HHS has been working since 1999 to improve the nation's bioterrorism preparedness, but the events of last fall underscored the urgent need for a more rapid, focused response by hospitals and the nation's public health system in the event of future emergencies. A year after the violence of Sept 11 and still-unresolved anthrax cases, a new public health infrastructure is slowly taking shape.
As the industry looks to cities such as New York and Washington to serve as models of public health readiness for future medical catastrophes, others have had a head start in such efforts. Washington state, for example, on the opposite side of the country, has played a key role in setting the bar for hospital preparedness.
"The risk of a bioterrorist attack is recognized now to be significant and pressing," Jerome Hauer, director of HHS' Office of Public Health Preparedness, wrote in a letter to New York City Department of Health Commissioner Thomas Frieden, M.D., earlier this summer. "We are working diligently to strengthen our national resources to be prepared and supportive, but success in dealing with an epidemic depends primarily on how rapidly and effectively local and state programs can respond."
To cope with emerging chemical and biological threats, hospitals and healthcare systems have spent much of the past year cementing critical relationships with local, regional and state agencies and completing needs assessments to determine the clinical, operational and technological infrastructures necessary to counter future attacks. Urban and rural providers are building reserves of medical supplies and vaccines for use in possible mass casualty events; hiring and training staff to use special equipment and diagnostic tools to combat disease outbreaks; and drafting and reworking mandated regional preparedness plans so they can collect their share of federal grant funding.
Money from Washington
"It's amazing the feds moved the money as fast as they did," says John Erickson, director of Washington state's public health and hospital preparedness response program. "Although some pipelines were already there with cooperative agreements states have with the Centers for Disease Control and Prevention."
In early January, President Bush signed into law $2.9 billion in supplemental bioterrorism appropriations that allocated a total of $1.1 billion to the states, territories and the cities of Chicago, Los Angeles and New York, with each state receiving at least $5 million to distribute according to its own preparedness strategy.
The bulk of the $1.1 billion grant came through the CDC, which contributed $918 million to support bioterrorism preparedness, infectious-disease awareness and other public health readiness activities among the states. The Health Resources and Services Administration provided $125 million in supplemental funding directly to hospitals for development of regional and facility response plans.
"That doesn't mean that some funding from the CDC won't end up benefiting hospitals, though," HHS spokesman Bill Pierce says. HHS released 20% of the grant money, or roughly $205 million, to cities and states on Jan 25. To receive full funding, Thompson instructed governors to work with their healthcare providers to design a detailed statewide workplan, with timelines and a budget, documenting infrastructure needed to enable states' public health systems to prepare for and respond to acts of bioterrorism. Plans were due to HHS by April 15, and the remaining 80% of funding was released to states in a June ceremony at 758-bed Saint Vincent's Hospital in New York.
"It is the largest one-time investment in our nation's public health system ever," Thompson said. "We've never really invested in our local and state public health networks like we should have."
HHS has approved plans for all 50 states and is strengthening more than its funding mechanisms. Just last week, the 21-member national Council on Public Health Preparedness, formed last October by Thompson during the anthrax attacks, held its first meeting in Washington. The diverse advisory group, chaired by D.A. Henderson, M.D., the secretary's principal science adviser for public health preparedness, will work with the department on developing appropriate actions to ready the nation's healthcare system for bioterrorism. Committee members say U.S. hospitals have a lot of work to do in terms of preparedness, and Henderson added that areawide planning is something new for most hospitals.
Although each state's preparedness plan developed collaboratively by providers and local government is unique because of factors such as population, geography and proximity to major metropolitan areas in neighboring states, the process through which Washington state formed its response initiative illustrates the challenges that come with forming new partnerships.
To receive a combined total of $2.5 million of roughly $20.6 million in CDC and HRSA funding, each of the state's 95 hospitals had to meet three HRSA preparedness benchmarks. Each facility had to appoint a coordinator for hospital bioterrorism preparedness planning; establish a hospital preparedness planning committee to provide guidance, direction and oversight with the state health department; and devise a plan for responding to a potential epidemic in their areas.
"Recognizing that many of these (epidemic) patients may come from rural areas served by centers in metropolitan areas, planning must include the surrounding counties likely to impact these cities," the HRSA also stipulated.
A major challenge for hospitals in Washington state, particularly those in rural areas, will be to develop regular communication and links with the state's large Native American population and include surrounding Indian communities in their regional preparedness plans.
"There are 29 recognized tribes, and we need to identify tribe-specific contacts because every tribe is different," Erickson says. "We also have international concerns (because of the state's borders with Canada), so our hospitals are asking how they can engage another country in all this."
Washington state had made notable strides in preparedness long before Sept. 11. The state began receiving bioterrorism response funding from the CDC in 1999 when the agency launched a coordinated national effort to expand laboratory capacity and disease-surveillance programs and create round-the-clock rapid communication systems to link local government with hospitals and others in the healthcare community.
Washington was also among the first states to establish plans for hospitals' receipt of material from the National Pharmaceutical Stockpile-eight existing emergency stockpiles of medical supplies and vaccines placed strategically around the country. Trauma centers in Washington, which hosted the World Trade Organization's 1999 global economic forum in Seattle, were forced to think about protective equipment and prepare for the possible use of chemical or biological weapons by various international groups protesting the forum.
States' homeland security committees and local police departments also pose initial hurdles for healthcare providers. Emergency-management organizations, law-enforcement agencies and the FBI are a whole new world for many hospitals, which are conducting preparedness exercises in their respective areas to gain experience working with new levels of government. The CDC, the HRSA and Congress all want to be able to measure success, Erickson says, and regular drills help sustain the skills necessary to achieve the desired state of readiness and also provide clear evidence of organizations' preparedness, he says.
"You do your needs assessment, write a draft plan, train your staff, have an exercise, regroup and rewrite your hospital or regional plan," he says. "Your plan is never final."
In concert with their local and regional providers, states are required to formally submit a progress report to HHS by Oct. 1 outlining their disaster-readiness progress.
For hospitals that are still working to complete a needs assessment, the Agency for Healthcare Research and Quality,independent of the CDC and the HRSA, late last month made available a new needs survey on its Web site: http://www.ahrq.gov/about/cpcr/bioterr.pdf. Facilities can use the 11-page checklist to assess their capacity to handle potential victims of bioterrorism or evaluate existing emergency plans. The 42-question survey covers subjects such as procedures to permit rapid recognition of credentialed staff from other facilities, on-call nursing policies and biological weapons training for personnel. The survey was developed as part of the AHRQ's $5 million bioterror initiative launched in 2000.
Using the trauma-care network
Duane Mariotti, director of clinical engineering and one of the emergency preparedness liaisons at 348-bed Harborview Medical Center, a Level I trauma center in Seattle, says the state's rigorous trauma system is being used as a framework to support its developing bioterrorism response plan.
HRSA funding will be distributed to 10 existing public health regions loosely tied to the state's separately designated emergency medical services and trauma-care regions, which will then funnel the money to hospitals once each facility completes its needs assessment and regional hospital plan-the immediate task. The next phase is to develop a regional response plan addressing issues such as hospitals' capability to handle large numbers of emergency patients, or "surge capacity."
Of the $2.5 million distributed to Washington's hospitals by the HRSA, $1.7 million has been used for assessment and planning, with another $400,000 earmarked for necessary equipment, mostly protective biohazard suits.
"We were going to put two suits in every hospital in the state, but realized that didn't make a lot of sense," Erickson says. "So we worked with the state's homeland security office to determine 23 hospitals that were in critical need, and we're going to give them eight suits apiece."
The state's Committee on Terrorism will share the cost and responsibility with providers by supplying urban facilities with decontamination tents or other systems, which Mariotti says won't arrive at the facilities until January 2003 because the military has priority for any new equipment.
"You hold your breath and hope that what you order today will show up in six months," he says.
One of the principal issues many hospitals nationwide are contending with is that although they have money in their pockets, equipment that hospital staff needs for training and to implement their plans may not be readily available.
"All the vendors are backlogged," Mariotti says. Harborview, for example, is waiting, in addition to the decontamination tents, for its respirators to arrive.
In the meantime, hospitals such as Harborview-which also serves a leadership role in improving the state's emergency medical communications-are training employees right down to the housekeeping staff to use what equipment is available and strengthening internal and external communications networks. Some funds from Washington state's CDC grant will help develop secure data systems to transmit information to and from providers, along with a private Web site that hospitals can visit to view a real-time count of beds available at each facility as well as the state's level of alertness.
"One of the things we realized after going through the events of last fall was that we couldn't communicate with one another," Erickson says.