1. Introduction
Purpose
The primary purpose of this study was to develop a Rocky Mountain Regional Care Model for Bioterrorist Events (RMBT) that addressed medical surge capacity needs in the event of a bioterrorist incident. The overarching purpose of this project was to develop an exportable surge capacity model that included tools for regional bioterrorism planners and decisionmakers at the national, State, local, and provider level.
The specific goals of this project as outlined in the Agency for Healthcare Research and Quality (AHRQ) contract were addressed in the following sections of the report:
Examine the effects of regional care models and their impact on resource allocation and capacity in the event of a potential bioterrorist event.
Throughout the report, using references, reports, and RMBT working group experiences.
Examine the effect of a potential bioterrorist event on hospital and health system's outcomes and staffing.
Five chapters of this report address the impact of a bioterorrist event and surge resource needs for hospitals and health care systems:
Identify the facility characteristics necessary for establishing individual facilities as isolation or quarantine units for the region.
Chapter 6: Isolation/Quarantine, focuses on identifying the issues that were considered by the RMBT working group for establishing quarantine hospitals.
Identify characteristics of the model that are exportable to regional, State, and local policymakers.
The methodology and tools that were developed are exportable to any region, State, or local policymaker. This will be outlined in the recommendations and conclusions.
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Background
In October 2002, AHRQ sponsored the establishment of the RMBT Working Group as part of a task order through the Integrated Delivery System Research Network (IDSRN). The Working Group was charged with studying the issues associated with providing regional surge capacity medical response and identifying a consensus-based model to improve regional medical response. The RMBT Working Group Principal Investigators solicited participation from Federal, State, and local agencies throughout Federal Region VIII. The concept of the need to collaborate with all levels of government when developing tools and models of bioterrorism preparedness was further strengthened by Tom Ridge, Secretary of the U.S. Department of Homeland Security. He stated, "We hope to change the old relationship—cities-State-Federal model—into one based on mutual cooperation, collaboration, and partnership."
The RMBT Working Group members represent providers and all levels of government:
Federal Level
- U.S. Air Force (USAF) Office of Surgeon General.
- USAF Homeland Security Office.
- USAF Development Center for Operational Medicine (DCOM).
- U.S. Northern Command.
- Colorado U.S. Air Force, Army, and National Guard Bases.
- U.S. Public Health Service (PHS).
- National Disaster Medical System (NDMS).
- Department of Veteran Affairs Medical Center (DVAMC).
State Level
- Colorado Department of Public Health and Environment (CDPHE).
- Montana Department of Public Health.
- North Dakota Department of Public Health.
- South Dakota Department of Public Health.
- Utah Department of Public Health.
- Wyoming Department of Public Health.
- Wyoming Office of Emergency Management.
- Colorado Hospital Association.
- Colorado Rural Health representative.
County/City Level
- Tri-County Health Department.
- Denver County Health Department.
- Jefferson County Health Department.
- Front Range Metropolitan Medical Response System (MMRS).
- Denver Center for Public Health Preparedness (DCPHP).
- Denver Mayor's Office of Emergency Management (OEM).
Providers
- Denver Health Medical Center (DHMC).
- University of Colorado Hospital.
- The Children's Hospital Denver.
- Exempla Healthcare.
- HealthONE.
- Centura Health.
- Kaiser Permanente.
Complete information on Working Group members is in Appendix A.
Federal Region VIII is comprised of six States located in the Rocky Mountain region of the country:
- Colorado.
- Montana.
- North Dakota.
- South Dakota.
- Utah.
- Wyoming.
This area differs from other Federal regions in that much of it is sparsely populated, representing only 3 percent of the U.S. population spread over 16 percent of the land area, with a population density only about one-fifth of the national average (Table 1). The region contains four Metropolitan Medical Response System (MMRS) cities (Appendix B), as specified in the Nunn-Lugar-Domenici Act—Salt Lake City, Utah and Denver, Aurora and Colorado Springs, Colorado—and two NDMS sites (Appendix C). The purpose of the 1996 Nunn-Lugar-Domenici Domestic Preparedness Initiative has been to train civilians and disaster workers to respond to an attack by a weapon of mass destruction (WMD), including any biological agents. The RMBT region is also home to U.S. Northern Command (the new military command for homeland defense), the U.S. Air Force Academy, and the North American Aerospace Defense Command (NORAD). These unique regional and strategic characteristics provided an ideal environment for the development of a regional health care system preparedness model for bioterrorist events.
The Denver Health Emergency Department has been one of the early training groups for Nunn-Lugar-Domenici funded preparedness activities (e.g., chemical table top and full exercise, biological table top) for hospitals in advance of and subsequent to important high-profile visits and events in Denver. In May 2000, Denver Health and all its components were important players in the national bioterrorism exercise, Operation TOPOFF 2000. During this largest ever, real-time, simulated exercise, local, State, and Federal officials along with staff of three metropolitan Denver hospitals had the opportunity to practice working together to address an epidemic caused by an infectious agent (plague, Yersenia pestis). Issues related to anti-microbial prophylaxis and infection control, isolation and quarantine, and surge capacity were essential learning points for those involved.
The State of Utah also has extensive experience in bioterrorism preparedness through preparations for and sponsoring of the 2002 Winter Olympics. The participants from Utah provided insight into collaborating and planning with multiple agencies.
Finally, the U.S. Department of Defense (in particular, U.S. Northern Command, Air Force, Army, and National Guard) played an integral role as members of the RMBT Working Group. They provided insight into what the military could offer the civilian population during a surge event and lessons learned for their preparations. The DoD also provided the RMBT Working Group with documents and information it had developed for bioterrorism preparedness.
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Defining a Region for Medical Response to Bioterrorism
When developing a regional model and tools for bioterrorism preparedness, it was useful to review the various regional concepts and structures that had already been developed. Webster's dictionary describes a region as a broad geographic area containing a population whose members possess sufficient historical, cultural, economic, or social homogeneity to distinguish them from others. Regionalism can be described as a sense of common interest and identity across an extended, if indeterminate space. When related to bioterrorism preparedness and surge capacity, the pooling of resources at a regional level distributes the burden of surge capacity planning and resource need. In a regional model, resource rich areas can share with resource poor area.
Most "regional" research and disaster planning models have been done within State boundaries (i.e. intra-State or local regionalism). The RMBT Working Group chose to define the "region" as an inter-State collaboration between six States:
- Colorado.
- Montana.
- North Dakota.
- South Dakota.
- Utah.
- Wyoming.
These States represent Federal Region VIII, as defined by the Federal Emergency Management Administration (FEMA) and the Public Health Service (PHS). The strengths for defining the region in this manner for developing surge capacity model in the event of a bioterrorist attack are:
- FEMA, NDMS, and the Public Health Service (PHS) currently use these regions to define resource allocation and the provision of manpower assistance; therefore, a communication infrastructure exists.
- These States represent a primarily rural population and therefore have common characteristics and infrastructure.
- These States have a history of sharing resources, particularly when it comes to hospital trauma and specialty services.
- Federal Region VIII States are relatively similar in land and population distribution.
- Characteristics of this model of regional bioterrorism preparedness can be exported to the other nine FEMA regions of the country.
Select for Figure 1: Federal Region VIII.
There are many other definitions of inter-State regions. For example, the Centers for Disease Control (CDC) defines Federal Regions such as Mountain: Montana, Indianna, New Mexico, Wyoming, Nevada, Colorado, Arizona, Utah and West North Central: North Dakota, South Dakota, Nebraska, Kansas, Minnesota, Iowa, Missouri. Other common definitions of a region used in disaster planning include Border States' agreements to share resources.
Many have noted that planning problems increasingly cross borders, both geographic and functional. This requires flexible institutional frameworks to address different planning problems and objectives depending on the scale at which problems are defined (Barbour, 2001). All States and the health care systems face large fiscal constraints; to deal with surge capacity requires a more efficient use of infrastructure. Environmental effects such as attack by a bioterrorist agent are usually felt in the "bioregion" irrespective of State boundaries.
Some advocacy work has already begun regarding regional collaboration for disaster preparedness planning. A national organization called the Alliance for Regional Stewardship (ARS) (www.regionalstewardship.org) has realized that regional organizations can play an important role in developing and implementing emergency preparedness plans. If Federal and State government and national private and civic leaders indicate support for regional compacts, regions have a unique opportunity to demonstrate an effective model of emergency preparedness through regional collaboration (Dodge, 2002).
Other groups have examined regionalism in the West specifically related to resource management. In the Rocky Mountain West, where water is a constant necessity to support rapid population growth, groups have had to develop innovative strategies to share resources in the region. Resource sharing issues mirror surge capacity issues in the West. McKinney et al. advocate looking beyond political and jurisdictional boundaries to recognize "the natural territory of public issues." In developing surge capacity, specifically in a resource poor area of the country such as Federal Region VIII it may be important to learn from resource sharing initiatives that have tried to create and sustain effective organizations that do not comfortably fit into established framework of local, State and Federal governments. Regional initiatives should be viewed as long-term experiments (McKinney, 2002).
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