U.S. hospitals take different approach than French in mass-casualty planning

Soon after terrorist attacks that led to 130 deaths and wounded more than 350 others Nov. 13 in Paris, the city activated its Plan Blanc strategy, a coordinated response to mass casualty. It was a calculated effort that was largely facilitated by the mostly municipal governance of its hospitals.

Within an hour of the attacks, hospitals in Paris called in their staffs, which remained on-site for about 26 hours. Doctors and nurses canceled a planned strike. They and other hospital workers began mobilizing beds, readying operating rooms, checking levels in blood banks and preparing to triage victims. Plan Blanc called for a deviation from the protocol to treat patients as much as possible at the scene.

The plan echoes some of the main tenets followed by U.S. providers in similar situations: efficiency and coordination. 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 natural disasters, public health emergencies, or, twice this year, acts of terrorism.

The U.S. government provides a number of federal 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 to 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 the federal level down, 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 state and local leaders plan and train for crisis situations, which makes sense in a country where different states face drastically different threats, particularly when it comes to natural disasters.

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. Although the makeup and size of these groups vary from state to state, HHS has tasked local healthcare leaders with making at least 20% of the coalition's total bed count available within four hours of a disaster.

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. It also provides the infrastructure to transfer patients across regional or state lines to ease overwhelmed hospitals, said Gretchen Michael of 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.

The federally recognized Emergency Management Assistance Compact, administered by the National Emergency Management Association, coordinates the process by which states can request and share supplies, personnel and other resources in the event of a catastrophe. Most states have 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 and use state communication centers.

Disasters don't respect borders or jurisdictions, which is why regional health officials have to work together and learn lessons from past events, said Cheri Hummel, vice president of emergency management and facilities for the California Hospital Association. “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 Sinai-Grace Hospital in Detroit.

And in some cases, hospital departments may have their own strong regional connections. For example, since burn centers tend to be small and normally vacant, they have a strong network to share patients in the event of an overflow, said ACEP spokesman Dr. James Augustine, an emergency physician at Fairfield Medical Center in Lancaster, Ohio. Meanwhile, regional poison control centers tend to play a strong interstate 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, all mentioned that funding for those efforts, which began after the Sept. 11 attacks, has subsided in the past decade. Funding for HHS' Hospital Preparedness Program in fiscal 2015 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.

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 Sinai-Grace Hospital in Detroit.

And in some cases, hospital departments may have their own strong regional connections. For example, since burn centers tend to be small and normally vacant, they have a strong network to share patients in the event of an overflow, said ACEP spokesman Dr. James Augustine, an emergency physician at Fairfield Medical Center in Lancaster, Ohio. Meanwhile, regional poison control centers tend to play a strong interstate 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, all mentioned that funding for those efforts, which began after the Sept. 11 attacks, has subsided in the past decade. Funding for HHS' Hospital Preparedness Program in fiscal 2015 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 do,” 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.”

The American disaster response system, with its state-led focus and reliance on private health systems, has worked well to the extent that it has already been tested, Blumenstock said. But even with intelligence efforts, countries need to prepare for whatever possible disasters may come.

“I could say with a high degree of confidence that 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.”