EIIP Virtual Forum Presentation — May 26, 2010

The Next Challenge in Health Care Preparedness
Catastrophic Health Events

Eric Toner, M.D.
Senior Associate, Center for Biosecurity
University of Pittsburgh Medical Center (UPMC)

Amy Sebring
EIIP Moderator

The following has been prepared from a transcription of the recording. The complete slide set (Adobe PDF) may be downloaded from http://www.emforum.org/vforum/UPMC/CHEpreparedness.pdf for ease of printing.

[Welcome / Introduction]

Amy Sebring: Good morning/afternoon everyone. Welcome to EMforum.org. I am Amy Sebring and will serve as Moderator today. We are very glad you could join us. For our first timers, we will be providing some instructions as we go along so you can relax and participate with us.

Our topic today is a recent report from the Center for Biosecurity at the University of Pittsburgh Medical Center (UPMC) titled The Next Challenge in Health Care Preparedness: Catastrophic Health Events. The recommendations made in this report is the culmination of a Dept. of Health and Human Services funded, two-year comprehensive assessment of its Hospital Preparedness Program (HPP), from the time of it was established in 2002 through mid-2007. Please note, you can access the report Web page either from our home page or from today’s Background Page.

Now it is my pleasure to introduce today’s special guest:

[Slide 1]

Dr. Eric Toner is a Senior Associate with the Center for Biosecurity at UPMC and Principal Investigator for the HHS Hospital Preparedness Program evaluation. Dr. Toner is an internist and emergency physician whose primary areas of interest include healthcare preparedness for catastrophic events, pandemic influenza response, and medical response to bioterrorism.

He is a Managing Editor of the Clinicians’ Biosecurity Network, an online network that sends clinical biosecurity reports to thousands of clinicians across the country and around the world and he is an Associate Editor of the journal Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science, the leading peer-reviewed journal in this field.

Please see today’s Background Page for further biographical details. Welcome Dr. Toner, and thank you very much for being with us today. I now turn the floor over to you to start us off please.


Eric Toner: Thank you, Amy, and thank you for that kind introduction. Hello and thank you to all the attendees. Thank you for your interest in this topic. As Amy said, these reports that I will describe today are the culmination of over 2 years of work by my colleagues and myself at the Center for Biosecurity, and we hope that you’ll find the results of interest.

[Slide 2]

We were asked a little over 2 years ago to assess HHS’s hospital preparedness program, which started in HRSA and eventually ended up in ASPR. We were asked to review the first 5 years of the program to assess its impact on the state of hospital preparedness and then to make recommendations for future directions of the program.

Our first task in this project was to come up with a working definition of health care preparedness. What are those elements of preparedness that we think are important and that others think are important? Our first task was to come up with this descriptive framework of preparedness.

We did this through a literature review of all U.S. literature and relevant international literature going back to 1980’s as well as many reports as we could find of actual events, and we looked at some scenarios of potential future catastrophic events and tried to estimate what kind of elements of response would be needed for them.

We then used this descriptive framework to assess the progress that occurred between 2002 and 2007 and to try to assess the impact of the HPP on that progress and preparedness. We were also asked to evaluate 2 other smaller programs that HHS had funded—the Healthcare Facilities Partnership Program and the Emergency Care Partnership Program. These were each competitive grant programs that were essentially pilot projects.

Lastly, building on our descriptive framework and informed by the research that we did for the evaluation report—that is, the report that looked back at the first 5 years, what we learned through the evaluation of the 2 pilot programs, we proposed a definition and a strategy for preparedness for the future. We made some recommendations for these approaches to how to assess progress going forward.

[Slide 3]

Our first major public report was the evaluation of were hospitals rising to the challenge in the first 5 years of the Hospital Preparedness Program, and priorities going forward. Its purpose was to assess if the progress had been made in U.S. hospital preparedness and to try and make some assessment of how much of that progress was achieved by or a result of the HPP. We did a comprehensive literature review of all U.S. literature starting from 1995 until 2007. This is literature that related to the state of preparedness in U.S. hospitals.

We then conducted interviews with 133 individuals who were involved in public health and hospital preparedness in 91 locations, including all states, major cities, and major territories. These were typically hour-long conversations. We used the descriptive framework, as I mentioned, as a guide to these conversations.

Once we completed the conversations, we conducted a meeting at our offices in June of 2008 to review the findings and vet some of our conclusions with a panel of experts.

[Slide 4]

This map just shows you graphically who we talked to. Approximately 1/3 of the people we talked to were from state health departments, approximately 1/3 were from hospitals, and the rest were a scattering of other individuals.

[Slide 5]

What did we find? The first thing we found was that there was significant improvement in hospital preparedness over the 6 years from 2002 through 2007. In our report, we specified in what ways we think hospitals improved. We also found that nascent coalitions consisting of health care, hospitals, other health care institutions, local and state agencies, are emerging across the country.

In fact, in each of the 91 locations we talked to, every one of them had some sort of at least nascent coalition evolving. We found these coalitions are essential to effective preparedness and response to those mass casualty events that occur with some frequency—events that are not truly catastrophic, but would overwhelm an individual hospital.

We concluded that these health care coalitions are creating a foundation for local and national health care preparedness, particularly for common kinds of events. We also found that planning and preparing for catastrophic events, that is, events that could injure or sicken many thousands of individuals, including work on crisis standards care, is only in very early stages in almost every place that we talked to.

[Slide 6]

When we talk about health care coalitions, we need to be specific. Health care coalitions are referred to in the medical surge capacity and capabilities handbook that HHS has put out and it’s often referred to as Tier 2. They describe it as a committee or group of health care facilities that come together to advise the local jurisdiction.

As we talked to people around the country, we found that this model existed in a few places, but even more commonly was a model in which public health played the central role. It was the hub that connected the health care institutions to each other. We consider both of these to be health care coalitions.

The essence is the hospitals work together closely linked in whatever way to public health and emergency management and EMS, and we found that both models seem to work equally well.

[Slide 7]

These were the important characteristics of health care coalitions that we came up with. Coalitions should include at least all the hospitals, at the least the acute care hospitals, public health, emergency management, and EMS. These entities should be formally linked in some way, perhaps by an MOU.

They should conduct joint threat assessment. They should to joint planning, purchasing, training, and exercises. The coalition should serve as an information clearinghouse with systems for tracking patient load and resources or assets. They should have a formal role in local and state incident command.

They should coordinate the use of volunteers—all health care volunteers. They should provide a forum for decisions regarding allocations of scarce resources and standards of care, if they are to be altered. They should coordinate the use of alternate care facilities.

[Slide 8]

We found evidence that in fact, some of the early coalitions have been demonstrably effective in proving response to some disasters so far. Here is a list of some of these. I won’t go into them in detail, but we go into them in a bit more detail in the report.

[Slide 9]

We also found evidence that the coalitions which have been developed so far had added value during the recent pandemic. In many places, they activated their coalitions as part of the response.

[Slide 10]

I’ll point out again that each of these events were relatively small scale, excluding the pandemic perhaps, but the other events were relatively small scale and would not qualify as a catastrophic health event. Our next report, which we nicknamed "the preparedness report", is our recommendations for directions for the future.

The purpose is to build on the previous work and propose a definition and strategy for health care preparedness for the future. The key finding, or one of the key findings, of the earlier report, the evaluation report, was that while much progress has been made in preparedness for common disasters in hospitals and in nascent coalitions, the health care system is still ill-prepared for a catastrophic health event, and there is still as yet no clear strategy as to how we would get prepared for a catastrophic event.

The definition of a catastrophic event we used was that which came out of HSPD-21, and it is basically tens of thousands of people who are sick or injured as a result of the event and therefore would require health care resources. It doesn’t refer at all to how many people are killed, and it doesn’t refer directly to the amount of damage that occurs—only to the amount of people who are sick and or injured.

[Slide 11]

This is our latest report. It was accepted by HHS in December and publicly released just last month. It is our proposal, the Center’s proposal, for a national strategy for preparedness for catastrophic events. It includes the description of the capabilities of prepared systems, our analysis of current response strategy and structure, recommendations that build on current successes and existing structures to make all hazards preparedness and response scalable to the size of the event that would qualify as catastrophic health events.

We make provisional recommendations for how to access progress going forward.

[Slide 12]

Our methods for this portion of the project were, again, a literature review, basically updating our literature review for the earlier phases of the project. We went back and looked at all the work my colleagues and I at the Center have done over the last decade—looking at mass critical care, pandemic flu, Katrina, mega-disasters, hospital coalitions, alternate care facilities, disaster standards of care, and NDMS.

We also spent a fair amount of time learning about and thinking about complex systems theory, because as most of you know, health care on a good day is certainly a complex system, and health care during a disaster is probably the most complex and chaotic system you can imagine.

We also considered 3 scenarios of catastrophic health events, each of which was derived from DHS’s National Planning Scenarios. After this work and this analysis, we conducted a second meeting and brought in 20 experts from around the country to review our findings and give us input.

[Slide 13]

What are we aiming for? What is our vision of success? We said the health care system prepared for a catastrophic event is able to provide care to disaster victims, protect the well, and maintain the essential health care resources and services for the general population. It would be able to respond quickly and agilely to mass casualty events of all sizes, including those that cross jurisdictional boundaries.

It would be able to function under a variety of adverse circumstances, such as prolonged surge of patients, patients needing prolonged care, a contaminated or contagious environment, loss of basic infrastructure, and imperfect situational awareness and a disrupted incident of command and management.

It would be able to harness all useful national resources, both public and private, and be able to recover quickly after a disaster, all the time providing essential health care to the population. I doubt many would argue with these points, but it is a tall order to be sure.

[Slide 14]

Getting more specific, what do we mean by a catastrophic health event? This is one of the scenarios we used in preparing this document. It’s from the National Planning Scenario for anthrax. The scenario proposes that 330,000 people are exposed in a covert aerosol release of Bacillus anthracis in a large city. The city is not specified, but for the purposes of our discussion, we considered it to be Washington.

The scenario projects that 13,000 people will become sick with inhalational anthrax and that most of these people, all would require hospitalization, most of these people would require critical care.

[Slide 15]

Reiterating, 13,000 people in need of critical care beds is what we’re trying to get to. In the National Capital region, that is within 20 miles of the Capital, there are approximately 40 hospitals. If we assume that they are each able to achieve a 30% surge capacity within a 24 hour period, that gets us approximately 3,000 hospital beds, but only 400 of which would be critical care beds.

To get 13,000 critical care beds, we need all the surge capacity of all the hospitals from Philadelphia to Norfolk.

[Slide 16]

In addition, there would be a massive screening problem. In addition to those thousands of people who would be obviously sick with inhalational anthrax, and in addition to the million or more people who may need prophylaxes because of potential exposure but who are not having any symptoms, there may be many thousands of people in addition who have mild, non-specific symptoms.

Some of these people will have early inhalational anthrax. Many, perhaps most of them, will not. They will have other diseases or perhaps, just anxiety. But it is essential, if we are to prevent hospitals from being crushed by this demand, that we screen out those people who are unlikely to be sick with inhalational anthrax.

Our problem is that we have no rapid diagnostic test for inhalational anthrax. In fact, we have no rapid diagnostic tests for any of the bioterrorism agents. We have no system for doing mass screening on this scale.

One of our first recommendations is that we need, as a country, much more research and development into rapid diagnostics. We need research and development of clinical triage protocols for use when health care systems are overwhelmed.

[Slide 17]

This brings us to further into the response to a catastrophic health event. Basically, we are only able to identify 3 types of response. The first is to bring stuff in, that is, deployable teams and deployable materiel to concentrate these resources in or around the affected area. The problem is, of course—how many resources are there available, and how quickly can they be deployed?

The next option is to move the patients out. The question here is—by what means, how far, how to track the patients, and what to do with their families, not to mention their pets?

The third option is to limit the medical care provided, what is now being called crisis standards of care. Here the problems are—how do you trigger it, how do you coordinate it, and how do you implement it fairly?

In fact, we think that all 3 options are needed in a multi-tiered or multilayered response.

[Slide 18]

Looking at these in a little more detail, in terms of bringing stuff in, the basic problem is we have limited resources. In terms of personnel, there are roughly 50 Disaster Medical Assistance Teams in the National Disaster Medical System, and there are roughly 6,000 Public Health Commissioned Corps personnel as well as some people in the Defense Department and the VA.

There are many people who have signed up for state Medical Reserve Corps, and other medical volunteer organizations. The federal government has federal medical stations, deployable "pop-up" hospitals, and some states have mobile hospitals, as well. But all of these take from days to weeks to deploy, and they are all hampered by the fact that they have limited capacity, particularly when it comes to critical care patients.

All of these are useful—all of these have demonstrated their utility in multiple, relatively small scale events, but collectively, they are insufficient for a catastrophic health event, as we defined it.

[Slide 19]

The second option is to move patients out. Here we are limited by the amount of medical transport that is available. I should point out that while it is absolutely true that medical surge capacity is limited in almost every hospital, and limited in almost every city, the health care capacity of this country is actually huge. The surge capacity available in this country is actually quite large as well—at this moment, somewhere between 100,000 and 150,000 staffed hospital beds are sitting empty. We have a big country.

The problem is getting the patients to where the beds are. The current plans involving use of a National Ambulance Contract that FEMA has, could provide hundreds of ambulances, and NDMS plans to use military aircraft provided by the USTRANSCOM. The problem with both of these is that they have limited capacity, again, particularly as it relates to critical care patients. With critical care patients, the numbers are surprisingly small.

In both the ambulance contract and the air transport, they take at least days to weeks to fully deploy. Again, these are useful, but they are insufficient for an event of a scale that we are discussing.

The U.S. as a nation has a massive transportation system in the private sector. One hundred million people or more commute every day to work or school, but they don’t do it in ambulances. What happens in large scale disasters, and we’ve seen many large scale disasters across the world in recent years, is that people get moved by private vehicles. They may be cars, they may be busses, they may be pickup trucks, they may be dump trucks—that’s actually what happens in large scale disasters.

We have not included the use of non-traditional, non-medical vehicles in our planning. Certainly they would require a different standard of care, both for the vehicle and for the personnel taking care of the patient. But in fact, this is probably what would happen in a catastrophic event.

[Slide 20]

The third option, of course, is to limit the medical care provided—changing the standards of care, what is now being called "crisis standards of care" by the Institute of Medicine. It means doing what is best for both the population and the individual patient.

We have traditionally thought about this as it relates to our care for the population, that is, if we spend too much time and resources on one individual, we will not be able to provide care for a larger number of other individuals. In other words, do the largest good for the greatest number. Interestingly, we’ve seen in the response to Haiti, the same principle of a different standard of care may be important for the individual himself.

In Haiti, we saw many examples of people who were given what would be considered normal first-rate care that was inappropriate in the context of the Haitian disaster, specifically people who had very complicated limb salvage surgeries without any intensive care unit to care for them afterwards, and without any availability of follow on reconstructive surgery.

Some of these patients died, who probably would have survived if they had simple battlefield amputations. Standard care doesn’t necessarily mean not providing care to somebody so you can provide care to others. It may mean also doing what is right under the circumstances for the individual involved.

Different standards of care are needed, not just for treatment, but also for triage and transportation as we discussed before. All of this needs to be coordinated, and it needs to be applied fairly and uniformly across a community.

[Slide 21]

All 3 of these options that I’ve discussed require multi-tiered coordination. Hospitals and other healthcare entities who are, as you all know, are mostly privately owned and fiercely competitive, must share and coordinate information, supplies, equipment, personnel, and a relatively fair distribution of patients.

This requires joint planning, exercises, and a mechanism for coordinated healthcare response that is closely integrated with public health, EMS, and emergency management. Again, this is the notion of the healthcare coalition that we talked about. As I said, these are evolving across the country, being driven by the requirements of HPP guidance, and also by the emergency management standards of the Joint Commission.

In very large events, like a catastrophic health event, this coordination must extend beyond the boundaries of local jurisdiction both vertically and horizontally. In other words, the coordination isn’t just up through the 6 tiers described in federal documents, but there also needs to be coordination with neighboring jurisdictions and neighboring coalitions.

[Slide 22]

What are some of the major challenges to response to catastrophic health event? First of all, many hospitals, and many more kinds of healthcare organizations don’t get to participate in fully functional coalitions. Most existing coalitions don’t yet have the ability to share information, resources, and decision-making directly with other coalitions.

There are inadequate systems to perform triage, immediate treatment, and transport of patients outside of the area stricken by the catastrophic event. Existing plans and resources for moving patients are inadequate for this scale of event that we are talking about.

There is not enough guidance. We heard this over and over again. There is not enough guidance on crisis standards of care that will be necessary through all phases of a catastrophic event. There is no plan that sufficiently outlines the roles and responsibilities, and most importantly, the actions that would be needed by multiple different actors during a catastrophic event, so that everybody knows what is expected of them and what they can expect from others.

[Slide 23]

We’ve made recommendations—general recommendations and specific recommendations to the federal agencies which are listed in our report. Some of the general recommendations:

  • Every U. S. hospital should participate in a healthcare coalition that both prepares for and responds to both common medical disasters, that is, bus crashes, tornados, and the like, and to catastrophic events.

  • Links should be established between neighboring healthcare coalitions, neighboring jurisdictions, to enable a regional exchange of information and assets during a catastrophic event without having to go all the way up and back down through the normal chain of command.

  • Out-of-hospital triage sites need to be established and they should be identified in advance.

  • Healthcare responders should be trained specifically in triage in a context in which the healthcare system is overwhelmed.

  • A patient transportation system that harnesses the private sector non-traditional kind of vehicles should be considered and created.

  • Development of crisis standards of care should be expanded and implementation across the state should continue to be promoted.

  • Finally, a national framework for healthcare response to catastrophic events should be developed to guide the states, jurisdictions, and local entities in developing their own plans for medical and public health response.

[Slide 24]

In conclusion, I’d like to thank my colleagues at the Center for Biosecurity who worked hard on this project over the last couple of years, and our colleagues at ASPR who have been a great assistance to us.

[Slide 25]

I think now we have plenty of time for questions, so I’ll turn it back to Amy.

Amy Sebring: Thanks very much Dr. Toner. Now, to proceed to our Q&A. I am sure Dr. Toner would also appreciate your feedback on the report recommendations.

[Audience Questions & Answers]

Ric Skinner, GISP: "Geography" is mentioned a number of times in your report, yet no mention there or in your presentation of the importance of GIS in contributing to Situation Awareness and a Common Operating Picture. What do you think are the obstacles in getting hospitals and healthcare organizations to embrace GIS for planning for, preparing for and responding to catastrophic health events?

Eric Toner: Thank you for that question. We think that GIS is an essential feature of computer based systems that would be needed to gain or to facilitate or enhance situational awareness at the coalition or jurisdictional level. There are many pieces of information that are needed to coordinate an effective healthcare response, including information about number of beds available, number of staff available, and other resources. But geographical information is an essential piece as well. I didn’t mean to exclude it, but I left many things out as we tried to be fairly high-level in our discussion. I absolutely believe the GIS is an important feature.

Jim Manley: Your presentation focused on hospital surge. What is the role of public surge [evacuation], particularly given an event in which transportation resources out of the affected region may not be available? What is your understanding as to the level of preparedness in this area?

Eric Toner: My interpretation of the question is that people can’t get out of the area by any means because roads are blocked, or whatever, and medical facilities locally are overwhelmed, what can the public do? How can we engage the public in caring for each other? Hopefully, that is what the questioner intended.

I think also that is a very important aspect. Colleagues of mine at the Center worked full time on this issue of community resilience. It was not specifically a part of this project. We were given specific instructions by HHS to address specific aspects of preparedness and response, and that was not one of them. It was not part of our report, but it is very important. A lot of people are doing a lot of work on it.

Maria Bull: Dr. Toner did you find different types of coalitions in your research? Are there some more successful than others?

Eric Toner: The answer to both parts of the questions is yes. We saw 91 examples of coalitions, and each of them was different. Some are very advanced and very successful, and some are very early in their evolution. So there is a complete spectrum.

What we tried to do in the report is put the coalitions into different buckets—to categorize them, to see if we could make some judgment about whether there is one approach that works better than any other approach. It was very difficult to do.

What we found is you can have very effective coalitions with very different assumptions, and these come from the history, local politics, whether there was a pre-existing organization in the community that was particularly effective, whether the health department was particularly strong or particularly weak, whether there was a particularly dominant hospital or not, how much the hospitals hated each other, how much the hospitals were hated by the health department, and vice versa.

We had nearly 100 different stories. We found that in all these different contexts, many people were able to put together very impressive coalitions, but how you do it is very dependent on particular location, and we advise that as for not trying to dictate what a coalition looks like, but rather specify the functions that it should be able to accomplish. How they accomplish that function needs to be left to the locals.

Stephen Pixley: My institution is currently trying to develop a functional healthcare coalition. I am specifically interested in how to involve primary care providers and community health centers, especially the primary care "safety net" services who provide care to the majority of populations known as vulnerable. This is a rich resource of personnel. In a long term experience such as pandemic flu, using these resources might prevent overwhelming emergency departments. We also know from Katrina evacuees that many of their needs are for routine primary care, for chronic diseases, for example. We might also be able to use these personnel to staff MRCs or alternate care centers. The dilemma is how to get primary care personnel involved in the planning process. The HPP grants for the next 3 years include formation of healthcare coalitions as a primary focus. However, unlike hospitals who are motivated by accreditation and grants, the non-hospital providers are not so motivated. Most are in autonomous practice settings, most are not accredited, and most consider themselves too busy to participate in anything that isn’t absolutely necessary. We do know from Florida nursing homes, that pre-existing relationships with community emergency services helps not only during evacuation, but after evacuation during hurricanes (e.g. getting generators, transportation, etc), but this is a "hard sell" to primary care providers that are already pushed to maximize efficiency. Do you have any thoughts on how we can involve them in the planning process?

Eric Toner: He’s not alone. I think this is a problem that many have faced. We have heard this over and over again. For the most part, most locations have had pretty good success in getting most of the acute care hospitals involved in the coalitions, but everybody has been struggling to get other kinds of healthcare facilities that don’t traditionally see themselves as part of emergency preparedness or emergency response involved, including not just clinics and physicians offices, but emergency care centers, surgery centers, etc.

We did see one example that seemed to work particularly well. I won’t identify the city. They were able to get their dialysis centers very involved because they were able to demonstrate to the dialysis centers how vulnerable they would be in a disaster. They are very dependent on infrastructure. They are very dependent on—if their machines go down, their patients are in trouble really quick.

They went out to dialysis centers and demonstrated that this was a two-way street. If they could provide some aid in surge capacity, which a dialysis center could conceivably do, the dialysis centers would also be linked into the coalition and jurisdictional response in terms of helping to support them in the event of a disaster.

This worked well for them. I’m not sure it works well for everybody in all circumstances. It is one of the issues that we made recommendations on in our report, specifically that we recommended that the government look at using CMS as a way of incentivizing all healthcare providers joining in emergency preparedness and response activities.

So far, it is my understanding that there is some interest in thinking about that.

James Jordan: It is not always easy to bring about a shared understanding of the importance of hospitals, service providers, and local governments sharing information and coordinating services in an emergency situation. What strategies do you have for getting beyond this barrier?

Eric Toner: You’re right. It’s often not easy for lots of reasons. There are barriers that have been formed over time between hospitals and between various agencies. Let me answer it in 2 parts.

One of the things we’ve recommended is that there be better coordination and harmonization of the 3 main pillars of preparedness and grants to communities. Those are specifically the hospital preparedness money, which goes through health departments to hospitals. The CDC preparedness funds go to public health departments. The DHS preparedness grant goes to emergency management agencies.

We think that if these were better coordinated and more focused on common goals, we would see a lot more coordination. That is one recommendation.

On a more practical and more immediate level, I think there is no substitute for going out personally meeting and talking with over and over again the people who need to be your partners. I have done this in my previous life and it’s not easy. You may have to have many, many meetings before you start to break down the barriers, but that’s the only way you’re going to get it done.

James Jordan: In getting past the barrier of coalition building I agree that the personal contact is most successful. It is time consuming, but important. Also, I think the question regarding who has the primary role as coordinator is important. Finally, region wide exercises held at least once a year will be helpful not only in preparing for a possible emergency, but also in getting the different entities in the same room working together. This exercise could be followed up with mini workshops and meetings. Again, the educational benefits of working together may become apparent over time.

Bruce K. Bickel: In a CHE, what efforts are being made to address the psycho-social response?

Eric Toner: That was not part of our charge. It is incredibly important, and others are working in this area. Our organization just had a meeting in Washington on response and effects of a improvised nuclear device, and we spent half the day talking about psycho-social issues. They would be a huge part of the consequences of any catastrophic event and would greatly affect the challenge of screening patients and the burden on triage sites and emergency departments.

It is critically important they be addressed as part of figuring out how you do mass triage and hospital interventions.

Darrell Ruby: Did you identify any statutory challenges in your coalition assessment across the nation, i.e. multi-county coalitions limited by their existing statutes within the state vs. a coalition simply confined within a county jurisdiction?

Eric Toner: Regulatory issues—we didn’t come across any that were major barriers. We came across some issues when people were initially reluctant to share information, but virtually every place we talked to, they were able to find a way to get around that, at least to some extent. In some cases, in many cases, hospitals are not willing to share all information with their competitors, only limited amounts.

Some places would only share with public health or emergency management, and won’t let their competitors see any of their information. I think there are work-arounds for those sorts of problems. I don’t recall any regulatory problems that came up that prevented or were big barriers to coalition building.

Lori Wieber: Could you speak to anything learned regarding coalitions that span international borders?

Eric Toner: We did not. We were interested in those that might cross international borders. We did not talk to anyone in those locations. Nor did we address that. It was not part of our charge. We did talk, however, to a number of locations—many, many of the locations crossed jurisdictional borders, and many crossed state borders. This was a huge problem for many.

Fortunately, it seems to be getting better in a lot of locations. A city may consist of several different overlapping jurisdictions. Some metropolitan areas involve several states. New York City, for example—D.C. is another example—Kansas City is the perfect example, where the state boundary runs right down the middle of a metropolitan area.

Initially, one side could not work effectively with the other side because of the stovepipes that initially were created through the funding streams, and the requirements that went along with them. We did find that in most of these locations, people were finding work-arounds. They were finding ways, often very creative ways, to be able to work very closely with people who were part of their natural coalition, that is, within the same metropolitan area, but were within a separate jurisdiction.

There is no easy fix for the jurisdiction problem because public health jurisdictions don’t overlap with emergency management jurisdictions, nor with police jurisdictions, nor with EMS jurisdictions, nor with Congressional jurisdictions, nor with state boundaries. It is such a hodgepodge. People around the country have found their own solutions to this problem.

Don Strubeck: Since 9/11 thru HRSA & HPP we've spent millions, maybe billions of dollars, mostly for stuff - a good portion of which is outdating. The AHA back in 2001 estimated that 4-8 M$ / hospital must be invested and annual $500 thousand to $1 million to maintain the competence & resilience. What do you think is the real cost of hospital preparedness? Can it be estimated? Can we really afford it? Is there national priority to achieve?

Eric Toner: The figure is we’ve spent about 3 billion dollars so far. We’re approximately spending at this point about 350 million dollars per year on the Hospital Preparedness Program. We spend much more than that on the Public Health Preparedness Program through the CDC, and much more than that on DHS grant programs.

Is it the right amount to spend? I don’t know. Have we achieved progress in healthcare preparedness? Absolutely. Was it a good buy? Was it the right amount of money to spend for what we have achieved? I don’t know how to assess that.

I would say, going forward, the questioner is absolutely correct. Particularly in the early years of the HPP program, we bought lots of stuff. Much of that stuff is now going out of date. Some of it will need to be replaced. Some of it probably should not be replaced. It was a mistake to buy it in the first place. Some of it will need to be replaced.

So if we want to maintain the gains we’ve made so far, we will need to have ongoing funding to support, to maintain hospital and healthcare preparedness. We will need additional funding if we are to do the things we’ve outlined in terms of preparing the country to become more resilient to catastrophic events.

We believe we’ve identified—we’ve made recommendations that are relatively cost efficient, relatively inexpensive for what they achieve, but we can’t fool ourselves that they won’t cost significant additional monies. In terms of is this is something the country can afford, I would point out, at least in our view, that preparedness for a catastrophic event is an essential part of national security.

If we are to protect our country from the harms of natural or intentional catastrophic events, we can either do it by prevention, or we can do it by lessening the impact of those events. That is what we are trying to work on—lessening the impact. I think it is as important as prevention.

If you take the 350 million dollars a year we spend on the Hospital Preparedness Program, and compare that to any budget item you can imagine in the Defense Department, I think you’d agree that this is actually a tiny drop in the ocean. I have little trouble with the amount we are spending on hospital and healthcare preparedness, except that I think it is too little.

Amy Sebring: Now that you’ve submitted that report to HHS, what happens next? What do you see for the future?

Eric Toner: Certainly, some of what we recommended, particularly in our first report, we see reflected in the new HPP Guidance. We are encouraged about that.

In terms of what HHS does with the second report with regards to catastrophic events, I think the intent now is to try to incorporate some of these ideas into the National Health Security Strategy, which was announced last December and is beginning to go into its implementation phase. We’ll see how much of our recommendations get incorporated into that.

We are working with ASPR on that. We are in a resource-constrained environment now, and will be for the next few years in terms of the budget, so it will be a challenge getting a lot of this done in the next few years. What we’ve tried to do is lay out a long-term strategy.


Amy Sebring: Time to wrap for today. Thank you very much Dr. Toner. I think the report is very honest and very useful. We wish you continued success in your efforts.

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