Soon after terrorists killed 129 people and wounded more than 350 others in Paris on Friday night, the city activated its “Plan Blanc” strategy, a coordinated response to mass casualty facilitated by its hospitals' largely municipal governance.
France, a country roughly the size of the state of Texas, organizes hospital response plans on a local level but within a national frame. Each region's Plan Blanc fits within the Orsan plan, a nationalized strategy to prepare for mass casualty events such as accidents, disasters or public health emergencies.
Within an hour of hearing about the initial attacks, hospitals in Paris called in their entire staffs, which were not allowed to leave until about 26 hours after being called in. The attacks coincided with a planned strike by some Parisian doctors, which was canceled because of the attacks. At hospitals throughout Paris, staffs went to work mobilizing beds, readying operating rooms, sending out ambulances, checking levels in blood banks and preparing to triage victims. Plan Blanc called for a deviation from protocol, which is to treat patients as much as possible at the scene.
The American federal government also provides a number of national resources and frameworks for hospitals to consult when preparing for terrorist attacks and other disasters, but much more planning is done at state and local levels as compared with France. One major reason is that ownership of the U.S. health system is significantly different: More than 60% of French hospitals are government-run, while only 17% of American hospitals are owned by state or local governments.
While most European countries conduct emergency planning from a top-down perspective from the federal level, American disaster plans tend to work from the bottom-up. Federal initiatives such as the Hospital Preparedness Program from HHS and the National Response Framework, a multi-agency plan crafted by the Federal Emergency Management Agency, provide funds and resources to hospitals and regional health officials, but those state and local leaders take initiatives to plan and train for crowded emergency rooms and crisis situations.
The Hospital Preparedness Program, created within the past decade, has given U.S. health officials and hospitals more than $4 billion to help prepare for patient surges and form local healthcare coalitions of hospitals, nursing homes, primary-care physicians and Emergency Medical Service providers that together can coordinate for situations. Although the makeup and size of coalitions can vary from state to state, HHS has tasked local healthcare leaders with opening up at least 20% bed availability out of the coalition's total bed count within four hours of a disaster.
In fact, the day after the Paris attacks, HHS sent out a notice to the nation's hospitals saying it was a good time to review and assess protocol at their facilities.
“It's about working together to leverage your assets to best prepare your community for an emergency or a mass casualty event,” said Gretchen Michael, a spokeswoman for HHS' Office of the Assistant Secretary for Preparedness and Response, which is also responsible for carrying out the healthcare-related doctrine of FEMA's National Response Framework.
HHS can also provide staffing support through the National Disaster Medical System, which sends federal employees—usually intermittent workers—to disaster areas to help fill temporary staffing needs following a surge in patients, and also provides the infrastructure to transfer patients across regional or state lines to ease overwhelmed hospitals, Michael said. The federally recognized Emergency Management Assistance Compact, administered by the National Emergency Management Association, facilitates the process by which states can request and share supplies, personnel and other resources in the event of a catastrophe.
Federal agencies offer resources and often help disseminate information across regions, but ultimately, state and local authorities do most of the planning and organize the response to disasters, which makes sense in a country where different states face drastically different threats, particularly from a natural disaster standpoint. Most states hold mutual aid agreements with their neighbors, and although laws and relationships can differ, most state health departments and coalitions plan for and practice responding to cross-jurisdictional events that can affect multiple states, and use state communication centers to facilitate communication.
Disasters don't respect borders or jurisdictions, which is why regional health officials have to work together and learn lessons from unfortunate events that do happen, said Cheri Hummel, vice president of emergency management and facilities for the California Hospital Association. It's impossible to prepare for every possible event, but persistent practice is the best way for hospitals to prepare, she said.
“I'm a firm believer that the system works, but there's always room for improvement. I think that we can do more exercises,” Hummel said. "You want to drill until you really have a breakdown, because that breakdown is what exposes a weak link that needs to be fixed.”
Hospitals in the U.S. tend to approach disasters in an all-hazards manner, planning for any type of patient surge rather than more frequently focusing on specific planned-out scenarios as is commonly the case in other sectors, said Dr. Marc Rosenthal, a spokesman for the American College of Emergency Physicians and an emergency physician at Detroit Medical Center's Sinai-Grace Hospital.
“You can't write for every event. When a disaster does occur you don't have access to plans anyway,” said Rosenthal, Sinai-Grace's medical director for emergency management. “The planning and training is to appropriately recognize what's going on with patient needs, hospital needs, and start responding to handle that.”
Beyond state health departments, some hospital services and local entities tend to be well-connected between regions on their own, said ACEP spokesman Dr. James Augustine, an emergency physician at Fairfield Medical Center in Lancaster, Ohio. Because burn centers tend to be small and normally vacant, they have a strong network in which they can share patients in the event of an overflow, he said, while regional poison control centers tend to play a strong cross-state role in coordinating communications in disasters that may involve poisoning.
Though state officials and experts largely praised the federal government's role in providing funding and support for emergency preparedness, none neglected to mention that funding for those efforts has subsided in the past decade, even after the Sept. 11 attacks. Funding for HHS' Hospital Preparedness Program in fiscal 2014 was $255 million—or roughly half of what it was a decade earlier, and funding for the Centers for Disease Control and Prevention's State and Local Preparedness and Response Capability program has dropped to just over $655 million, more than a third below peak appropriations.
"If we had a strong and existing infrastructure, we wouldn't have to use (supplemental emergency) funds as much as we are," said James Blumenstock, chief of health security for the Association of State and Territorial Health Officials. "If we had a larger, stronger, more effective system in the first place, that type of bump-up or emergency funding wouldn't have been nearly as severe."
Working in a state-focused government system tasked with enlisting private entities in a very public purpose, the American disaster response system has worked well to the extent that it has already been tested, Blumenstock said. But even with intelligence efforts, countries under attack need to prepare for whatever possible disasters may come their way.
“I could say with a high degree of confidence even though we have a different model than our friends overseas, it's a different means to the same end, and the end is trying to be as responsive as possible,” Blumenstock said. “The federal-state coordination interface is strong. State-to-state relationships are just as strong, if not stronger.”