Medical facilities are not civic services and do not receive funds for disaster training –and have few standards under which they should train – yet they are expected to respond in coordination with civic services, particularly first-responder agencies, in the event of a major disaster. In fact, medical facilities are among the few private businesses that are expected to increase their capacity in times of crisis. In these circumstances, the general lack of training and of the development of critical capabilities for medical staff working in the nation’s medical centers represents a glaring oversight in disaster planning, particularly in the field of homeland security.
Although a great deal of legitimate focus and effort has gone into developing more and better response capabilities for firemen, policemen, and emergency medical services (EMS) personnel, the same cannot be said for medical facilities. In fact, the lack of a similar focus and effort for medical systems may be creating a first-responder “bridge to nowhere.” Investments in the development of pre-hospital medical-care capability are useful only if there is a medical facility to which a victim can be delivered. But without a prepared medical facility in reasonable proximity to the site of a mass-casualty event or incident, investments in the pre-hospital extrication and stabilization of victims may be a waste of money. However, before considering ways to create a viable medical disaster-response system, it would be useful first to explore some of the key barriers in the way, discuss a proposed methodology for improvement, and only then attempt to make a case for greater investments in medical training.
Existing Barriers to CBRNE Training
The key barriers to training medical staff, and developing medical facilities, to deal with chemical, biological, radiological, nuclear, or explosive (CBRNE) disasters are:
- Current financial and regulatory constraints on the business of healthcare;
- The complexities of building, maintaining, and operating high-overhead/high-volume medical facilities;
- The lack of established benchmarks to which training can be directed; and
- The realities posed by the necessities of using both transient staff and part-time staff, compounded by the need to meet many other facility obligations.
The most significant fact to remember in this context is that almost all U.S. medical facilities are private businesses that are financially compensated for providing medical care – not for investing in disaster preparedness. In addition, the most important reality of the medical care business as a business is that disaster training, equipment, planning, and personnel, considered as a whole, represents a largely unfunded mandate.
Another important point to keep in mind is that private-sector medical facilities also are among the nation’s most regulated businesses. Hospital food service, nuclear and other sophisticated medical equipment systems and medicines, various clinical laboratories, electronic medical records, blood banks, For most if not all of the nation’s medical facilities, disaster preparedness translates into longer waits, and fewer appointments available complicated (and expensive) medical procedures, and a large and variable human resources element are some but not all of the complex components of a modern health care system that itself requires a multitude of specialists to regulate.
The Cost of Doing Medical Business
The establishment and enforcement of disaster or CBRNE competence benchmarks and/or training standards represent yet another significant financial and workload burden imposed on the nation’s private-sector medical facilities. That workload will increase significantly as the desired benchmarks become another feature of health care upon which the facilities must be evaluated, regulated, and surveyed. In that context, it should be kept in mind that, although medical facilities are and should be regulated on their ability to carry out their core missions, the cost of preparing to cope with major disasters – on short or no notice – must in most cases be derived primarily by diverting reimbursements for healthcare that otherwise could and should be re-invested in the facility’s healthcare delivery system. For most if not all of the nation’s medical facilities, therefore, disaster preparedness translates into longer waits, and fewer appointments available, for current patients.
For practical purposes, the current high-overhead/high-volume business model for hospitals and other medical facilities means that the hospital (or facility) must always be at or near capacity in order to pay not only for the high cost of medical equipment – as well as the salaries of doctors, nurses, and technicians of various types – but also for the increasingly expensive medicines, medical procedures, and advanced treatments developed in recent years. Numerous studies and surveys show that U.S. medical facilities must be and remain at or above 95 percent occupied, on average, to be financially solvent. To reach and maintain that average requires, in turn, that almost all of the hospital or facility’s medical personnel either be at work, on the job, or off shift – but in many if not all cases in an on-call status. In other words, there is little if any down time in a modern medical facility, and very few idle hands.
Not incidentally, the same business model also dictates that a significant portion of the theoretically “disposable” time that medical personnel do have must be spent working on continuing education credits to remain current with ever-advancing medical knowledge and techniques. In that context, the fact that the majority of today’s medical providers have little or no CBRNE knowledge and/or practical disaster-response skills translates into a general need to retrain many key personnel.
A Perfect Storm of Natural and Manmade Difficulties
Each of these several realities of modern medicine represents a major barrier to the creation of medical facilities, and the training of medical staff, to the levels needed to cope with a major mass-casualty disaster – natural or manmade. Considered in combination, they form a “perfect storm” in which there is little if any financial incentive to develop CBRNE skills and/or disaster consequence-management capabilities.
The inevitable result is that there are now very few medical personnel with the knowledge or skills needed to cope with major disasters, and fewer still who would be willing or able to participate in the difficult training required to obtain that knowledge and hone those skills.
It seems obvious that the current strategy of using disaster drills as medical staff training is woefully inadequate both as an instructional tool as well as an attempt to capture and train a significant number of staff personnel. One or two disaster drills per year will train at most one shift of doctors and nurses – some of whom will be residents, while others will be part-time employees (who in many but not all cases are selected for drill duty while concurrent medical care is delivered by others). In short, the self-selection of drill personnel, combined with the infrequency of drills, makes the development of a useful number of trained staff not just unlikely but almost impossible.
A Single-Problem Focus, a Partial Solution Proposed
To further complicate matters, most drills focus primarily on a single problem. This is perhaps inevitable, because the terrorism threat that now faces the nation ranges from bombs, to dirty bombs, to infectious diseases, to other types of CBRNE disasters. But even the best-run drill can cover only a single potential disaster, or perhaps two – but no more than that. For these and other reasons, it should be recognized that the current disaster training methodology for medical systems has created, at best, a false illusion of medical preparedness.
Although hospital disaster drills are too few and too infrequent for the development of real knowledge and/or new skills for all of the personnel participating, there are at least some partial answers that might be solved through the innovative use of today’s advanced technology. New medicines are being developed, new medical advances are being introduced, and new techniques are being acquired on a nearly constant basis throughout the nation’s medical system by the development and use of advanced training modules that are tailored to the individual learner. The training of personnel in disaster preparedness can be carried out in a similar tailored or “non-contiguous” fashion.
The creation of knowledge modules, available on the web, that allow medical personnel to learn at their individual convenience is a particularly promising methodology that should be examined. Skills can be developed either in seminars or through a “drop-in” training room concept. The ability already exists to build physiologically accurate mannequins that could simulate the disease and/or injury features characteristic of many CBRNE victims. The training key here would be the translation of established benchmarks into readily accessible knowledge-skill combinations. By investing more funds in knowledge technology, rather than in additional drills, more individuals may be trained for less money. Drills still would have their place – an important one, in fact – but primarily as measurements of system-wide capabilities, rather than in the learning of individual knowledge and skills.
Is the Cost Worth the Investment?
Despite the clear and urgent need to retrain medical personnel, it is still possible – and perhaps likely – that well-intended critical capability benchmarks and training standards will be established and enforced without the provision of additional training funds, in which case the costs of retraining staff will necessarily be borne by the existing financial structure. This added cost would of course further diminish the funds available that might otherwise be used to update equipment, hire additional staff, and/or expand capabilities in other critical areas. The net effect, therefore, might well be to degrade current medical care, not improve it.
The cost of retrofitting a medical system to cope with CBRNE threats would still be necessary, though, because without the CBRNE knowledge and skills needed, not only would the immediate victims of a CBRNE event be lost, but there would be other adverse consequences as well. Hospital personnel would be contaminated and sickened, for example, and patients already ill would be further endangered, and perhaps die. Obviously, a contaminated medical facility is of little or no use in the midst of a crisis.
By taking into consideration the usually ignored financial realities facing private-sector medical facilities today, and determining the key skills needed by staff members, advanced educational materials can be created and used to the extent needed to ensure that all medical staff are educated and skilled in disaster preparedness. Using a “raise all the boats” strategy to expand and improve current medical facility preparedness is necessary in any case, if only because the best and most available surge capacity for a medical facility will come from its off-duty staff. Without a medical facility prepared to receive disaster victims, the investment in first-responder capability will have been lost. The responsibility for solving this problem lies with medical leaders, but they can accomplish their important mission only by working in close cooperation with other leaders of the greater homeland-security community.
Dr. Allswede is the Director of the Strategic Medical Intelligence Project on forensic epidemiology. He is the creator of the RaPiD-T Program and of the Pittsburgh Matrix Program for hospital training and preparedness. He has served on a number of expert national and international groups on preparedness.