Are We Ready?
A large-scale disaster like a pandemic flu or terrorist attack could overwhelm the nation's healthcare providers
Brian O'Neill is paid to worry. As vice president of emergency services for the North Shore-Long Island Jewish Health System, he is charged with making sure his organization's 15 hospitals are prepared for a nightmarish list of naturally occurring and man-made threats. What would happen if there were a repeat of the Long Island Express, the 1938 hurricane with 121-mph winds that destroyed 4,500 homes and killed 700 people? What if healthcare workers battling infectious disease in protective gear got overheated and exhausted? What if staffers were stranded in their homes by the weather? If any of these situations became a reality, the system's emergency preparedness center, located in an inconspicuous, low-slung building in the Long Island town of Syosset, would spring to life. Emergency workers would don the reflective vests now draped over chairs, consult binders filled with contingency plans, and examine chain-of-command charts. "We plan for everything," O'Neill says, "and hope for the best."
Some hospitals in big cities and high-risk areas are well prepared to cope with individual disasters like, say, a plane crash. But overall, the nation's healthcare system is not yet ready to handle a large-scale emergency like pandemic flu or another major hurricane. That was the consensus of experts assembled at last week's U.S.News & World Report Health Summit on emergency preparedness. "The problem is, we are just good enough for what happens now," said panelist W. Frank Peacock, chairman of emergency preparedness for the Cleveland Clinic. "We have trouble now managing flu in February across the country." Added summit panelist Arthur Kellerman, chairman of emergency medicine at Emory University Hospital in Atlanta: "Our trauma and emergency care system in this country is absolutely stretched like a piano wire."
Contingency plans. In fact, the Trust for America's Health, a nonprofit group focused on public health and disease prevention, recently gave the federal government a D+ for emergency preparedness. Almost 60 percent of states failed to meet more than half of the group's requirements, which include things like having the lab capacity to quickly test thousands of samples for anthrax or smallpox. Meanwhile, hospitals nationwide say U.S. funding woes and lack of guidance make it hard to enact contingency plans. Over the past few years, Johns Hopkins Medicine has spent $10 million on emergency preparedness, said summit panelist CEO Edward Miller. "And it comes out of other programs we are not funding," says Miller. "This is not a sustainable business plan."
The best preparedness approach, most experts say, is to plan for "all hazards," concentrating on the common elements shared by most disasters, rather than planning separately for an individual event. It doesn't matter whether it's a hurricane, terrorist attack, or pandemic. "You have a certain number of trauma patients, a certain number of infections, a certain number of respirator requirements," says James James, director of disaster preparedness for the American Medical Association. And all catastrophes require sufficient surge capacity--enough staff, supplies, and space to treat patients--and a coordinated response by healthcare providers in monitoring potential outbreaks and managing the influx of injured.
Surge capacity is the biggest concern. Hospitals can handle some overflow within their walls. Rooms can be reconfigured, elective surgeries canceled, and extra staff called in. But most hospitals simply can't absorb the huge influx of patients that might result from a pandemic or biological attack. So hospitals must plan to use other facilities, such as healthcare clinics or dialysis centers, or malls, stadiums, and schools. Thanks to preplanning by the Louisiana Department of Health and Hospitals, the Pete Maravich arena at Louisiana State University in Baton Rouge, for example, was quickly turned into a field hospital during Hurricane Katrina. The Trust for America's Health says hospitals in almost a third of states haven't sufficiently prepared to handle a surge.
Arranging for temporary space is just the beginning, as field hospitals must be manned. A study released last week found that nearly half of local public-health department staffers would not report to work if there were a pandemic. "When people are worried about their families, they'll put family before work," says Richard Bradley, an emergency medicine physician at the University of Texas Health Science Center in Houston, who noted that a number of his staffers were no-shows two days before Hurricane Rita's projected landfall last year. That's why Kaiser Permanente's Walnut Creek Medical Center, for example, is urging its staffers to make personal preparedness plans--like arranging meeting areas--for their own families, in the hopes they'll breathe easier and report to work if they know their kids are safe. Other hospitals are considering whether to provide child care or offer incentives, like vaccinations that may be in short supply, for employees and their families. And it's not just physicians and nurses who need attention; a hospital can't run without kitchen staff, janitors, and other support workers.
Volunteers. Hospitals also need to ramp up employee preparedness training. "The average physician is very familiar with his or her role as a clinician, but not in terms of his or her role in a public-health response," says James of the AMA, which has developed a standardized curriculum for disaster preparedness training. An example: how to decontaminate a patient exposed to a biological agent.
Conscripting other hands should also be part of any disaster plan. Some experts recommend more active recruitment of volunteer medical personnel for the federal disaster response system (box, Page 62). States and localities need to develop their own volunteer registries, too. Veterinarians, dentists, and out-of-state physicians could be on standby, as well as patients who have recovered from the flu and could perform basic tasks like organizing supplies. One obstacle that emerged during Katrina: finding a way to quickly credential out-of-state medical professionals.
In addition to staff and space, surge capacity includes having enough supplies--from protective masks to medications to disinfectants--to handle a disaster. The Centers for Disease Control and Prevention's Strategic National Stockpile plans to deliver to communities "push packages" of essential drugs and supplies within 12 hours in case local supplies run low, but hospitals and communities still need to be prepared to sustain themselves. That's expensive. It also takes precious space: Kaiser's Walnut Creek facility is exploring whether it can position containers outside; in an area already short on parking, it's hard to find the room. Supplies become more crucial the longer the disaster persists. If a hurricane wipes out access for days--as Katrina did--hospitals need to worry about food, water, and generator capacity.
Some threats are scary because of their sheer scope, straining resources for an extended period. A severe flu pandemic would demand thousands of beds, not to mention the 740,000-plus ventilators estimated by the Bush administration's preliminary flu strategy. (Currently, there are only about 105,000.) In a just-in-time global economy, goods aren't stacked in warehouses but arrive only when needed. With a pandemic, that delivery system would grind to a halt if enough people were sick and unable to manufacture or transport goods, says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Hospitals could run out of oxygen, spare parts, medical devices, masks, food, and medications--pretty much everything that can't be produced locally.
Even the thought of an outbreak could tax the system. "Much likelier than a bird flu epidemic is a concern about a bird flu epidemic," says Kent Sepkowitz, director of infection control and an infectious disease specialist at Memorial Sloan-Kettering Cancer Center in New York. In 2001, 15 anthrax cases prompted thousands of people, worried that they had been contaminated, to flood emergency rooms in the New York City area. A more likely scenario for a bird flu outbreak, says Sepkowitz: "a case or two of avian flu in humans and a crush of snifflers and people who have flulike symptoms."
Hospitals are trying to identify infections early on, when they can be more readily contained. Some promising technologies include syndromic surveillance, which would allow healthcare providers to identify patterns that could signal bioterrorism or an outbreak--such as an unusually high number of patients reporting flulike symptoms. In Texas, nine hospitals in the Memorial Hermann Hospital system now pool symptom data from their nearly 340,000 emergency room visits annually, says Bradley. The technology has potential, says Richard Platt, chair of ambulatory care and prevention at Harvard Medical School, who is testing such a system. It's expensive, though, and needs further study to determine how--or whether--it will actually help.
As with the Texas hospitals, institutions need to coordinate both before and during disasters--something they haven't always done. "There are 67 acute-care hospitals in New York City; each one, though it may have a network, operates independently," says Isaac Weisfuse, deputy commissioner of disease control in the New York City Department of Health and Mental Hygiene. His department is working to improve ties between those entities with, say, more frequent forums. The New York State Department of Health, meanwhile, set up a program after 9/11 that allows hospitals to share capacity information to see where beds are available in case of an emergency.
Rebuild it. The city of Seattle, experts say, is on the right track. A coalition of 200 people, including CEOs of medical centers, physicians from private group practices, pharmacists, and nurses, is rethinking emergency care there. "We wanted it to be like Apollo 13: Dump all the pieces on the table and rebuild it," says Dorothy Teeter, interim director and health officer in Seattle and King County's health department. The team's task: deciding who would do what if a disaster occurred--not hospital by hospital, but on a regional basis.
Despite such efforts, many hospital executives say the lack of accountability standards from the feds remains a big problem. "What is missing in action is a definition for what we mean by 'prepared' for hospitals or communities," says Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University's Mailman School of Public Health.
In the end, it comes down to money. "To ask any industry to double its productive capacity with no funding is really a hard row," said the Cleveland Clinic's Peacock. Just adding decontamination showers at his hospital, Peacock noted, cost an estimated $1 million. Dan Hanfling, an emergency room physician with Inova Health System in Northern Virginia, told Congress last month that the $2.1 billion appropriated over the past five years to give hospitals a basic level of preparedness isn't nearly enough. The American Hospital Association estimates that stockpiles of pharmaceutical supplies and medical equipment, plus personal protective equipment, decontamination facilities, computer systems, and training, would cost about $11 billion.
Public-health facilities need help, too: Labs in more than a quarter of the states don't have the equipment or staff to respond to a bioterrorist attack. After 9/11, more federal funds were directed to shore up the system. But it had been neglected for so long that much of that money went toward basic upgrades, and local funding was often cut in light of the federal increases, says Nicole Lurie, codirector for public health at Rand's Center for Domestic and International Health Security.
It's not just healthcare providers who must gear up for disaster. "It's critically important that individuals in the private sector take responsible steps to prepare themselves," Department of Homeland Security Secretary Michael Chertoff told summit participants. A personal preparedness plan, plenty of canned food, and avoiding shaking hands during an epidemic can go only so far, though. "You need to be asking state and local governments what they will do," says Minnesota's Osterholm. "Demand answers beyond 'We've got it covered.'"
On Long Island, Brian O'Neill believes his hospital system can handle all but a major pandemic. But as proud as he is to show off his stockpiles of antidotes, masks, and portable ventilators, he'd be just as happy never to have to use them.
This story appears in the May 1, 2006 print edition of U.S. News & World Report.