Are American Hospitals Behind the Disaster Curve?

The average wait to be seen in U.S. emergency rooms in 2005 was 3 hours and 42 minutes. (EMS Responder, July 8, 2008) This delay highlights the inability of U.S, hospitals to respond in a timely manner to an emergency bed surge need in the event of a major disaster. The average emergency room wait in New Orleans pre Katrina was approximately 12 hours — and we know what happened there.

"The number of emergency patients is increasing while the number of hospital beds continues to drop," Dr. Linda Lawrence, president of the emergency doctors’ group, said. "It is a recipe for disaster." (White Coat Notes, January 15, 2008) Independent actions by health care providers and those responsible for emergency response to counter this lack of surge capability are being made. One such action has taken place in our nation’s capital.

A 2008 Congressional study (The House Oversight and Government Reform Committee “The Lack of Hospital Emergency Surge Capacity) found that American hospitals were unprepared for a disaster surge — facilities, staff, beds, and infrastructure. The Institute of Medicine (IOM) found the same thing: we aren’t prepared nationally for a disaster surge, and efforts should be undertaken to develop partnerships on a national level that focus regionally. Maryland Senator Barbara Mikulski has sought $25-million to create a Partnership for Prince George’s County, MD. Could this be the start of state initiatives? It would be hard to expect any new financial undertaking in, say, California, already in debt several billion dollars and looking for hand outs. How other states are fairing in the current recession is less certain. It’s a fact of competitive hospital life that they only make money when there are patients in beds. They don’t get rent for empty beds or betting on the next hurricane or seasonal fire…to have FEMA pick up the tab. Another issue that’s local and applies nationwide is that in San Diego, federal institutions and agencies have to put logistics requirements up the Chain-of Command — they can’t cross the street laterally to fulfill needs. This is for record keeping and getting refurbishment from FEMA.

In 2004, the CEOs of Suburban Hospital and the National Naval Medical Center (NNMC) shook hands and agreed to work together to prepare for disasters in the National Capital Region (NCR) — no money up front, no military budget input — just a “Gentleman’s Agreement” to work together sharing staff and equipment to provide emergency health care to the excessive numbers of patients expected during national disasters, natural or man made.

Five years later, the “Bethesda Hospitals’ Emergency Preparedness Partnership (BHEPP)” is a shining example of collaboration and community interface. The Partnership, today, consists of Suburban Hospital, NNMC, the National Institutes of Health Clinical Center (NIH CC), and the National Library of Medicine (NLM). The first three are true hospitals; NLM inclusion affords immediate research and dissemination of medical information for health responders, worldwide. NLM is internationally renowned and unequaled in medical reference material. Partnership real estate lies within one mile of each institution. Disaster functions include sharing of hospital beds, medical equipment, talented staff (doctors and nurses), and several redundant communications systems.

Later into the Partnership, local Montgomery U.S. Rep. Chris Van Hollen was able to legislate an earmark of $14.2 million for the Partnership. This is unique since partners represent the funding spectrum: federal, department of defense, and private. Van Hollen’s dollars bought immediate support equipment among which were a laser communications system, two mobile hospitals (NNMC and Suburban), and sundry medical-specific technologies such as a radio frequency patient tracking system, a lost patient tracking system, and an electronic trauma-recording computer pen. The Research and Development projects will have impact on all American Medicine. BHEPP is a great collaborative partnership which would be useful nationwide. Partners can get anything from another Partner; a local Memorandum of Agreement (MOA) covers logistics activity.

The long-range challenge, then, is to export the BHEPP model across the country. An effort is in preliminary stages to transport some aspects of BHEPP cooperation to the Naval Medical Center San Diego, Balboa Hospital. As in most communities, state and county offices of emergency management have agreements in place with local institutions, trauma centers, hospitals, and clinics. A BHEPP model need not be superimposed onto local response structures. But there are collaborative aspects of BHEPP that could apply across the board, such as agreeing to share equipment. A robust communications link would be regionally beneficial. (BHEPP enjoys three back-up communications systems beyond local phone and cell connectivity.)

Regional groups of hospitals — VA, civilian, military — can determine how much of what could be applied during a disaster. Annual drills are required by the Joint Commission on Accreditation of Healthcare Organizations, the not-for-profit national body that overseas safety and quality of healthcare. Bethesda runs an annual drill that encompasses all Bethesda first responders and much of the NCR emergency agencies. Many in Congress would be transferred to Bethesda or Walter Reed in the event of tragedy. (Walter Reed will marry up with NNMC in 2011.)

Other regions need to recognize the need to collaborate and establish Partnerships. In larger metropolitan areas, it may be advantageous to group Partnerships into “clusters.” Over four partners, the administration may become cumbersome; partnerships of two, their, or four are workable. More should probably be “clustered.” What is direly needed is national oversight that could be set up in a “National Hospital Partnership Alliance (NHPA)” — or any other workable title. The goal is to create regional partnerships across the country that will help with meeting the surge requirements occasioned by a disaster — Swine Flu Pandemic, chem.-bio terrorist attack, weather phenomena, or other man-made catastrophe. Pre-planning is the key to recovery. In his 2005 book, Catastrophic Event Response Planning, Matthew Pope wrote: “A catastrophic event — regardless of whether it is mechanical, technological, biological, physical, chemical, or meteorological — is generally characterized by an utter failure or total disruption.” We saw this in Hurricane Katrina…and usually yearly with California fires that hospitals are unprepared for a surge need.

Beyond Bethesda, Maryland, very little is underway to address the problem. The communicative links are present with the NLM regional medical librarians — over 5,800. These can be enlisted for local assistance with law enforcement and medical institutions. It remains to be done. A National Hospital Partnership Alliance would not supplant functions afforded in the National Disaster Medical System (NDMS) that provides actual medical teams to regions hit by disasters. A Partnership Alliance would facilitate regional hospitals prepare to function better within their own environments and legal infrastructure, which differ region to region. The time to start the effort is past. If history is any lesson, the next disaster is around the corner, and we’re not ready.