Disaster preparedness and response represents a formidable challenge to the nation’s emergency medical response community. Effective disaster planning requires partnership between and among multiple levels of government, traditional first responders, hospital and public health officials, and a variety of public and private organizations. Each of these entities requires coordination in several key areas – including, but not limited to, policies, procedures, technologies, and training – in order to effectively perform.
Specific funding streams may be available to ensure that policies and procedures for personnel, communications, logistics, supplies, facilities, and equipment are developed. Further funding usually is available to ensure that first responders and hospital staffs are properly trained and that the procedures agreed upon by all parties involved are exercised. However, obtaining the funding needed for high-acuity, low-frequency events remains a primary challenge in emergency medicine. Such events are, by nature, uncommon, and are always vulnerable to budget reallocation for daily or current emergencies. On the other hand, federal grants provide significant funding to state and local government agencies and private-sector EMS (emergency medical services) organizations.
Congressionally Mandated Tithing
In an effort to integrate preparedness assistance, the Department of Homeland Security (DHS) has continued its efforts to create a common planning framework in which agencies at all levels of government and across multiple disciplines can operate. The department’s National Preparedness Goal establishes objectives for multi-jurisdictional cooperation of public and private-sector organizations to work together to provide a layered range of products and services.
Congress has helped both by mandating that states and urban areas provide a minimum of ten percent of their total preparedness grant funding to EMS providers and by requiring states to report to Congress on the distribution of funding to the EMS community. In fiscal year 2005, DHS and HHS (the Department of Health and Human Services) made $3.9 billion in grant and cooperative-agreement funds available to state and local jurisdictions to assist them in building and sustaining their preparedness and response capabilities. Therefore, at least ten percent of that total should be earmarked for emergency medical services and will have to be allocated out of those funds.
FY 2005 DHS/HHS Preparedness Programs
Program Title Sponsoring Agency FY2005 Funding Homeland Security Grant Program Office of Domestic Preparedness, DHS $2.5 billion Public Health Emergency Preparedness Cooperative Agreement Centers for Disease Control and Prevention, HHS $862 million National Bioterrorism Hospital Preparedness Program Health Resources and Services Administration, HHS $491 million Bioterrorism Training and Curriculum Development Program Health Resources and Services Administration, HHS $25 million
Although first-responder communities – EMS units, fire departments, and law-enforcement agencies – are supposed to be provided for in these grant programs, many first responders still have not received funding (in at least some cases, probably, because they are not aware of the process established for executing programs that qualify for funding). New program guidance for grant application completion is available from DHS, however – but close attention should be paid to ensure that the DHS target capabilities areas are addressed. However, practical experience demonstrates that it is critical for all stakeholders to work closely with their state and local government grant organizations. This is because the applications must not only meet the grant requirements established, but also demonstrate that a multi-jurisdictional team of participants is involved.
An Entry Point and Safety Net
To ensure that emergency medicine preparedness and response programs are funded, consideration also should be made to reaching out to the stakeholders in the emergency management supply chain and, when that has been done, to approach funding agencies with specific projects that are under consideration. Emergency management first responders, hospital services, pharmaceutical providers, public health officials, and health advocates all interact with the emergency medicine community on a regular basis.
Another factor to consider is that emergency medicine is defined by its availability for any type of problem. In many situations, EMS facilities and organizations represent the entry point for many crucial health services professionals – e.g., trauma surgeons, infectious disease specialists, and mental health workers. In addition, the emergency department serves by default as the safety net of the nation’s overall medical system, making it “the place to go” when the public is not sure.
Moreover, besides sometimes responding to mass casualty disasters, emergency medical staffs perform the disease analyses required to diagnose illnesses that might result from a CBRNE (chemical, biological, radiological, nuclear, explosive) incident or event. It is difficult, in fact, to envision any type of incident in which the emergency department would not play a central role.
Preparedness Policies and Procedures
Although disaster preparedness is inherent in the mission of emergency medicine, hospital facilities that receive government reimbursement are required – by the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) and the Centers for Medicare and Medicaid Services (CMS) – to have developed and tested disaster plans. In addition, a number of other organizations, both state and federal, have issued specific mandates covering such related items as personal protection equipment training and/or the handling of radioactive material.
Despite the collective reach of these various mandates, there still are relatively few standardized policies and training curricula that might serve as models for the EMS community in general. Perhaps the most fundamental guidelines for hospital preparedness are those spelled out in the Hospital Emergency Incident Command System (HEICS), developed in 1997 by the California Emergency Medical Services Authority.
Basically, HEICS applies the well-known Incident Command System (ICS) concepts to hospital disaster operations and, for many hospital officials, serves as their first exposure to any formal disaster management system. Efforts are now underway in many states to integrate HEICS with the NIMS (National Incident Management System) framework.
Most policy goals are dictated as specific benchmarks in grants allocated by the HHS’s Health Resources and Services Administration (HRSA). Organizations, typically grouped by geographical regions, apply the HRSA funding they receive to meet specific goals, such as increasing surge capacity and/or implementing specific mandates spelled out in the Modular Emergency Medical System (MEMS) guidelines. Additional policy guidance comes from position statements provided by national medical organizations such as the American College of Emergency Physicians (ACEP) and the National Association of EMS Physicians (NAEMSP).
Nonetheless, although significant guidance and policy goals may have been received from both federal agencies and recognized national organizations, the execution of programs that meet these benchmarks is still the responsibility of each local or regional organization. The local development of emergency medical policies and procedures for health care organizations is critical, therefore, to ensure that organizations are prepared for and in position to respond to likely events based upon state or region probabilities (e.g., Florida or Gulf Coast hurricanes), while also maintaining preparedness for the unlikely terrorist event.
FY 2006 DHS/HHS Preparedness Programs Program Title Month Issued Application Deadline Emergency Management Performance Grants November 2005 December 14, 2005 Homeland Security Grant Program (19 Grant Programs) December 2005 March 2, 2006 Homeland SecurityPreparedness Technical Assistance Program January 2006 April 9, 2006
An Abundance of Training Guidelines
Although only a minimum of disaster training is mandated for emergency medicine providers, most emergency medicine residency does require at least some training in disaster management. Fellowship training in EMS and/or disaster management also is available, as is training in various other related subjects – e.g., trauma surgery, toxicology, and infectious diseases.
In addition, HEICS and NIMS (National Incident Management System) training has become increasingly common for hospital staffs involved in disaster management. Nonetheless, most U.S. emergency departments and hospital staffs still have little formal training in disaster preparedness and management. This is particularly important given the fact that most U.S. homeland disasters are what are called Level I incidents, which are managed primarily by local personnel.
A broad spectrum of standardized courses has been developed to train providers to cope with disaster situations. The American Medical Association, for example, developed a National Disaster Life Support (NDLS) program. The curricula for Basic Disaster Life Support (BDLS), Advanced Disaster Life Support (ADLS), and Pediatric Disaster Life Support (PDLS) were developed by other organizations.
Healthcare workers also can participate in federally developed preparedness training programs. Both the Federal Emergency Management Agency (FEMA) and the United States Fire Administration (USFA) offer online certifications in a number of important fields. In addition, several state centers for domestic preparedness provide specialized hands-on training for a variety of disaster situations. Building on existing programs is recommended, though, so that future funding does not duplicate efforts already underway.
An initiative specific to the emergency department, the so-called ER-One project, has been established to develop an “all-risks ready” emergency department that could serve as a national model for urban emergency department preparedness. When completed and externally validated, ER-One will represent a formal “best practices” application for emergency department disaster preparedness.
Technological and Equipment Improvements
Advances in technology have been crucial in improving and upgrading provider training, disaster preplanning, and incident management. A number of internet-based resources and training programs have been developed to deal with biological terrorism and other threats. Among those resources are some innovative slide presentations, interactive scenarios, video clips, and examinations. Real-time video conferencing allows remote training to be carried out from specialized training centers, and permits increased collaborations as well. High-fidelity simulators often are employed to improve teamwork training. Novel technologies such as virtual-reality systems are used by military as well as civilian training centers to maximize the realism of disaster events.
Computer modeling also is becoming increasingly important in disaster planning. Sophisticated models can be used to predict just about every phase of a disaster from toxin dispersion to the arrival of patients at a hospital or other medical facility. Computers also can be used to quickly calculate surge capacities and to serve as MEMS staffing models. In addition, handheld computers, bar code systems, and advanced radios and instant messaging systems already have led to major improvements in communications, patient tracking, and resource utilization.
Computer models for patient triage – e.g., the Sacco Triage Method – and for patient distribution also are being developed. From the decision makers’ point of view, the use of GOTS (government off the shelf) training tools is a cost-effective approach that should be recommended to state, local, and private-sector first responders.
The Challenges Faced, and the Lessons Learned
Many of the lessons learned from disaster planning are universal in scope. Communications must, can, and should be improved through a combination of preplanning, the use of advanced technology, and the establishment of an appropriate command hierarchy. Training also has to be emphasized – and frequently repeated.
There are, in addition, certain lessons learned that are particularly relevant to the emergency department itself – for example, the recognition that most incoming patients from a disaster will arrive at the hospital (or other medical facility) by private vehicle, a fact that has direct and important implications for the decontamination and patient-triage processes. Moreover, sicker patients often arrive later those who are in somewhat better condition, especially in situations where rescue is required. That combination of circumstances may force a paradoxical reservation of resources during the early stages of a disaster to remain prepared for the more seriously injured patients expected later.
Another fact of life that has to be dealt with – primarily because so many emergency departments operate near or at maximum capacity every day – is that truly realistic drills for emergency department staff usually will be extremely limited. There has been an increasing push in recent years for evidence-based and validated practices, but the low frequency and unpredictability of disasters makes research in this area exceptionally challenging, and standardized “best practice” models are therefore very difficult to develop. (However, applicants may apply for funding to build these types of models.)
In summary, it seems evident that the basic framework for capturing federal funding by partnering with state and local government agencies is already in place. The government’s grant-management system may take time, though, to get actual dollars into the hands of emergency medical teams. However, establishing programs now will result in an improved funding stream later. In short, navigating through the current grant-management system requires a clear understanding of the requirements, the development of a persuasive stakeholder strategy, and the writing of a clear and comprehensive outline for a proposed project that will improve emergency medicine.
Ms. Ungar is the CEO of Nolan Mar International, Inc, a global management consulting firm focused on the defense and homeland security marketplace. With over 20 years of government and commercial consulting experience and a proven track record in government and industry strategic planning, program management, risk management and cost effective project execution, Ms. Ungar provides the leadership for Nolan Mar to achieve their mission in “Designing and Executing Operational Effectiveness©”. Ms. Ungar is instrumental directing the firm’s deployment of the Nolan Mar SAFE© meth