7. Other Surge Capacity Issues
The RMBT Working Group meetings also discussed additional issue areas that relate to surge capacity development. The issues may affect a region's planning efforts and could be taken into consideration when using the above tools. It is up to each area to decide if they want to address these issues in their surge capacity planning.
In October 2001, thousands of "worried-well" flocked to Washington, DC, area hospitals for perceived anthrax concerns. This surge in demand overwhelmed the health care delivery system and impacted its ability to maintain services. Unprecedented demands for health care services related to anthrax also occurred in Florida, New Jersey and New York, and to some degree across the United States. The primary reason for these surges involved communication, more precisely inadequate health information and risk communication capacity. The Assistant U.S. Surgeon General, Edward Baker, M.D., M.P.H., in December 2001 summarized this weakness as:
"...the major public health challenges since 9/11 were not just clinical, epidemiological, technical issues. The major challenges were communication. In fact, as we move into the 21st century, communication may well become the central science of public health practice."
There must be communication resources to inform the public about health emergencies, to provide them information about potential health impacts and to help them determine the most appropriate actions, if any, for their particular situation. Without such information and decision-support resources that are easily accessed, preferably for one's own home, the public's only alternative is to seek out information from health care systems thereby creating a greater need for surge capacity. A surge capacity system that includes both a risk communication component to inform the public via the media and a health information component where questions and concerns from the public can be addressed via contact centers or hotlines will ultimately minimize the need for surge capacity elsewhere in the health care delivery system.
It is therefore important for any surge capacity system to incorporate risk communication and health information components to more efficiently and effectively handle surges related to public health emergencies, rather than trying to accommodate them solely with surge capacity planning at hospitals and health departments. Though surge capacity planning and resources will still be needed for health emergencies, the objective of providing the public with accurate, consistent and up-to-date information is to reduce the overall surge demand. In order to better understand what constitutes these two additional components, basic principles about risk communication and potential solutions for providing health information with established community resources are addressed in this section.
During times of crisis people become stressed and upset. They tend to focus more on the negative aspects of a situation than on the positive. In addition, they often have very different concerns and perceptions of threat than those of the experts. Because of this, effective communication with the public is crucial to overcome these barriers to information exchange and comprehension. When people are under stress they tend to have difficulty hearing, understanding, and remembering information. Even when the information being relayed is understood and remembered, the fear associated with the event can cause feelings of distrust. This distrust can result in people losing confidence in those in charge. Feelings that leaders are not listening, that 'experts' are not really competent, or that the 'whole' truth is not being told can arise during times of crisis.
Because of these factors, risk communication during a crisis is vital. Vincent Covello, of the Center for Risk Communication, defines risk as "a threat to that which we value or the probability of loss of that which we value." Risk communication is defined as "a science-based approach for communicating effectively in high-concern, high stress, emotionally charged, or controversial situations." According to the National Academy of Science, "risk communication is successful to the extent that it raises the level of understanding of relevant issues or actions and satisfies those involved that they are adequately informed within the limits of available knowledge." The objectives of risk communication are first, to provide knowledge and understanding of the situation at hand, second to enhance trust and credibility between the public and responders, and third to encourage constructive dialogue. Above all else, the goal is to avoid communication regret.
When trying to reach any goal or objective there are always challenges involved. Several challenges arise when dealing with the issue of risk communication. Both intra- and inter-organizational concerns come into play. Does your institution have an internal communication chain during a time of crisis? What other institutions do you need to be in contact with during this time? Other challenges arise in communication between the public and community organizations. How are these organizations going to relay information to the public? How is the public to contact the organizations with questions and to receive information? As stated by Monica Schoch-Spana, a Senior Fellow at the Johns Hopkins Center for Civilian Biodefense Strategies:
"The general public should be approached as true allies in managing bioterrorism, and not as the problem to be managed."
No matter whether communicating within an organization or to the public, there are some basic tenets and four theories common to all types of risk communication. Understanding these theories and their associated strategies can improve communications in high-stress, high-concern situations. The four major risk communication theories are:
When people are stressed or upset, they have difficulty hearing information, understanding information, and remembering information. Providing messages to the public that are brief, concise, and clear while still providing all necessary information is a way to overcome this challenge.
When people are stressed or upset, they often distrust that others are:
- Listening.
- Caring.
- Empathetic.
- Honest.
- Open.
- Hard working.
- Competent.
- Expert.
Winston Churchill, by all accounts an effective risk communicator, suggested that you can establish trust by demonstrating compassion, empathy, conviction, courage, hope and optimism. While being informative, he suggests that speakers convey belongingness by using pronouns such as "we, our, us" versus "I, me, my" and that both listening and perseverance are practiced. Distrust can often cause people to take the position opposite of what others demonstrate. In a situation where little information is known, the "Seesaw Effect" (Peter Sandman, Ph.D.) allows you to take the seat you don't want others to occupy. If you are worried and concerned your audience will likely take a wait and see stance. As more information becomes known it allows both seats to move to the fulcrum.
When people are stressed or upset, they often focus more on the negative than the positive. A good rule to overcome this challenge is to follow every negative statement with three positive ones. Positive statements that direct the public to do something and give them some control greatly help counter negative statements. In addition, speakers must be careful to ensure that their non-verbal communication (gestures and physical positioning) is consistent with what they are saying.
When people are stressed or upset, their concerns and perceptions of threat are often different from those of experts. In a crisis, perception is reality for someone. Perception of a risk includes both the hazard and the outrage associated with it. A person's outrage is based on many factors that weigh upon perceived trust, control and benefits. The best way to address outrage is to accept it, understand that it is not the same for everyone, and provide information that will help people understand the situation and feel they have control. Perceptions of control are gained by knowledge, trust, input and participatory actions.
It is important to remember that while providing necessary information is essential during a time of crisis, listening is a fundamental component in gaining the trust of the community. Those who are in a position of leadership need to be understanding of the needs, wants, and feelings of the community they serve. Hearing and understanding prior to speaking to the public will create feelings of trust between the community and the experts, breaking down the barriers that arise during times of stress. One-on-one communication becomes very important when broader risk communication strategies fall short.
A way to address public concerns that may not be recommended even by the best risk communication efforts is to listen to individuals and then provide specific answers to their questions. This two-way communication or dialogue can greatly ease community concerns and help reinforce trust and credibility. A common way to provide this resource is to establish a contact center or hotline. Another AHRQ grant, the Rocky Mountain Regional Health Emergency Assistance Line and Triage Hub (HEALTH), has developed a model for surge capacity in providing public information that can decrease patient surges to the health care delivery system during bioterrorism or health emergencies.
There are many Internet resources for obtaining more information about risk communication and strategies for improving it. A partial listing follows:
- Center for Risk Communication—New York City, NY (Vincent Covello, Ph.D.)
www.centerforriskcommunication.org
- Peter Sandman Risk Communication Web Site
www.psandman.com
- Centers for Disease Control and Prevention—Emergency and Risk Communication
www.cdc.gov/communication/emergency/curtools.htm
- Harvard Program on Public Opinion and Health and Social Policy (Robert Blendon, Ph.D.)
www.researchmatters.harvard.edu/story.php?article_id=326
- Agency for Toxic Substances and Disease Registry
www.atsdr.cdc.gov/HEC/primer.html
- Agency for Healthcare Research and Quality
www.ahrq.gov
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In the event of a bioterrorist incident, special populations may be at increased medical risk compared to the general population. Special population categories can include people with a variety of characteristics, but for the purpose of bioterrorism preparedness the focus is on those segments of the general population who:
- Are more susceptible to disease.
- Require special approaches to care.
- Have difficulty with access to care.
- May lack support structures to provide the individual with lower, non-hospital-based levels of care (e.g. home care).
The special populations of people that may have any of the above characteristics and are vulnerable include:
- Children and adults with disabilities.
- Children.
- Elderly.
- Rural residents.
- Low income, including the homeless.
- Immunocompromised.
- Chronically ill, particularly with chronic respiratory illness.
- Non-English speaking.
This section describes the issues related to bioterrorism preparedness for some of the special populations listed above and the extent to which they are represented in Region VIII. A large portion of the population may be considered vulnerable according to the characteristics listed. The degree of risk will be highly variable not only between each of the groups of these special populations but also among those within each group. For instance, some members of the rural population have greater access to health care than other rural population members depending on whether they live close to a rural hospital or clinic. In addition, the isolation and immobility of some disabled and elderly people may provide a lower medical risk compared to those mobile, younger groups during the event of a communicable incident.
One option for addressing the specific needs of these groups is to do nothing to specifically target special programs for preparedness, but insure that the needs of these groups can be supported through the general planning process. The other option is to identify and develop specific plans and programs that will address the needs of those most vulnerable to a bioterrorist incident.
Children and Adults with Disabilities
The American Disability Association (ADA) definition of disability is an individual who:
- Has a physical or mental impairment that substantially limits one or more major life activity.
- Has a record of such impairment.
- Is regarded by the covered entity as having such impairment.
The U.S. Census Bureau definition of disability is an individual who has:
- Difficulty performing certain functions, seeing, hearing, talking, walking, climbing stairs, lifting, and carrying.
- Difficulty with certain social roles: working at a job and around the house.
The types of disabilities include:
- Sensory.
- Physical.
- Mental.
- Self-care.
- Ability to go outside of the home.
- Employment disability.
Some disabilities may require special approaches to care, such as those who are obese with limited mobility or those with an uncontrolled mental impairment. If obese patients are located at an alternative care site with cots, these cots may not be adequate for a larger patient. The majority of disabilities may have an effect on access to care and others in society who may help with lower, non-hospital-based levels of care. For example, there are limits in communication for the hearing impaired that may affect their access to care.
According to the U.S. Census for 2000, 1 in 5 persons in the United States have some type of disability. Table 10 indicates that in the States in Region VIII, one in six persons are disabled, slightly less than the country as a whole.
Children and Elderly
Children and elderly may require special approaches to care depending on their age and health status. Some believe that "children can be treated like small adults" and that no special approaches are necessary. However, this can be refuted by the clear needs for specialized airway equipment, IV equipment, and drug types and dosages needed for the appropriate treatment of children. The elderly also can be at various levels of health, which can vary dramatically from person to person of the same age. Beyond a certain age that has not been defined, all humans become frail and more susceptible to disease. For some of the frail elderly, there may not be support structures available to provide lower, non-hospital-based levels of care. Table 11 describes the children and elderly population in Region VIII. Thirty percent of the population in the region are children and 12 percent are age 65 and over. Therefore, 42 percent of the regional population would be considered vulnerable under this category of special populations.
Rural
As described in the Background section, Region VIII is the most rural region of the country. Figure 37 indicates that 58 percent of the counties in Region VIII are frontier and 89 percent are rural counties. Table 12 describes the regional rural/frontier population. Over 38 percent of the population live in rural counties and 23 percent in frontier counties. The most frontier State is Wyoming and the most rural State is South Dakota.
Populations in rural areas are at increased medical risk for various reasons. Rural areas often lack the capacity to address a surge event and therefore the population could lack access to medical services and trained personnel. Health care is often not available 24/7 as it is in urban areas, and communication technology is generally not as sophisticated. In the event of a communicable incident, rural populations could expose wide geographic areas since this population generally travels far distances as a way of life. Rural areas also lack the resources for surveillance. Finally, a bioterrorist incident could be confusing to rural populations since some agents (e.g., anthrax) are generally available in rural areas. For instance, the Montana Department of Public Health reported that during the anthrax cases of 2001 on the East Coast, farmers in Montana were giving animal anthrax vaccine to their families. If a bioterrorist event occurred in an urban area, rural areas could also experience an influx of urbanites, overwhelming rural health care systems.
On the other hand, if a bioterrorist case was identified in a rural area, rural providers could provide advance warning to more populated areas. If the event was contained in an urban area, rural area providers could help supplement urban medical resources.
Others
The homeless are at a higher medical risk because of lack of access to care and, because of their living conditions, are more susceptible to disease. They also lack support structures that would provide lower, non-hospital-based levels of care. The homeless are also highly mobile, which can cause greater harm to an urban area if there is a communicable event.
About 10.4 percent of the population in Region VIII live below poverty (Table 13); that is lower than the national average of 12.4 percent. The poor are considered to have lower access to care, although with government programs such as Medicaid and the State Child Health Insurance Plan (SCHIP) the gap in access to health care for the poor is decreasing.
Table 14 describes the percent of the population that is uninsured. The uninsured may not have a primary care provider, and have reduced access to care. Over 13 percent of the region's population is uninsured, compared to 14 percent of the Nation as a whole.
Those who do not speak English as their primary language may also have reduced access to care. This represents 11.7 percent of the regional population compared to 17.9 percent nationally (Table 15).
Those who are more susceptible to disease and who require special approaches to care include people who are immuno-compromised and the chronically ill, particularly those with chronic respiratory illness. It will be important to identify these patients during the early stages of a bioterrorist incident so that their medical needs can be addressed.
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The focus of this project is on developing a model for surge capacity and preparedness in the event of a bioterrorist attack; however, most discussions by experts in emergency response focus on an "all hazards approach" to preparedness. To demonstrate the degree to which a bioterrorism preparedness model can apply to an "all hazards" approach, a comparative table was created listing the factors to be addressed for each type of event (Table 16). This table provides an overview of the primary factors that need to be considered in developing a model or plan for emergency preparedness across the four traditional types of potential events:
- Biological.
- Chemical.
- Nuclear.
- Conventional.
Biological events include those caused by infectious agents, both viruses and bacteria (which may or may not be communicable), and bacterial/plant derived toxins. Chemical events include those caused by chemical agents that directly cause injury/illness to the body (e.g., chlorine, sarin, mustard gas). These are not communicable, but can be spread to a limited degree by contamiNation and person-to-person contact. Nuclear events include those caused by radioactive contamiNation ("dirty bomb") or by nuclear explosion. Conventional events include those caused by natural disasters such as floods, tornadoes and hurricanes, and accidents such as plane and train crashes.
The primary findings from this broad overview for each type of event include:
- Comparing a biological event to the other three potential events, the only major differences in the factors considered lie in the area of decontamination and isolation/quarantine.
- In a broad overview of factors considered for a plan, while the messages to the public, who is in command, how the event was identified etc. would vary, many issues and methods to address these events are similar regardless of the hazard type.
- Because biological, chemical and nuclear events are not dealt with on a routine basis, knowledge and skills acquisition and retention represent a special preparedness challenge.
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