1.
Project Origin and Background
The Catastrophic Incident Supplement (CIS) to the National
Response Framework assumes that up to 100,000 casualties may require transport,
regulating, and tracking from a catastrophic incident site to health care
facilities providing definitive care that are located in the surrounding
community, the surrounding region, or in other parts of the country.2 The Department of
Homeland Security's Interagency Security Planning Effort identified patient and
evacuee mobilization planning for catastrophic events as a long-term and
high-priority initiative.3
One outcome of this planning effort was that in October
2005, the Agency for Healthcare Research and Quality (AHRQ) awarded a contract
to Abt Associates and its subcontractor, Partners Healthcare, with the goal of
supporting development a national strategy for the design, development, and
implementation of an interagency mass patient and evacuee movement, regulating,
and tracking system. The project was undertaken with funding by the U.S.
Department of Homeland Security Federal Emergency Management Agency, and the U.S.
Department of Health and Human Services Office of the Assistant Secretary for
Preparedness and Response. AHRQ and the
Department of Defense jointly led the project and a steering
committee guided the project (Appendix A).
AHRQ
Vision
The project is consistent with AHRQ's vision to create a
set of umbrella systems that fill identified information gaps in disaster
planning, response, and recovery. These systems are intended to link, but not
replace, local and public-private systems and to serve as a solution in those
localities where access to such systems is not currently enabled. As such,
these systems need to be designed for flexibility and interoperability with
pre-existing systems in the public and private domain over a predefined problem
area. The targeted problem area addressed by these systems is depicted in the
diagram below.
AHRQ has funded several systems that address this need.
Two, in particular, are relevant to the project described here. The National
Hospital Available Beds for Emergencies and Disasters (HAvBED) System,
developed by Denver Health, provided a prototype national real-time
hospital-bed tracking system to address a surge of patients during a mass
casualty event. HAvBED focused on acquiring bed availability data from existing
systems, rather than replacing existing systems. An important contribution
of this project was the development of data standards for defining and
communicating bed availability information.
AHRQ has also funded development of planning tools that
can be used to estimate resource and staffing needs resulting from disasters.
As noted earlier, one of the two goals for the Abt Associates' AHRQ project was
to develop a Mass Evacuation Transportation Model that estimates the required
transportation resources needed to evacuate persons from health care and other
facilities. In addition, AHRQ funded Abt Associates to create the Hospital Surge
Model, which estimates the hospital resources needed to treat victims of
various weapons of mass destruction scenarios. The model is available at http://hospitalsurgemodel.ahrq.gov.
Lessons
Learned from Prior Disasters
This project is also an outcome of the lessons learned
from prior disasters, including hurricanes Katrina and Rita. Four major
lessons are particularly relevant to this project here.
Need for tracking. The Health and
Social Services Committee of the New Orleans Commission recommended "generating
databases with reliable and up-to-date demographic information that can
contribute to enhancing hospital planning and decisionmaking during crisis
situations."4
The need for information with which to plan and respond is germane both to
those communities directly impacted by an event and to those communities
serving as a lifeboat in accepting evacuees. The need for tracking was also
emphasized by Abt Associates Inc. researchers in a recent report in which
issues of separation between patient-family and family-family (in particular,
children separated from parents) and the need for reunification were noted.
These tracking needs are compounded by the fact that many complex evacuations
across the U.S. involved an average of 3.5 moves, most of which were made
across State lines.5
Need to include and integrate multiple evacuee source
locations. Nursing homes are not typically incorporated into
disaster-relief planning based on experience from Hurricane Andrew in 1992, the
1994 Northridge earthquake, and Hurricane Katrina in 2005.6 While hospitals
are typically included in such planning activities, mandatory evacuations
automatically exclude hospitals. Another report noted that hospitals become magnets
for people needing help or seeking refuge during a crisis and recommended that
automatic exclusion from evacuation orders be revisited and emphasized that a
system for tracking evacuees is essential.7
At Tulane University during Hurricane Katrina, the numbers of individuals in
need of evacuation included patients, staff, families of staff, families of
patients, other nonpatients, and pets.8
Other types of evacuee source locations would include health care clinics,
ambulatory surgery centers, formally designated shelters, temporary shelters
such as public buildings (e.g., schools, churches, airports), hotels/motels
(particularly in tourist areas), residences, and/or stranded mass
transportation vehicles (i.e., trains, ships, planes).
Need for medical information. Health care
workers in Houston receiving evacuees from Hurricane Katrina-affected areas
found that many evacuees coming from the Superdome and other shelters arrived
with pressing medical needs such as chronic illnesses, prescription fills for
missing medications, replacement of eyeglasses, basic dental needs, and
psychiatric services.9
Portable personal health records and/or electronic medical records that could
be readily accessed from secure servers would facilitate critical health information
exchange.
Need to prioritize evacuee status. Medical
and social needs must be considered in triaging evacuees. The traditional
medical model for triage in the U.S. is to treat the most critically injured
first; in an overwhelming disaster situations, health care providers may shift
to battlefield triage practices in which those with the highest probability of
survival are treated first. Little is known about lay clinicians' abilities to
shift paradigms during response. Further, guidelines on how to consider
accompanying social issues, such as maintaining family units, need to be
clearly structured. Consistent guidelines and associated protocols would
support planning and decisionmaking during times of crisis.
In summary, during a disaster, data exist on patients,
institutionalized individuals, and public citizens residing in or visiting a
community. Effective response in times of disaster requires that such data be
readily accessible and linked to support tracking needs. We lack the capability
to exchange meaningful data across systems to facilitate evacuation
holistically. The need to integrate siloed systems so that they can inform
decisionmakers on sources/destinations, critical personal information, and
evacuee status is emphasized by experience from prior disasters.
2. U.S. Department of Homeland Security, National Response Plan (NRP), December 2004. (N.B., The NRP was superseded by the National Response Framework (NRF) in January 2008. The NRF is available at http://www.fema.gov/nrf. In February 2009, the CIS was undergoing review and revision to align it with the NRF.)
3.
September 22, 2004 letter from the Secretary, Department of Homeland Security to Secretary, Department of Defense.
4. Health and Social Services Committee of the New Orleans Commission, 2006: "Bringing New Orleans Back: Report and Recommendations to the Commission, January 18, 2006," www.bringneworleansback.org.
5. Estimating Loss of Life from Hurricane-Related Flooding in the Greater New Orleans Area: Health Effects of Hurricane Katrina. Cambridge (MA): Abt Associates. May 2006.
6. Saliba, D, J Buchanan, RS Kington: "Function and Response of Nursing Facilities During Community Disaster," AJPH 94(8):1436-1441, 2004.
7.
Gray, BH and K Hebert (The Urban Institute): "Hospitals in Hurricane Katrina, Challenges Facing Custodial Institutions in a Disaster," July, 2006, http://www.urban.org/url.cfm?ID=4113&renderforprint=1.
8.
Bovender, JO and B Carey: "A Week We Don't Want to Forget: Lessons Learned from Tulane," Frontiers of Health Services Management, 23(1):3-12, Fall, 2006.
9.
Van Gorder, C: "Lessons from a Tragedy," Hospitals & Health Networks, hospitalconnect.com e-newsletter, http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?derpath=HHNMAG/PubsNewsArt.
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