U.S. hos­pi­tals take dif­fer­ent ap­proach than the French in plan­ning for mass ca­su­al­ties

Modern Healthcare - - NEWS - By Adam Ruben­fire

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 fol- lowed 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 Ameri- can 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.

“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.”

“Ia high could de­greesay withof con­fi­denceeven though thatwe 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.”

Dr. James Blu­men­stock, Chief of health se­cu­rity, As­so­ci­a­tion of State and Ter­ri­to­rial Health Of­fi­cials

Within an hour of the at­tacks on Nov. 13, hos­pi­tals in Paris called in their staffs, which re­mained on-site for about 26 hours.

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