Barbara I. Braun, PhD; Nicole V. Wineman, MA, MPH, MBA; Nicole L. Finn, MA; Joseph A. Barbera, MD; Stephen P. Schmaltz, PhD; Jerod M. Loeb, PhD
Acknowledgments: The authors thank the hospital staff who participated in the project and committed substantial time and effort to complete the questionnaire. The authors also thank the members of the technical expert panel for their assistance: Mark Ackermann, St. Vincent's Catholic Medical Center of New York; Christine Bradshaw, DO, MPH, Centers for Disease Control and Prevention, Public Health Practice Program Office; Ed Gabriel, EMT-P, New York City Office of Emergency Management; Darlene Isbell-Gidley, RN, MPH, Orange County California Health Care Agency; Jane Maffie-Lee, MSN, RN-CS, Manet Community Health Center, Quincy, Massachusetts; Ralph Morris, MD, MPH, Public Health Preparedness, Minnesota Department of Health, Bemidji, Minnesota; Sally Phillips, RN, PhD, Agency for Healthcare Research and Quality; Barbara Russell, RN, MPH, ACRN, CIC, Infection Control Services, Baptist Hospital of Miami, Miami, Florida; Tim Sashko, Fire Chief, Fire Department, Buffalo Grove, Illinois; and Steve Smith, MPH, USPHS, Bureau of Primary Health Care, Division of Clinical Quality, Health Resources and Services Administration, Rockville, Maryland. The authors also thank Dennis O'Leary, MD; Chandrika Divi, MPH; Scott Williams, PsyD; Mark Beezhold; Brette Tschurtz; and Tasha Mearday for their contributions.
Grant Support: In part by a grant from the Agency for Healthcare Research and Quality as part of its Partnerships for Quality Initiative (Cooperative Agreement Number 1U 18HS18808-01).
Potential Financial Conflicts of Interest: Consultancies: J.A. Barbera (Joint Commission on Accreditation of Healthcare Organizations); Grants received: B.I. Braun (Agency for Healthcare Research and Quality), N.V. Wineman (Agency for Healthcare Research and Quality), N.L. Finn (Agency for Healthcare Research and Quality), J.M. Loeb (Agency for Healthcare Research and Quality).
Requests for Single Reprints: Nicole V. Wineman, MA, MPH, MBA, Joint Commission on Accreditation of Healthcare Organizations, Division of Research, 1 Renaissance Boulevard, Oakbrook Terrace, IL 60181; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Braun, Ms. Wineman, Ms. Finn, and Drs. Schmaltz and Loeb: Joint Commission on Accreditation of Healthcare Organizations, Division of Research, 1 Renaissance Boulevard, Oakbrook Terrace, IL 60181.
Dr. Barbera: Institute for Crisis, Disaster and Risk Management, The George Washington University, 1776 G Street NW, Suite 110, Washington, DC 20052.
Author Contributions: Conception and design: B.I. Braun, J.A. Barbera, J.M. Loeb.
Analysis and interpretation of the data: B.I. Braun, N.V. Wineman, N.L. Finn, S.P. Schmaltz.
Drafting of the article: B.I. Braun, N.V. Wineman.
Critical revision of the article for important intellectual content: N.L. Finn, J.A. Barbera, J.M. Loeb.
Final approval of the article: J.M. Loeb.
Statistical expertise: S.P. Schmaltz.
Obtaining of funding: B.I. Braun, J.M. Loeb.
Administrative, technical, or logistic support: N.V. Wineman, N.L. Finn, J.M. Loeb.
Collection and assembly of data: B.I. Braun, N.V. Wineman, N.L. Finn.
Strong community linkages are essential to a health care organization's overall preparedness for emergencies.
To assess community emergency preparedness linkages among hospitals, public health officials, and first responders and to investigate the influence of community hazards, previous preparation for an event requiring national security oversight, and experience responding to actual disasters.
With expert advice from an advisory panel, a mailed questionnaire was used to assess linkage issues related to training and drills, equipment, surveillance, laboratory testing, surge capacity, incident management, and communication.
A simple random sample of 1750 U.S. medical–surgical hospitals.
Of 678 hospital representatives that agreed to participate, 575 (33%) completed the questionnaire in early 2004. Respondents were hospital personnel responsible for environmental safety, emergency management, infection control, administration, emergency services, and security.
Prevalence and breadth of participation in community-wide planning; examination of 17 basic elements in a weighted analysis.
In a weighted analysis, most hospitals (88.2% [95% CI, 84.1% to 92.3%]) engaged in community-wide drills and exercises, and most (82.2% [CI, 77.8% to 86.5%]) conducted a collaborative threat and vulnerability analysis with community responders. Of all respondents, 57.3% (CI, 52.1% to 62.5%) reported that their community plans addressed the hospital's need for additional supplies and equipment, and 73.0% (CI, 68.1% to 77.9%) reported that decontamination capacity needs were addressed. Fewer reported a direct link to the Health Alert Network (54.4% [CI, 49.3% to 59.5%]) and around-the-clock access to a live voice from a public health department (40.0% [CI, 35.0% to 45.0%]). Performance on many of 17 basic elements was better in large and urban hospitals and was associated with a high number of perceived hazards, previous national security event preparation, and experience in actual response.
Responses reflect hospitals' self-perception of linkages. The quality of linkages and the extent of possible biases favoring positive responses were not assessed.
In this baseline assessment, most hospitals reported substantial integration. However, results suggest that relationships between hospitals, public health departments, and other critical response entities are not adequately robust. Suggestions for enhancing linkages are discussed.
Recent natural disasters and terrorist attacks have underscored the necessity for health care facilities to integrate their activities with other community response teams.
The investigators developed and administered a nationwide survey questionnaire to assess the existence and character of hospital–community services linkages that facilitated the response to local emergencies. Most responding hospitals conducted community drills; analyzed threat vulnerability; and planned for additional supplies, equipment, and decontamination facilities. Other linkages were less widespread.
Hospital response rate to questionnaires was low, and answers were unverified.
Effective coordination of effort requires development of national standards for community preparedness.
Domains and stakeholders for assessing community emergency preparedness and response linkages.
Table 1. Topics Addressed in the Questionnaire
Table 2. Characteristics of Hospitals in the Population and Sample
Appendix Table 1. Community Planning Process and Linkage-Related Topics Addressed in Community Emergency Operations Plan
Appendix Table 2. Linkage Items Related to Characteristics of Established Response Capability
Appendix Table 3. Linkage Items Related to Ongoing Surveillance, Laboratory Identification, and Resource Reporting
Frequency of perceived community hazards or threats.
Table 3. Weighted Prevalence of Basic Elements and Association with Hospital Characteristics
Table 4. Associations between Weighted Basic Elements and Perceived Hazards and Experience Factors
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
James D. Blair
Center for HealthCare Emergency Readiness (CHCER)
June 11, 2006
Non-Federal Hospital Industry vs NRP Integration
Post 9/11/2001,the Nation's strategy for protection against future Terrorist attacks called for the establishment of the Department of Homeland Security(DHS).The principal authorities that guide DHS are found in a plethora of statutes, executive orders, and presidential directives (HSPDs) spanning decades. The 2005 National Response Plan (NRP) evolves from these derivative sources. There was a significant change in expectations for the non-federal sector as the Federal Response Plan evolved into the NRP. Ownership of non-federal enties range from eighty- five (85%) percent to approximately ninety (90%) percent. Non-federal ownership within the Healthcare Industry has been placed within this range.
These realities force the healthcare industry to take a hard look at the readiness of all private and public healthcare organizations. References in this article have identified both "think tank" and governmental oversight organization criticism, some characterize the industry as the "weakest link in the Homeland Security Chain".
Homeland Security Presidental Directives- 5-7-8 have identified the non-federal healthcare industry as expected full-partners in the NRP and the National Incident Management System (NIMS). Presidental Directives have designated Hospitals and other healthcare resources as Critical Infrastructures/Key Resources CI/KR. Those same directives have identified healthcare personnel as; First Responders and First Receivers.
The National Infrastructure Protection Plan (NIPP)designed to implement the protection of critical infrastructures has had little influence on the current design and construction of Healthcare Facilities. The Industry is in a cycle of building healthcare working environment for the next 30-40 years. Failure to incorporate known "best practices" protection (mandatory for Federal Healthcare Facilities) is folly on a national scale.
Your research reflects findings consistent other research and reinforces the appearance of a lack of industry leadership for full integration in the NIMS. Emerging infectious diseases, more robust natural disasters, and increasing evidence of Hospitals as terrorist targets does not bode well for those who fail to become full partners the Nation's strategy for Homeland Security Readiness.
Mark P Jarrett
Staten Island University Hospital
July 6, 2006
Defining Community in Emergency Preparedness
The article by Braun, et al. underscores the need to accelerate integration of hospital disaster preparedness with community planning (1). The initial linkage for hospitals is with first responders: fire, police, and EMS. Coordination of these services is usually provided by a governmental body, such as the Office of Emergency Management in New York City. It is clear, however, that in a widespread disaster scenario communities will need to be self sufficient for at least the first 48 hours. This requires an expansion of the term community beyond hospitals and the agencies listed above. There needs to be an integrated plan that also includes skilled nursing facilities, chronic disease facilities, free standing dialysis centers, correctional facilities and most critically the community based physicians. We learned on 9/11 that having our physicians all rush to the hospital or to ground zero was not only non-productive, but also actually dangerous. In a pandemic, for example, it would be necessary to have physicians maintain office hours in order to triage the less critically ill away from overburdened hospitals. Similarly, in a mass casualty event, coordination with skilled nursing facilities will expedite the rapid discharge of stable patients in order to provide surge capacity. On Staten Island, which has a population of 470,000, the Richmond County Medical Society in cooperation with the two hospital systems is developing linkages between all healthcare entities. Since communication is frequently the weak link in the management of the response to a disaster, we have conducted a tabletop drill involving both hospitals, the Richmond County Medical Society, a New York State Psychiatric facility and the skilled nursing facilities. The next step will be to repeat this drill also attempting to reach out to all physicians in the county. Other healthcare entities such as hospice and home care have been part of the initial planning and will be included in follow up drills. It is our suggestion that physician leadership drive this type of integration of resources since the health of our communities is ultimately our mission.
1. Braun BI, Wineman NV, Finn NL, Barbera JA, Schmaltz SP, Loeb JM.Integrating Hospital into Community Emergency Preparedness Planning. Ann Int Med. 2006;144:799-811.
Center for Health Servicess research: JCAHO
October 17, 2006
Response to "˜Defining Community in Emergency Response'
Dr. Jarrett makes the point that integration among all medical assets in the community is a necessary step toward increasing response capacity and capability. The authors fully support this concept. Too often, disparate local health care organizations are not planning collaboratively for a coordinated, community-wide emergency response , particularly in the health and medical arena. Resources expect to work together during an emergency, but don't necessarily share plans or have a commonly understood framework for coordination under the urgency and uncertainty of a rapidly evolving incident, and major problems result. For example, during Hurricane Wilma, several hospitals had transportation agreements with the same ambulance companies, which became overwhelmed with requests for services (1). As Dr. Jarrett suggests, physicians in private practice have a vital role in maintaining local access to care and preventing unnecessary influx of patients to hospitals. Accomplishing collaborative planning and drills, such as those undertaken by the Richmond County Medical Society, is important to prepare for effective response. This planning group is similar to the emerging model of the "˜healthcare coalition' for emergency preparedness planning and response. The healthcare coalition is composed of healthcare facilities and other health and medical assets that form a single functional entity to maximize medical surge capacity and capability in a defined geographic area. It coordinates the mitigation, preparedness, response and recovery actions of medical and health providers, facilitates mutual aid support and serves as a unified platform for medical input to jurisdictional authorities (2).
The health care coalition is part of a tiered response management system for integrating medical and health resources during large scale emergencies. The 2006 Health Resources and Services Administration Program recently incorporated this tiered model into its Guidance for the National Bioterrorism Hospital Preparedness Program (3 ). This management framework describes a process for interfacing medical and health resources with widening levels of responders from the individual health care organization (Tier 1), through the healthcare coalition (Tier 2) to local (Tier 3), state (Tier 4), interstate (Tier 5) and federal (Tier 6) levels.
Communities around the country have begun to recognize the value of health care coalitions (4, 5), but additional guidance on the development and implementation of health care coalitions is necessary to ensure wide- spread adoption of the model. This model was not available at the time that our study questionnaire was developed and disseminated. Our study focus was on the healthcare organization integrating into the community, rather than the hospital organizing the community.
Dr. Jarrett's closing statement suggests "that physician leadership drive this type of integration of resources"¦" We disagree that common physician credentials make them the only uniquely qualified leaders for this initiative. Interested physicians should move beyond currently disjointed "disaster medicine" concepts to understand "medical emergency management" (6), with the scientific and professional qualifications for developing and managing complex systems. Understanding these concepts and principles will become even more important as the National Incident Management System (7) standardizes terminology and concepts across response disciplines and across the United States.
Barbara I Braun PhD1, Nicole V Wineman MA MPH MBA1, Joseph A Barbera MD2, Jerod M Loeb PhD1
1 Joint Commission on Accreditation of Healthcare Organizations, Division of Research Oakbrook Terrace, IL 2 The George Washington University, Institute for Crisis, Disaster and Risk Management, Washington, DCReferences
1. Lessons learned from Hurricane Wilma. Joint Commission Perspectives. March 2006: 26 (3) 5-7.
2. Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies. Washington, DC: U.S. Department of Health and Human Services; 2004.
3. National Bioterrorism Hospital Preparedness Program, Program Guidance, Fiscal Year 2006 U.S. Department of Health and Human Services, Health Resources and Services Administration, July 2, 2006.
4. Tanielain T, Ricci K, Stoto MA, Dausey DJ, Davis LM, Myers S, Olmsted S, Willis HH. Exemplary Practices in Public Health Preparedness. Center for Domestic and International Health Security. The RAND Corporation, 2005. Accessed August 8, 2006. http://www.rand.org/pubs/technical_reports/2005/RAND_TR239.pdf
5. Altered Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010. AHRQ Publication No. 05-0043. Rockville MD: Agency for Healthcare Research and Quality. April 2005.
6. Barbera JA, Macintyre AG, Shaw GL, Seefried VI, Westerman LT, de Cosmo S. MSEmergency Management (EM) Principles and Practices for Healthcare Systems. U.S. Department of Veterans Affairs, Veterans Health Administration. June 2006. Accessed August 14, 2006. http://www1.va.gov/emshg/page.cfm?pg=122
7. National Incident Management System. U.S. Department of Homeland Security. March 1, 2004. Accessed August 14, 2006. http://www.dhs.gov/interweb/assetlibrary/NIMS-90-web.pdf
Braun BI, Wineman NV, Finn NL, Barbera JA, Schmaltz SP, Loeb JM. Integrating Hospitals into Community Emergency Preparedness Planning. Ann Intern Med. ;144:799–811. doi: 10.7326/0003-4819-144-11-200606060-00006
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Published: Ann Intern Med. 2006;144(11):799-811.
Emergency Medicine, Hospital Medicine.
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