National Hospital Available Beds for Emergencies and Disasters (HAvBED) System

VI. Recommendations and Discussion

The HAvBED project has demonstrated the feasibility and utility of a system that captures and integrates currently accessible bed availability data from divergent systems in use across the country and coupling those data with data from hospitals that do not currently participate an these systems to produce a large-scale picture of patient bed availability across the country. These amalgamated data would be of assistance at a local, regional or national level in dispositioning patients from one (or more) large-scale multi-casualty events from either natural causes or from the use of weapons of mass destruction.

The HAvBED Project Group, after testing, evaluation and review of the demonstration system, recommends the following:

A. Conceptual Recommendations

• The HAvBED demonstration system should be implemented on a national level and expanded to interface with all other existing bed capacity systems currently in operation. This will require developmental effort on the part of the many systems not currently included in the HAvBED demonstration, but will be facilitated by the EDXL communication schema developed as part of this project.
• The HAvBED system should not replace any existing systems, but rather it should acquire and amalgamate data already being gathered by these pre-existing systems. The imposition of an additional bed capacity system that does not uses preexisting system data would be viewed as an unacceptable imposition by the public and private sectors.
• Hospitals not participating in a multi-institutional bed capacity system should provide necessary data via the HAvBED manual data entry Web interface. Although many institutions do participate in such systems, an incomplete picture of bed availability would result if allowances were not made for these "unaffiliated" hospitals to supply their data.
• The reporting structure and framework of the HAvBED system was developed by a national representation consensus. If modification is deemed necessary, it should occur only after very careful deliberation.
• The concepts and operation of the expanded HAvBED system should remain simple and user friendly. Major expansion of the scope of the system will put the potential for success at risk.
• Incentives for hospital participation in the HAvBED system should be developed and implemented. This could include such management tools as capacity trend reports for hospitals as well as regions. Hospitals would be more inclined to participate if they received some value for their efforts.
• The Department of Health & Human Services (HHS) should work with State and local departments of health, EMS agencies and emergency managers to inform and educate them of the utility of this system. These groups, in turn, will be instrumental in encouraging participation at the local level. This could be done via a series of conferences or meetings. Additional partners in this effort may include the Department of Homeland Security, the American Hospital Association, State hospital associations, emergency management professional organizations and selected medical specialty professional organizations. This approach will offer and provide collaborative efforts at multiple levels as well as the greatest opportunity for acceptance and widespread implementation of such a system.
• HHS, in concert with potential State, local and national users, should develop a mechanism for testing the utility of the HAvBED system at these different levels of operation.
• Concerns raised regarding the legality of ongoing collection of bed capacity data by the federal government should be investigated and addressed.
• As currently designed, the HAvBED system provides limited utility for use by field personnel in their day-to-day operations as the HAvBED data structure may not include some bed types felt to be of local importance for these operations.
• The implementation of the expanded HAvBED system should be done by an impartial organization or contractee working with HHS (such as achieved by the Booz Allen Hamilton collaboration with the Department of Defense in the creation of TRAC²ES).
• A national patient tracking system may be of help during a time of national emergency but supplying data to such a system may prove too burdensome to make it efficacious. A patient locating system may be easier to successfully implement.

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B. Technical Recommendations

• The HAvBED hospital data base (based upon the American Hospital Association [AHA] hospital data) should be edited and updated to:
  1. Remove non-acute care institutions.
  2. Correct errors in institutional location (longitude/latitude) and AHA bed numbers.
  3. Add institutions that are not AHA members (such as some military installations).
  4. Indicate those institutions that are NDMS and/or TRICARE participants.
• The Web interface for data entry and retrieval should be refined to be more intuitive and to be ADA and eGov compliant. Additional specific search and data retrieval modalities should be implemented, such as:
  1. NDMS/TRICARE institutions only.
  2. Time specific criteria, i.e. all data that are less than "X" hours old.
  3. Geographic specific criteria, i.e. all hospitals within a specified number of miles of a specific location.
  4. Data point specific criteria, i.e. all available ventilators or all institutions with available mass decontamination units.
• The symbology of the GIS maps should be improved and extended, including providing detailed institutional data on mouse-over of the institution's icon. A multiple, expanded icon set could be utilized to easily convey additional information on the graphical displays.
• The system should be reconfigured in a more robust manner to provide improved responsiveness. Efforts could include increased multi-processing, refinement of the database design and moving the GIS functions to their own dedicated processor(s).
• An extensive acceptance test procedure should be implemented to verify system operation and data reliability. The limited time frame of this demonstration project precluded methodical validation of all aspects of system operation. Systems that transmit data should note and deal with any errors in the reception of their data. Any data reception errors should be immediately brought to the attention of system administrator for corrective action.

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C. Discussion: Patient Tracking

The identification and tracking of patients from a mass casualty incident pose significant challenges and difficulties. The first question which must be answered is to determine at what point the identification and tracking processes begin. The ideal answer is for this activity to be initiated at the actual incident site. Unfortunately, past experiences clearly indicate that casualties do not necessarily remain at a disaster scene. If they are capable of ambulating, most victims will not await the arrival of public safety agencies, including EMS, but rather will seek alternative transport modalities to obtain medical care. In fact, prior incidents suggest as many as 80% of casualties will make their own way to the hospital. Therefore, any patient identification and tracking system must be flexible and be capable of permitting data entry about recognized victims at various points in the medical treatment point-of-entry chain. This includes such locations as the incident scene, receiving hospitals (both near and distant) and points in-between, as patients who attempt to get to a hospital, but are unable to do so, enter the EMS or healthcare delivery system at locations remote from the actual disaster scene.

To date, all patient identification and tracking systems are associated with significant cost, both financial and in manpower, for data entry. Systems such as the Raytheon Patient Tracking System partially automate the initial data entry process and provide for FedEx-style patient (package) tracking using scannable bar coded armbands. This system has significant financial cost associated with it and ultimately still requires manpower costs to acquire and enter personal identifying data for each patient. New York State includes a less robust patient identification and status system in HERDS for purposes of being able to track what victim is being treated at a particular hospital. This functions more as a patient locator system and also requires an expenditure in manpower for data entry.

In the development of any patient tracking system, decisions will also need to be made about the definition of a victim, the time frame in which they present for care and other similar issues. A consensus will need to be reached about who should be included and identified as a victim as well as how open-ended the time period will be for including victims in such a database.

In addition, for any patient identification and tracking system to work effectively, it must either be extremely easy and intuitive to use or it must be used on a routine basis. If routinely used, once again on-going costs associated with such a system become an issue.

In summary, a "patient tracking" system is currently technologically feasible, however, the implementation, sustainability and manpower costs present significant fiscal challenges.

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D. Discussion: Decisions Concerning Alternate Care Facilities

The development of specific algorithms to assist local, State and national planners in making decisions for the use of alternate care facilities is a complex process that involves the analysis and integration of many factors that are beyond the scope of data collection for the current project. However, prior experiences both actual (Fairfax, Virginia, on September 11, 2001⁸) and simulated (Denver Health surge capacity exercise, January 2005) provide for general recommendations. Evidence suggests that as many as 25% of the beds in a hospital could be made available for casualties from a catastrophic event by early discharge of currently admitted patients. Thus, a preliminary guideline for implementation of alternative care sites appears to be that such sites should be considered if the number of victims from an incident will likely exceed 25% of the local or regional hospital bed capacity. This is, of course, a general recommendation based upon a small sample size and warrants additional investigation to identify and include the various factors which affect the decision to open an alternative care site and thus better refine the recommendation.

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⁸ Hick JL, et al: Health care facility and community strategies for patient care surge capacity. Ann Emerg Med.2004;44:253-261.

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E. Discussion: Testing the System with State, Local and National Command Centers

The HAvBED demonstration system interfaced with several pre-existing hospital bed reporting systems that are currently in use in a variety of local and State command centers and emergency operations centers. While not a direct test of the HAvBED system in these command centers, the ability of the HAvBED system to integrate with and amalgamate data from these other systems demonstrates the interoperability responsiveness of HAvBED.

As mentioned in our recommendations, we believe that in order to achieve widespread acceptance and implementation of the HAvBED system, numerous meetings and conferences with local, State and regional departments of health, EMS agencies and emergency managers should be held to inform and educate them about the system. Once this has been accomplished, formal testing of the HAvBED system in local, State and national command centers can proceed. This should include using this system in local, regional, State and national drills and exercises.

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