Gaps in Healthcare Preparedness

This has really been a week for examining public health and disaster medicine.

In that vein, PricewaterhouseCoopers Health Research Institute (HRI) released a study of the disaster preparedness of the healthcare system. Their report focuses on “the seams” in the state of preparedness and provided recommendations. There aren't a lot of surprises here. The gaps that exist have also been reported elsewhere. This study collects them nicely, though. HRI concluded:

We found that facility and staff resources are limited, public health and private medical sector plans are inadequately coordinated, communications and tracking systems are incompatible, and funding is not sufficient to support development of a sustainable infrastructure for an effective response.

The most stubborn of these problems may be a lack of surge capacity:

There is no federal or state requirement for communities to maintain a certain level of hospital capacity for disasters, and most health system resources are owned and operated by private organizations that are pressured to improve their operational efficiency and financial bottom line.

Funding benchmarks and reporting requirements are modified each year, causing recipients to shift rather than sustain focus. “The current funding forces the funds to be utilized on gidgets and gadgets because you need to liquidize the funds rather than hire and develop infrastructure for the long term,” said Jimmy Guidry, M.D., Louisiana’s state health officer.

Experts have estimated that hospitals could free up to 25% of their beds for emergency use during a disaster, but many are skeptical of how quickly and safely that could take place. ... HRI’s survey found that over 40% of health professionals lacked confidence in their ability to transfer patients to non-health facilities, and 25% lacked confidence in their ability to transfer patients to other health-related facilities.

Another potentially significant problem is a potential lack of staff. Staff levels are already low, and they are likely to suffer further in the event of a health emergency, as some healthcare workers may also be affected:

Availability of staff during a disaster is another major challenge. “Personnel are a major limiting factor and a critical need,” said Sally Phillips of AHRQ. The average hospital has an 8.5% vacancy rate among its nurses, and many have shortages in the physician specialists needed in an emergency.

The situation is not expected to improve. The federal government is predicting that by 2020, nurse and physician retirements will contribute to a shortage of approximately 24,000 doctors and nearly 1 million nurses.

And even if staff is available, training and other preparation may be insufficient:

Primary care physicians were substantially less knowledgeable than other health professionals surveyed regarding what to do in natural or manmade disasters. Fewer than 20% of primary care physicians said they were “well prepared” about what to do in a disaster, which was substantially less than other health professionals.

Coletta Barrett, head of hospital operations at the Louisiana Emergency Operations Center during Hurricane Katrina, explained that hospitals typically are underprepared. “At Charity Hospital, we knew we needed enough food and water to support the facility for three days. We didn’t take into consideration any of the staff that would remain in-house, or family members of patients or staff that would come and shelter in place.” Due to the effects of the disaster on the surrounding community, families of the injured and of hospital staff are likely to be present in the hospital, in addition to casualties.

HRI provides some recommendations. I'll focus not on the specifics, but on the general strategy:

Health and medical systems should adopt a systems-oriented approach and infrastructure for disaster response.

During a disaster, medical priorities must shift from focusing on individual patient-based outcomes to population-based outcomes.

Alternate care sites should be considered to alleviate the patient demand at hospitals and increase healthcare surge capacity within a community. Potential sites may include: shuttered hospitals, mobile medical facilities, ambulatory care centers, dormitories, and large public buildings.

One of the keys to planning, whether it involves solving the problem of capacity, pharmaceuticals, staff preparedness, communication - is to collaborate on solutions. Healthcare facilities compete in the marketplace, but in the event of a major disaster, they will be called on to share the load. A coordinated response will be more effective.

Given the wide range of needs that must be met during a healthcare emergency, advance planning that involves a wide set of stakeholders is essential.

The health system was not designed to address the complexity of disaster response, which often requires a public-sector response and coordination across multiple organizations and regions.

Communities should actively engage a wider range of stakeholders who have not traditionally been at the planning table, particularly primary care physicians, community clinics, and nursing homes.

Collaboration provides an opportunity for healthcare organizations to share resources, learn from one another, leverage best practices, and combine forces to achieve together what they each could not do alone. Disaster responders should work locally and regionally to organize resources, share expertise, and formalize mutual aid agreements.

But this doesn't happen automatically, just because there is a need:

Respondents to HRI’s survey indicated that coordination remains a concern. In particular, health professionals questioned the ability of their organizations to coordinate with physicians in private practice, federal agencies, clinics, and nursing homes.

Still, there have been some model programs for regional planning:

Collaboratives in New York, California, and Northern Virginia provide a template on the importance of regional planning. For example, the Greater New York Hospital Association created the Emergency Preparedness Coordinating Council, which includes hospitals as well as local, state, and federal public health and emergency management organizations.

California created the California Office of Emergency Services, which divided the state into six mutual aid regions. If requests for aid overwhelm a region, the state coordinates with other unaffected regions for resources. Local authorities have a span of control over local personnel and supplies, while the state can provide support from a larger pool of resources, if necessary. At the local, county, and state levels, medical health operation area coordinators communicate medical needs, collect and provide consistent information, and relay mutual aid requests.

Collaborative efforts play into our strength as a society. We are remarkably capable when we combine our various strengths to achieve a common goal. We can anticipate the kinds of health emergencies we may face in the future. We will succeed in responding to them only if we plan ahead and bring together all the resources available to us.