“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.