Preparedness under assault

Boston's efficient and effective medical response to the Patriots Day bombing and the good reviews given local responders in the massive explosion at a fertilizer plant in Texas sent the nation a largely positive message about the healthcare system's preparedness for mass casualty events. But the funding and training that enabled those responses is under siege, which is raising troubling questions about the healthcare system's ability to sustain its readiness.

Hundreds of people were injured in Boston and in West, Texas, with at least three deaths confirmed by the Boston Police Department and at least 12 deaths stemming from the fertilizer plant blast. The wailing sirens, grieving families and wall-to-wall media coverage capped a year in which hospitals and emergency response teams faced disasters as varied as superstorm Sandy, which led to the evacuation of nine hospitals in New York and New Jersey, two of which are still closed, and mass shootings in Aurora, Colo., and Newtown, Conn.

For public health officials across the country, the twin disasters last week served as a wake-up call. If a terrorist attack or a massive industrial accident came to their town, would the EMS teams and hospital emergency rooms be able to respond as well as the six Level 1 trauma centers within a few miles of the finish line of the Boston Marathon?

“Generally, across the country, hospitals and healthcare systems are much better prepared than they were a decade ago,” said Dr. Eric Toner, senior associate with UPMC's Center for Biosecurity, a research and analysis organization at the Pittsburgh-based health system that focuses on national security issues.

Toner and other policy analysts applauded the response executed by Boston's hospitals and its police, fire and emergency medical services departments, which may soon serve as a textbook example of how a city can address a mass casualty event.

But many other U.S. communities and cities do not have the resources of the nation's leading medical training center. Federal, state and local budget cuts, requirements that some say are not rigorous enough, and a lack of coordinated disaster planning in competitive hospital markets may have undermined some of the readiness measures adopted in the wake of the 9/11 attacks.

“Every healthcare provider has to, in the back of their mind, say: Am I ready? Do I know how to make this play? And will we be able to rise to the occasion?” said Dr. Arthur Kellermann, a policy analyst for RAND Corp. and former professor of emergency medicine at Emory School of Medicine.

The characteristics of the scene in Boston and the subsequent response from the region's providers were unique in many ways.

The bombs exploded outside, during a weekday, at a site filled with EMS staff and other first responders. There are six trauma centers within several miles of the marathon's finish line. Those hospitals, prepared to treat dehydrated runners, were not running their operating rooms at full capacity. In addition, several of the hospitals had surgeons and other clinicians who had served in Iraq and Afghanistan and were familiar with blast injuries.

“The fact that no one died who wasn't killed instantly given the horrific injuries they sustained is just remarkable,” Toner said.

The hospitals that treated victims of the plant explosion in tiny West, Texas, say they benefitted from emergency preparedness planning, said Larry Holze, public information officer and director of communications for the nearby city of Waco.

According to Holze, Waco's two main hospitals, 260-bed Hillcrest Baptist Medical Center and 306-bed Providence Health Center, were able to swiftly activate their preparedness protocols and accommodate the surge in emergency cases. He credited the smooth response to rigorous training and regional drills. “We had planned for scenarios like this, and the response was well-executed,” Holze said. “The level of preparation paid off.”

While policy experts say that hospitals and communities are more prepared now than they were in the years leading up to 9/11, there are concerns that recent budget cuts and the quality of some preparedness planning practices could be undermining hospitals' ability to respond to a similar crisis.

In a report released in December, the Trust for America's Health said that while “major accomplishments” in preparedness planning have occurred through the creation of public health laboratories and extra surge capacity, providing mass care during emergencies remains a major area of vulnerability. “It's clear that we're seeing more threats, not less, and I'm not just talking about terrorism or bioterrorism,” said Rich Hamburg, deputy director for the Trust for America's Health. “There are more severe weather-related events, pandemic flu outbreaks (and) hurricanes.”

The Bioterrorism Act of 2002 led to the formation of the Hospital Preparedness Program, now administered by HHS' Office of the Assistant Secretary for Preparedness and Response. The program, reauthorized by Congress for a second time in March, has shrunk from $515 million at its peak to $380 million this year, down about 26%. President Barack Obama's proposed budget for fiscal 2014 would cut another $125 million from the program.

“Preparedness is not a state you get to and then you just stop,” said Roslyne Schulman, a director of policy development for the American Hospital Association. “It's dynamic and the stressors and hazards are constantly changing. These cuts will hurt.”

Disaster preparedness experts warn the budget reductions will affect hospitals when they conduct annual preparedness exercises. “I have no doubt that some of the cuts will (mean communities will) be doing less rigorous exercises ,and I think over time that will be reflected in a less robust response to an event,” Toner said.

As part of accreditation, the Joint Commission requires hospitals to conduct two annual preparedness drills, including one that involves community agencies, such as local fire and police departments and EMS units. However, the commission has allowed hospitals to conduct so-called “tabletop” exercises in place of real-time physical drills since 2003.

That year was also the first year that the Joint Commission required hospitals to conduct exercises with their community partners. “Some communities don't have funds to do that. So to facilitate that, we allow this to be a tabletop.” A majority of Joint Commission-accredited hospitals conduct physical exercises each year, he said.

That clearly wasn't the case in Boston, where the strong ties between local hospitals, EMS, long-term care facilities, local law enforcement agencies, public health groups and university officials were evident last week.

The Boston Healthcare Preparedness Coalition, which was established in preparation for the 2004 Democratic National Convention, meets bimonthly to review upcoming events, discuss potential hazards and fine-tune response protocols, said Meg Femino, director of emergency management for 642-bed Beth Israel Deaconess Medical Center and the coalition's co-chair. Beth Israel Deaconess was one of several hospitals in Boston to receive patients from the bombings. Member hospitals meet monthly.

“What really sets Boston apart is that we all know everyone,” Femino said. “We have worked together for so long and we're all on a first-name basis. I have everyone's numbers in my cellphone. We're well-connected, and that makes it a lot easier to prepare.”

Beth Israel Deaconess conducted 12 emergency preparedness drills in 2012, including two infant-abduction drills and a five-day escalating infectious-disease drill. That's far above the Joint Commission's two-drill requirement, Femino said. The coalition also schedules three high-alert events each year: New Year's Day, the Boston Marathon and July 4.

“We were already in a heightened alert state with a full marathon plan,” she said. “As horrific as Monday's events were, I have to say that there were a lot of lives saved because the medical tent was there and the hospitals were prepared.”

At 395-bed Boston Children's Hospital, staff had only a 10-minute window from the time the event happened to the moment when three critically injured pediatric patients arrived at the emergency department. Yet they were ready. “The minute we got word of the explosion, we activated our command center and assembled trauma teams,” said Fran Damian, nursing director in the hospital's emergency department and the incident commander during last week's response. “There was no delay.”

Those hospitals say they depend heavily on funding from the Hospital Preparedness Program. Even at a hospital as large as Beth Israel Deaconess, the emergency management department “operates on a shoestring” and relies on the program's funds, Femino said.

But regions without Boston's fiscal and professional resources and that of other cities of its size probably don't have the same level of coordination and readiness. Many of the required preparedness drills conducted by hospitals in the U.S. may not be rigorous enough, are planned in advance and often focus on natural disasters or biological events. They are a “box to check” for most hospitals, RAND's Kellermann said.

The Office of the Assistant Secretary for Preparedness and Response, or ASPR, contracted with RAND to conduct a pilot project that assessed no-notice drills in a few trauma centers in the U.S. The only notice provided to the hospitals was that the RAND team would appear within seven days. The hospitals were then evaluated by their responses within the first 90 minutes to a scenario that rose to the same level as the 2004 Madrid train bombings, which killed 191 people and injured another 1,800.

Kellermann said that “99.8% of drills in America don't rise to that standard. Therefore, none of them are practicing for what it's going to be like when it really happens.” The communities that are likely to be most at risk during a disaster are midsized cities with two to three hospitals, especially if the emergency departments in those facilities are often full on a day-to-day basis.

In January 2012, the Hospital Preparedness Program shifted its focus to the concept of coalitions, which are expected to better coordinate care between a region's hospitals and its partners during a disaster. One goal of the program is to ensure that a coalition's providers can make 20% of their staffed acute-care beds available within a four-hour timeframe. “If we're successful in building those coalitions then we anticipate that we would be able to provide better care to survivors and victims just like we're seeing in Boston,” said Dr. David Marcozzi, director of ASPR's National Healthcare Preparedness Program.

However, only about 80% of the nation's nearly 5,000 hospitals participate in the coalitions, in part because some facilities have concerns about working with competitors. “It's a hurdle that we're working to overcome,” Marcozzi said.

But cities that are participating say they would be as prepared as Boston. For more than a decade, Seattle has had in place a similar emergency management coalition, now composed of 20 hospitals in two counties, local police and fire departments, blood banks, hazardous materials officials and other groups, said Marianne Klaas, administrative director of accreditation and safety for Swedish Health Services, a four-hospital system headquartered in Seattle. “I believe we can mobilize as well as Boston did, and we've demonstrated that in smaller events,” Klaas said.

Swedish conducts at least two active drills a year at each of its hospitals, as well as several tabletop drills. Many of their planning activities involve steps to address a sudden surge in the number of patients, strategies such as stopping elective surgeries, discharging some patients early and locating creative places for additional beds and stretchers.

In St. Louis, in the event of a catastrophic situation, Barnes-Jewish Hospital could be mobilized in minutes to support incoming victims, while also coordinating staff and supplies with other St. Louis and Southern Illinois hospitals that are members of the St. Louis Medical Operations Center, said Jerry Glotzer, the hospital's director of environmental health and safety.

That group is part of a larger consortium known as the St. Louis Area Regional Response System. “That's the liaison to all those hospitals, and that liaison would then be able to coordinate with the state, the regional entities, police and fire departments. It's another entity that would help this load balance. Building these relationships with our colleagues in other sectors of the community makes it more robust,” Glotzer said.

Those relationships were tested in May 2011 when the deadliest tornado to hit the U.S. since 1947 struck the town of Joplin, Mo., about 300 miles from St. Louis. Physicians from Barnes-Jewish and nearby Washington University School of Medicine were immediately deployed to Joplin, along with antibiotics and other supplies. “We're always in preparation mode,” Glotzer said.

But Glotzer acknowledged that even though you can't prepare for every situation, you can be “perpetually ready,” as he calls it, by implementing and engaging in this kind of training and discussion.

“Sometimes conditions change in a second, and sometimes they arise where you haven't drilled that particular event,” Glotzer said. “But you have the ability to morph or scale your response because you've practiced all the other basic stuff. You can pull from those tools and craft a response for an event you've never dealt with before.”

—with Rachel Landen

TAKEAWAY: U.S. hospitals are more prepared to handle disasters than 12 years ago, but funding cuts and other challenges could hobble their ability to do as well as Boston hospitals handled the marathon bombing.

Follow Jaimy Lee on Twitter: @MHjlee

Follow Maureen McKinney on Twitter: @MHMMcKinney