcare system is undoubtedly better prepared for disasters than it was before the events of 9/11, it is not well prepared for a large-scale or catastrophic disaster,” the authors wrote in the report, which was released in late February. “Just as important, other segments of society that support or interact with the healthcare system and that are needed for creating disaster-resilient communities are not sufficiently prepared for disasters.”

The authors conducted a literature review that identified 119 articles from 2010 to 2015 focusing on “U.S. health system preparedness or resilience.” The authors then conducted a series of interviews and held two working group meetings, two conference calls, and a focus group. They said they spoke with 44 “subject matter experts and thought leaders,” who discussed how changes in the healthcare system affected emergency preparedness and offered suggestions on how to increase preparedness and resilience.

The consensus was that changes in the healthcare system since 9/11, a tragedy that swiftly led to the implementation of new government programs to respond to similar crises, “created both problems and opportunities” that were never “adequately explored.” The people with whom the authors spoke also generally agreed that there has been “real progress in building health sector resilience” but that “different types of disasters require quite different responses.”

‘Less prepared’ for larger-scale events
After concluding their literature review and research, the authors identified four broad types of disasters — each with a distinct set of characteristics and each requiring different levels of scope and response — for which they feel the U.S. healthcare system must prepare.

The first category is defined as “relatively small-scale mass injury and illness events,” covering events such as bus crashes, tornados, multiple shootings, and small disease outbreaks.

The second category is “large-scale natural disasters” like Hurricanes Sandy and Katrina and the devastating floods that followed. 

The third category is complex mass-casualty events. Real-life examples include the 2012 shooting at Sandy Hook Elementary School and the Boston Marathon bombing in 2013. This category also includes burn events, chemical or radiological incidents, limited-scale acts of bioterrorism, and limited outbreaks of infectious diseases such as Ebola or SARS.

The fourth category, which the authors defined as the least likely but the most severe, is “catastrophic health events.” Examples include nuclear detonation, large-scale bioterrorism, a severe pandemic, or a major earthquake or natural disaster.

“The current healthcare ‘system’ and disaster preparedness and response programs do not equally address all of these [categories],” they wrote. “Each type of disaster has its own requirements and necessary approaches. Many disasters have common preparedness and response elements, and this is the logical basis for all-hazard preparedness. But it is also true that a hurricane versus a pandemic versus a mass shooting have highly distinct characteristics, and so some (or much) of what will be required will not be addressed by an all-hazards approach.”

They added: “Preparing for one type only partially prepares us for other types and focusing solely on the common elements leaves gaps for specific actions or capabilities required for each type of event. Different events require different mixes of skill sets, resources, and response capabilities when the principal goal is to reduce injury and illness and to save lives.”

After conducting a gap analysis, the authors concluded that while the U.S. healthcare sector is “reasonably well prepared” for the first category of disasters, which happen often, it is “less prepared” for large-scale disasters and complex mass-casualty events. And the authors found that the healthcare sector is “poorly prepared” for the catastrophic fourth category.

“Much of civil society and many parts of the health sector are not resilient and are not participating in preparedness activities, as was demonstrated in Hurricanes Katrina and Sandy,” they concluded. “When disaster strikes and these entities fail, people suffer and the hospitals become overwhelmed, leading to cascading hardship and suffering. To address this, many more components of the health sector and civil society need to be more resilient and connected to formal preparedness and resilience activities in their communities.”

Facilities as prepared as they can be?
Barbara B. Citarella, RN, BSN, MS, CHCE, CHS-V, president and CEO of RBC Limited Healthcare and Management Consultants in Staatsburg, New York, agrees there is room for improvement when it comes to preparing for larger-scale disasters — albeit with a key caveat.

“I think [healthcare facilities] are prepared as they can be with their surge capabilities,” says the certified National Healthcare Disaster Professional. “There are only so many pounds you can squeeze into a box because our healthcare system — beds, emergency rooms — are shrinking with a lot more of a push towards outpatient or ambulatory care. In general, our capacity for surge is not great. So, I think they’re as prepared as they could be given their situation.”

Citarella recently lectured a group in Florida about “optimistic bias,” which she said is “a big issue in disaster preparedness” that can be experienced by “first responders and emergency planners.” Essentially, she says, “We can all talk ourselves into some behavior by saying, ‘Oh, that won’t happen to us. It will happen to somebody else, but it won’t happen here.’”

Based on her experience, she believes “most providers have a decent preparedness plan.” Still, beyond the first, relatively minor category of disaster, they cannot handle it alone.

“I think we still tend to operate in silos somewhat,” she says. “And I think when you get into a catastrophic event, when we move into something that is really large scale and maxes out our resources, there’s only so much we can do. It’s not like we have extra beds. It’s not like we have extra nursing room beds or extra assistant living beds out there being empty.”

It doesn’t help, Citarella argues, that the focus on and the funding needed for emergency preparedness have waned after the initial push post-9/11 to brace for the unexpected.

“Other issues become more important and each president comes in with their own viewpoint, and so we have had a lot of changes with healthcare reform,” says Citarella. “So, disaster preparedness kind of got pushed to the back table, and that’s where it has remained. We had their big surge after 9/11 and then it just kind of petered out, and that’s unfortunate. So, I think the issues that are here are still the same issues, and the reason that they are still the same issues is because the funding for disaster preparedness has been cut [significantly].”

Collaboration needed for improvement
Citarella says it takes a lot of coordination and collaboration to be ready for larger-scale events, which is why she advocates for the creation of healthcare coalitions and bolstering existing ones, saying that “they are helpful in breaking down that silo” from what she has seen. She says those coalitions allow healthcare facilities to “understand what each other’s role is and what their strengths and weaknesses are” in the frenzy following a disaster, allowing them to “move people through the continuum of care” without overloading emergency facilities.

“You have to be able to utilize and mobilize your resources quickly. You have to be able to quickly identify where people are going to go, and you should have practiced for it,” she says. “But there’s very limited mobility in our healthcare system for surge. So, unless they are planning on including all of the outpatient resources — the ambulatory care people, the home care, the hospices — they’re not going to be able to respond. ... [Outpatient facilities] have more flexibility in their patient caseload than hospitals and ERs and urgent care centers do.”

The authors of the study shared the same viewpoint. Among their recommendations for the healthcare industry to try to close those gaps was to create a “network of disaster centers of excellence,” increase the support for and encourage collaboration with healthcare coalitions, and designate a “federal coordinator for catastrophic health event preparedness.”

They also called for the creation of “a regionalized network of geographically and demographically distributed disaster resource hospitals” that should be enrolled through “a competitive process and guided by stringent capability and accountability standards.” Those designated hospitals should, the authors said, “be part of an active network with the other disaster resource hospitals that includes collaboration over practice, education, and research.”

Steven MacArthur, a senior consultant with The Greeley Company in Danvers, Massachusetts,   also believes that preparation and coordination can be better, particularly with the community and other government agencies. But he praises the response to some of the recent large-scale natural disasters and mass shootings that were not part of the Johns Hopkins report.

“Look at Las Vegas,” MacArthur says. “There were a lot of casualties in Las Vegas, and I haven’t seen anything to the effect that hospitals were not able to appropriately respond to that event. Is it a struggle? Can you get overwhelmed in certain moments? Absolutely. That’s the nature of a catastrophic event. It’s not business as usual. But I didn’t hear about anybody having to close their doors completely or not being able to participate in response activities.”

MacArthur added that he has been working with a hospital in Houston the past two years and thinks that the healthcare facilities there were “better prepared this time than they were last time,” comparing the flooding last summer to 2008, when Hurricane Ike struck the area.

“It’s all about improvement,” he says. “Hospital leadership changes. You have people in different roles that come and go and move onto other places. It’s not a static thing. We’ll never get to the point where we can say, ‘OK, we’re prepared now.’ Because that state doesn’t exist.”

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