The Design of the Future U.S. Hospital System

by James J. Augustine

When emergency planners and healthcare officials – including financial planners and political decision makers at all levels of government – want to envision the U.S. hospital system of the future, they ask themselves a host of complex questions, including the following: What sites would be ideal for a community’s investment in preparedness to meet a broad spectrum of disasters?  What healthcare facilities would be the heart of healthcare provision for the treatment of disaster victims, regardless of cause? What have Americans learned from recent experiences with blackouts, hurricanes, ice storms, and earthquakes?  

The community hospital almost always emerges as the facility favored for investment by all stakeholders in the collective effort to improve the nation’s domestic-preparedness capabilities. Now and for years to come, it seems likely, such hospitals not only will fill a community’s everyday basic need for health care, but also will serve as the key component of a durable infrastructure that will survive all but the worst and most destructive disasters possible.

That conclusion is inevitable when one considers just the physical attributes required for a facility built to serve the community in times of major disaster. More specifically, community hospitals and other major medical facilities: (a) Are built to standards that require durable construction; (b) Typically are built in locations that are both “high and dry”; (c) Possess large quantities of their own power and water, as well as telephone and Internet lines; (d) Are backed up by innovative power reserves and communication resources; (e) Are able to manage unexpected surges of needy persons, many if not all of them suffering from major medical problems; (f) Are experienced in and capable of managing persons with “special needs,” either physical or behavioral; (g) Can usually if not always provide and maintain tight security; (h) Possess a large and varied supply of medications (usually stored in heavy-security areas); (i) Also are stocked with a relatively large supply of food; (j) Are capable of carrying out patient evacuations by either ambulance or helicopter; and (k) Have usually been well maintained and, to meet ever-higher preparedness standards, are frequently upgraded.

There are potential alternative sites, of course, worth considering for the same type of financial investment:  airport facilities, for example, as well as hotels, large nursing homes, convention centers, and sports arenas.  But each of these, whatever their other qualities, has significant limitations in terms of serving and caring for large numbers of medically needy citizens.

The Hospital Solution

It is apparent that, in most American communities, the hospital is already the focal point of most community health preparedness programs. Public health is a very important factor, of course, in the wellbeing of every community, but in essentially all crises (or future crises when considered from an “all hazards” point of view), the hospital is the centerpiece around which all else revolves. Fortifying that obvious fact is the certainty that almost all programs related to the prevention and/or management of future natural or man-made epidemics will be hospital-centered.

Today, most U.S. hospitals are privately-owned and -operated entities, and their emergency departments (EDs) are staffed by independent emergency physicians.  But the federal government, through various laws, particularly those enacted since the 11 September 2001 terrorist attacks, has made today’s ED essentially a mandated community resource – which, fortunately, can be leveraged with a relatively small capital investment. For that reason, a federal program to “wrap a preparedness program around the ED” would synergistically combine an abundance of physical assets already available with new as well as ongoing surveillance programs and the plans and standards coming into place for responding to sudden emergencies – all of which would (or at least should) be quickly linked to other community assets. The end result would be the most cost-effective preparedness program possible for the size of the investment, and one that could be used on a day-to-day basis rather than being reserved “for emergency use only.” 

Combining public and private resources would be critical in developing such a preparedness program, but the concept described above would provide a sturdy framework for such a sizable investment. There also would be ample opportunities not only for joint investments by the federal, state, and local governments but also for similar investments by the many businesses, charitable organizations, and individual citizens who want and are willing to pay for a new and higher level of emergency preparedness in their communities.  Essentially, every ED in the country might well benefit from a retrofit to fill a new role in community surveillance and the provision of medical care in the aftermath of mass-casualty incidents.

There are several historical indicators that investments in hospitals and other healthcare facilities can be used to build the most critical elements of a bigger and better community health system for the future.  The nation’s healthcare system faced a similar need for capital investment after World War II, for example, when most U.S. communities were growing rapidly, advances in the health sciences had dramatically improved medical treatment, and U.S. leaders (perhaps with the 1941 Japanese attack on Pearl Harbor still in mind) feared the possibility of other military or natural disasters occurring on American soil. Those fears escalated, of course, with the beginning of the Cold War.

The executive and legislative branches of government considered the needs as well as several possible solutions, and crafted an infrastructure healthcare building program funded under and governed by the guidelines postulated in the Hill-Burton Act – which became law on 13 August 1946 as Public Law 725. Today, the much increased potential for more, and more destructive, mass-casualty incidents – which can be dealt with only by providing a similar increase in hospital preparedness capabilities – has led to recognition in some quarters of the need for another round of Hill-Burton funding programs to build more and better community hospitals and other facilities.

Another factor to consider is that, in recent years, the federal government has downgraded much of the previously very large naval/military healthcare system. The “major incident centers” in the emergency departments of today’s civilian hospitals must now be capable, therefore, of caring for many military as well as civilian patients, and also must serve as the training grounds for those medical providers who will provide care in the military emergency system.  The federal government also is charged with the responsibility of preparing for “worst case” events involving American citizens that occur either in this country or overseas.  Here, the broad definition of worst case includes such varied scenarios as a California earthquake, a dangerous military operation overseas, or even the explosion of a nuclear device.

With the commitment to building new hospitals that already exists in many U.S. communities, disaster planners can explore a relatively broad range of concepts related to the improvement of hospital infrastructures to the degree needed to support major disaster and evacuation functions. It seems safe to assume that the most important components of a disaster-ready hospital construction plan would include, but not necessarily be limited to: (a) a design “friendly” to patients, the hospital staff, and the local community; (b) modern high-speed information systems linked with a regional healthcare coordination center; (c) spaces and/or departments geared specifically to the handling of mass-casualty incidents; (d) other spaces specifically designed for the safe management of patients contaminated by (or exposed to) hazardous substances; and (e) links to the community’s out-of-hospital emergency system.

Coordinated Contributions:  The Role of Non-Government Organizations

The hospital preparedness program envisioned above should be paid for by a joint and mutual investment, funded and facilitated by the federal, state, and local governments – then carried out in cooperation with the numerous businesses, charitable organizations, and individuals who want and are willing to support the new and higher level of emergency preparedness previously mentioned. Here it is worth emphasizing, again, that the new and better community disaster systems being funded would also be available to provide routine emergency medical care for the same community. Common sense and sound fiscal management both require that an effective disaster response system be built on a solid foundation of effective day-to-day emergency care.

The new, improved, and more versatile facilities built would include Level One trauma centers, which provide many of the critical-care services needed by regional groups of patients. But trauma centers cannot accommodate all of a community’s medical needs, either on a day-to-day basis or in the aftermath of a major disaster, natural or manmade. All U.S. hospitals, in fact, are now responsible for developing plans to prepare to handle victims of any type of crisis, from trauma, to contagious disease, to radiation exposure or burn.

Federal funding for the new emergency system would have to be allocated under guidelines developed to support, among other things, the central role played by emergency care systems in community preparedness and syndromic surveillance and healthcare forecasting. Those goals can be met only through federal direction, but individual states can contribute the regional-application models of these systems.

Local governments can and should provide support for necessary roadway changes, zoning approvals, the movement and upgrading of public utilities that surround and serve the hospital, and by cooperating with local public safety agencies in developing and implementing community emergency medical preparedness plans.

Hospitals themselves should provide the space and customized designs needed to incorporate new Major Incident Preparedness Centers (MIPCs – the individual hospital would then be capable of expanding the center around the existing ED to provide more patient care area and additional spaces to buffer tight inpatient resources). There should be a consistent approach in designing an MIPC in which the space “wraps around” the hospital’s existing emergency department and provides, among other things, a reassuring and reliable approach to greet incoming emergency patients, both on an everyday basis and in the aftermath of a major incident.

The system for greeting patients should be designed both to safely manage incoming EMS (emergency medical services) or ambulatory patients, and to facilitate use of the high-tech systems that must survey for syndromes related to natural outbreaks of disease and/or indicative of terrorist or criminal activity. The MIPC also would house the supplies needed to cope with mass-casualty incidents throughout the community, including the new wave of detection systems required to identify hazardous chemical, biological, and/or radioactive agents.

National businesses, foundations, and service organizations should contribute to, and be recognized for, the development of a uniform approach to community emergency medical preparedness programs.  The elements needed to organize a system such as that described already exist in other industries, and those industries should be given incentives to contribute specialized expertise that could be disseminated nationwide.  There also should be a way developed to recognize those community organizations and corporations that contribute to these new models of community preparedness. 

The new hospital systems envisioned would provide a unique opportunity for businesses to contribute to the development of innovative applications of information technology.  Like many other industries, the nation’s healthcare industry would benefit greatly from a robust, user-friendly, and effective technology base.  An effort to integrate information solutions to fill a major community preparedness need should be encouraged.  This would spur the development of regionalized, coordinated, and fiscally accountable emergency care systems and the promotion of the emergency medical workforce.

The hospital-based ED Major Incident Preparedness Center would serve as the new heart of a much more comprehensive community preparedness plan.  Able to simultaneously serve as a community-based health management center, it would be fully integrated with the overall state/local healthcare system and the community’s emergency-response program.  The simple beauty of a major capital infusion in EDs today would provide the opportunity to benefit from that investment tomorrow and every day thereafter for the foreseeable future. The best way to meet the time-sensitive need for a major structural upgrade of healthcare facilities is to modernize present EDs to the degree needed to help them not only receive and process everyday patients, but also to develop the physical and process changes required to meet the community’s “all hazards” preparedness needs of the future. In short, the term “hospital preparedness” would very soon mean that all U.S. citizens would have access to critical medical services in their times of greatest need.

Dr. James Augustine is an emergency physician and medical director of the Atlanta Fire Rescue Department and Atlanta Hartsfield Jackson International Airport.  He also is a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, Ohio. Augustine served as chair of the ASTM Task Group that developed ASTM Standard E2413 on Hospital Preparedness, and is now chair of the Atlanta Metropolitan Medical Response System.